Evaluating Progress in the Global Surgical Crisis: Contrasting Access to Emergency and Essential Surgery and Safe Anesthesia Around the World

Registered Nurse Anesthetists' Perceptions of Providing Care Within a Global Health Framework: A Qualitative Study

PURPOSE

The purpose of this study was to investigate how Registered Nurse Anesthetists (RNAs) who have been working for nongovernmental organizations in low- and middle-income countries perceive their role in global health.

DESIGN

A qualitative design was used in this study.

METHODS

Data were collected by means of semistructured interviews with 11 participants who met the inclusion criteria, and qualitative analysis of the interview content was performed.

FINDINGS

The analysis resulted in three categories and six subcategories. Of the categories, "Using skills" includes the respondents' varying levels of responsibility, tasks, and perceptions of how far they are applying their expertise. "Encountering new cultures" is about adapting to new cultural norms in nursing, education, and cooperation in the international team. "Promoting change through volunteerism" comprises personal and professional development, and impact - both local and potentially global.

CONCLUSIONS

This study highlights the relevance of RNAs in global health and emphasizes the cultural encounters, exchanges, and challenges associated with volunteer medical missions. RNAs' knowledge of, and humble approach to the host country's culture are essential for their ability to provide nursing care, engage in cooperation and training, and promote global health in a high-quality, sustainable and effective way.

A Call for the Application of Patient Safety Culture in Medical Humanitarian Action: A Literature Review

OBJECTIVES

The aims of the study were to assess lessons learned on patient safety in Organization for Economic Cooperation and Development (OECD) countries and to assess whether they are applied or can be applied to the humanitarian medicine.

METHODS

This is (a) a 2013-2018 rapid literature review of reviews and systematic reviews articles (PubMed database) on "patient safety" and "medical error" to look for lessons learned regarding patient safety in OECD countries and (b) a rapid literature review (PubMed and Embase databases) on "humanitarian medicine" and "patient safety," from their creation to 2018, to find any articles related to patient safety in humanitarian medicine. In both reviews were excluded articles specifically related to one device, disease, or medical act. These reviews were complemented by a Google search.

RESULTS

Of the 245 references retrieved, 104 met the inclusion criteria. Of 308 references, 39 respected the inclusion criteria. In OECD countries, patient safety comprises correlated measures taken at three levels. The micro level focuses on individual staff involved in healthcare provision or management; the meso level focuses on medical institutions; the macro level focuses on national healthcare systems. Only one reference mentioned the implementation of a medical error reporting and analysis system in medical humanitarian organization.

CONCLUSIONS

The adoption of strategies and a culture of safety will need to be adapted to address the variety of intervention contexts and to respond first to the fears and expectations of humanitarian staff. Medical humanitarian organizations, in the absence of an overarching authority for the sector, have a major responsibility in the development of a general patient safety policy applicable in all their operations.

Knowledge, attitudes, and Expectations of Medical Staff Toward Medical Error Management Policies in Humanitarian Medicine: A Qualitative Study

BACKGROUND

Patient safety, a major component of quality of care, is now an attribute of health care systems in developed countries at least. Although there is ever more research on this subject in developed countries, humanitarian medicine, mainly implemented in resource-poor countries, has yet to structure its own set of policies and strategies on patient safety and the management of medical errors.

OBJECTIVES

We assessed the knowledge, attitudes, and expectations of medical humanitarian staff regarding the development of policies and strategies related to patient safety and medical error management in medical humanitarian action.

METHODS

We conducted 36 semistructured interviews with international medical and paramedical staff active in 6 medical humanitarian organizations after having interviewed the medical directors or the person in charge of quality of care and the legal advisors. Interviews were transcribed verbatim and subjected to a thematic analysis.

RESULTS

The interviews confirmed the current absence of clear investments in dealing with safety risks in the selected medical humanitarian organizations. The difficulties experienced by medical staff in reporting medical errors such as blame culture, lack of training, and absence of leadership committed on patient safety are nonspecific. Other arguments are related to the specific conditions of humanitarian settings: coexistence of different medical culture, absence of international or local regulations or external pressures, and great diversity of activities and contexts.

CONCLUSIONS

Interviewed staff expressed high expectations of receiving guidance from their organizations and support to adopt clear patient safety and medical error management policies adapted to their complex operational and clinical realities.

Barriers to training in laparoscopic surgery in low- and middle-income countries: A systematic review

Laparoscopic surgery has the potential to improve care in resource-deprived low- and-middle-income countries (LMICs). This study aims to analyse the barriers to training in laparoscopic surgery in LMICs. Medline, Embase, Global Health and Web of Science were searched using ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Two researchers screened results with mutual agreement. Included papers were in English, focused on abdominal laparoscopy and training in LMICs. PRISMA guidelines were followed; 2992 records were screened, and 86 full-text articles reviewed to give 26 key papers. Thematic grouping identified seven key barriers: funding; availability and maintenance of equipment; local access to experienced laparoscopic trainers; stakeholder dynamics; lack of knowledge on effective training curricula; surgical departmental structure and practical opportunities for trainees. In low-resource settings, technological advances may offer low-cost solutions in the successful implementation of laparoscopic training and improve access to surgical care.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala

BACKGROUND

International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development.

METHODS

In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented.

RESULTS

Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking.

CONCLUSIONS

This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

Surgical Instrument Reprocessing in Resource-Constrained Countries: A Scoping Review of Existing Methods, Policies, and Barriers

BACKGROUND

Surgical infections are a major cause of morbidity and mortality in low- and middle-income countries (LMICs). Inadequately reprocessed surgical instruments can be a vector for pathogens. Little has been published on the current state of surgical instrument reprocessing in LMICs.

METHODS

We performed a scoping review of English-language articles in PubMed, Web of Science, and Google Scholar databases describing current methods, policies, and barriers to surgical instrument reprocessing in LMICs. We conducted qualitative analysis of all studies to categorize existing practices and barriers to successful surgical instrument reprocessing. Barriers were non-exclusively categorized by theme: training/education, resource availability, environment, and policies/procedures. Studies associating surgical infections with existing practices were separately evaluated to assess this relationship.

RESULTS

Nine hundred seventy-two abstracts were identified. Forty studies met criteria for qualitative analysis and three studies associated patient outcomes with surgical instrument reprocessing. Most studies (n = 28, 70%) discussed institution-specific policies/procedures; half discussed shortcomings in staff training. Sterilization (n = 38, 95%), verification of sterilization (n = 19, 48%), and instrument cleaning and decontamination (n = 16, 40%) were the most common instrument reprocessing practices examined. Poor resource availability and the lack of effective education/training and appropriate policies/procedures were cited as the common barriers. Of the case series investigating surgical instrument reprocessing with patient outcomes, improperly cleaned and sterilized neurosurgical instruments and contaminated rinse water were linked to Pseudomonas aeruginosa ventriculitis and Mycobacterium port site infections, respectively.

CONCLUSIONS

Large gaps exist between instrument reprocessing practices in LMICs and recommended policies/procedures. Identified areas for improvement include instrument cleaning and decontamination, sterilization aspects of instrument reprocessing, and verification of sterilization. Education and training of staff responsible for reprocessing instruments and realistic, defined policies and procedures are critical, and lend themselves to improvement interventions.

Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala

Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.

Providing anesthesia in resource-limited settings

PURPOSE OF REVIEW

The article reviews the reality of anesthetic resource constraints in low and middle-income countries (LMICs). Understanding these limitations is important to volunteers from high-income countries who desire to teach or safely provide anesthesia services in these countries.

RECENT FINDINGS

Recently published information on the state of anesthetic resources in LMICs is helping to guide humanitarian outreach efforts from high-income countries. The importance of using context-appropriate anesthesia standards and equipment is now emphasized. Global health experts are encouraging equal partnerships between anesthesia health care providers working together from different countries. The key roles that ketamine and regional anesthesia play in providing well tolerated anesthesia for cesarean sections and other common procedures is increasingly recognized.

SUMMARY

Anesthesia can be safely given in LMICs with basic supplies and equipment, if the anesthesia provider is trained and vigilant. Neuraxial and regional anesthesia and the use of ketamine as a general anesthetic appear to be the safest alternatives in low-resource countries. Environmentally appropriate equipment should be encouraged and pulse oximeters should be in every anesthetizing location. LMICs will continue to need support from outside sources until capacity building has made more progress.

Surgery with Limited Resources in Natural Disasters: What Is the Minimum Standard of Care?

Purpose of Review

In a challenging scenario, such as in the aftermath of a natural disaster, minimum standards of care must be in place from the moment surgical care activities are launched.

Recent Findings

Natural disasters cause destruction and human suffering, especially in low- and middle-income countries, which suffer the most when exposed to their consequences. Health systems can quickly get overwhelmed and can collapse under the burden of injured patients during this event, while qualified surgical care remains crucial. Medécins Sans Frontières (MSF) has a vast experience providing surgical care after natural disasters, and quality is assured through the Donabedian model. Minimum structure standards are put in place from the beginning of an emergency response, together with standard operating procedures providing guidance to professionals working in challenging conditions.

Summary

MSF believes that it is always possible to deliver surgical care, ensuring the best possible quality guaranteeing adequate levels of structure and process. The "do no harm" principle must always be respected as adherence to medical ethics is a must in any context, even a challenging one.

Building a safety culture in global health: lessons from Guatemala

Programmes to modify the safety culture have led to lasting improvements in patient safety and quality of care in high-income settings around the world, although their use in low-income and middle-income countries (LMICs) has been limited. This analysis explores (1) how to measure the safety culture using a health culture survey in an LMIC and (2) how to use survey data to develop targeted safety initiatives using a paediatric nephrology unit in Guatemala as a field test case. We used the Safety, Communication, Operational Reliability, and Engagement survey to assess staff views towards 13 health climate and engagement domains. Domains with low scores included personal burnout, local leadership, teamwork and work–life balance. We held a series of debriefings to implement interventions targeted towards areas of need as defined by the survey. Programmes included the use of morning briefings, expansion of staff break resources and use of teamwork tools. Implementation challenges included the need for education of leadership, limited resources and hierarchical work relationships. This report can serve as an operational guide for providers in LMICs for use of a health culture survey to promote a strong safety culture and to guide their quality improvement and safety programmes.

Anaesthesia in austere environments: literature review and considerations for future space exploration missions

Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceflight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simplified general anaesthesia.

A Retrospective One-Year Estimation of the Volume and Nature of Surgical and Anaesthetic Services Delivered to the Populations of the Fako Division of the South-West Region of Cameroon: An Urgent Call for Action

BACKGROUND

Surgery-related conditions account for the majority of admissions in primary referral hospitals in Sub-Saharan Africa. The role of surgery in the reduction of global disease burden is well recognized, but there is a great qualitative and quantitative disparity in the delivery of surgical and anaesthetic services between countries. This study aims at estimating the nature and volume of surgery delivered in an entire administrative division of Cameroon.

METHODS

In this retrospective survey conducted during the year 2013, we used a standard tool to analyse the infrastructure and human resources involved in the delivery of surgical and anaesthetic services in the Fako division in the south-west region of Cameroon. We also estimated the nature and volume of surgical services as a rate per catchment population.

RESULTS

Public, private and mission hospital contributed equally to the delivery of surgical services in the Fako. For every 100,000 people, there were <5 operative rooms. A total of 2460 surgical interventions were performed by 2.2 surgeons, 1.1 gynaecologists and 0.3 anaesthetists. These surgical interventions consisted mostly of minor and emergency procedures. Neurosurgery, paediatric, thoracic and endocrine surgery were almost non-existent.

CONCLUSIONS

The volume of surgery delivered in the Fako is far below the minimum rates required to meet up with the most basic requirements of the populations. It is likely that most of these surgical needs are left unattended. A community-based assessment of unmet surgical needs is necessary to accurately estimate the magnitude of the problem and guide surgical capacity improvements.

Creating a Global Acute Care Surgery Fellowship to Meet International Need

INTRODUCTION

Existing Acute Care Surgery (ACS) fellowships are positioned to develop well-trained surgeons with specific skills to facilitate improvements in care delivery in Global ACS. Many resident and fellowship programs offer clinical electives that expose trainees to operative experiences, exposing trainees to the needs in resource-challenged settings. However, most lack a focus on long-term development and research designed to enhance the country's local skills, capability, and capacity. The Global Acute Care Surgery (Global ACS) fellowship produces a surgeon who focuses on capacity building and systems development across the world.

METHODS

At Vanderbilt University, the current American Association for the Surgery of Trauma-Acute Care Surgery (AAST-ACS) fellowship was adapted to create an academic Global Acute Care Surgery (Global ACS) fellowship. This fellowship specifically enhances fellowship trainee's skills in needs assessment and performing research to facilitate the development and implementation of trauma and acute care surgery systems in low- and middle income countries. This research will foster context-appropriate data, collected and based in low- and middle-income countries, to guide practice and policy.

RESULTS AND CONCLUSION

Two fellows have completed the Global ACS fellowship at Vanderbilt University. The fellowship requirements, clinical skills, project development and overall goals are outlined within the article. Challenges, funding, and mentorship must also be addressed to develop a comprehensive fellowship. A sample two-year timeline is provided to complete the fellowship track and meet the defined goals. A structured global acute care surgery fellowship enables fellows to reduce the surgical burden of disease and contribute to surgical systems development at both local and international levels by creating meaningful research and developing sustainable change in LMIC countries.

A geospatial evaluation of timely access to surgical care in seven countries

OBJECTIVE

To assess the consistent availability of basic surgical resources at selected facilities in seven countries.

METHODS

In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available.

FINDINGS

Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh.

CONCLUSION

Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

Where Are They Now? Evolution of a Nurse Anesthesia Training School in Ghana and a Survey of Graduates

Ghana, like other countries in sub-Saharan African, has limited access to surgery. One contributing factor is the inadequate number of anesthesia providers. To address this need, Kybele, Inc., a US-based non-governmental organization, partnered with the Ghana Health Service to establish the third nurse anesthesia training school (NATS) in Ghana. The school, based at Ridge Regional Hospital (RRH) in Accra, opened in October 2009. This paper describes the evolution of the training program and presents the curriculum. Second, the results of a voluntary survey conducted among the first four classes of graduates (2011–2014) are presented to determine their perceived strengths and gaps in training and to identify employment locations and equipment availability. Seventy-five of 93 graduates (81%) responded to the survey. The graduates reported working in 39 hospitals across 7 of the 10 regions in Ghana. Six providers (8%) worked alone and 16 (21%) were one of only two providers. Fifty-three providers (71%) had no physician anesthesiologist at their facility. Most providers had access to basic anesthesia equipment; however, there was limited access to emergency airway equipment. While most graduates felt that their training had prepared them for their current positions, 21% reported experiencing a patient death during anesthesia. The NATS at RRH has been sustained and most of the graduates are working in Ghana, filling an important void. Quality improvement and continuing education must be emphasized in an effort to reduce surgical morbidity and mortality in Ghana.

Anesthesia Provision in Disasters and Armed Conflicts

PURPOSE OF REVIEW

Disasters and armed conflicts are characterized by high numbers of trauma cases, and occur mainly in developing countries where the healthcare response is already impaired, resulting in an inadequate response. Aside of the trauma cases, other surgical health conditions are also still present and require urgent care. Surgical care needs are different from context to context and depend on local means and capabilities.

RECENT FINDINGS

Doctors without Borders (MSF) has proven that even in precarious situations, safe administration of anesthesia is possible, and the "do no harm" principle can and must be upheld. Anesthesia providers need to recognize the difficulties linked to these contexts.

SUMMARY

Local, spinal and general intravenous (mainly with Ketamine) anesthetics seem to be the most widely accepted. Inhalation anesthesia has constraints; regional is underused and epidural is not recommended. Standard operative procedures should be in place, and an informed consent from the patient must be granted.

Anesthetic Care in Mozambique

BACKGROUND

The World Bank and Lancet Commission in 2015 have prioritized surgery in Low-Income Countries (LIC) and Lower-Middle Income Countries (LMICs). This is consistent with the shift in the global burden of disease from communicable to noncommunicable diseases over the past 20 years. Essential surgery must be performed safely, with adequate anesthesia monitoring and intervention. Unfortunately, a huge barrier to providing safe surgery includes the paucity of an anesthesia workforce. In this study, we qualitatively evaluated the anesthesia capacity of Mozambique, a LIC in Africa with limited access to anesthesia and safe surgical care. Country-based solutions are suggested that can expand to other LIC and LMICs.

METHODS

A comprehensive review of the Mozambique anesthesia system was conducted through interviews with personnel in the Ministry of Health (MOH), a school of medicine, a public central referral hospital, a general first referral hospital, a private care hospital, and leaders in the physician anesthesia community. Personnel databases were acquired from the MOH and Maputo Central Hospital.

RESULTS

Quantitative results reveal minimal anesthesia capacity (290 anesthesia providers for a population of >25 million or 0.01:10,000). The majority of physician anesthesiologists practice in urban settings, and many work in the private sector. There is minimal capacity for growth given only 1 Mozambique anesthesia residency with inadequate resources. The most commonly perceived barriers to safe anesthesia in this critical shortage are lack of teachers, lack of medical student interest in and exposure to anesthesia, need for more schools, low allocation to anesthesia from the list of available specialist prospects by MOH, and low public payments to anesthesiologists. Qualitative results show assets of a good health system design, a supportive environment for learning in the residency, improvement in anesthetic care in past decades, and a desire for more educational opportunities and teachers.

CONCLUSIONS

Mozambique has a strong health system design but few resources for surgery and safe anesthesia. At present, similar to other LICs, human resources, access to essential medicines, and safety monitoring limit safe anesthesia in Mozambique.

Survey of the capacity for essential surgery and anaesthesia services in Papua New Guinea

OBJECTIVE

To assess capacity to provide essential surgical services including emergency, obstetric and anaesthesia care in Papua New Guinea (PNG) in order to support planning for relevant post-2015 sustainable development goals for PNG.

DESIGN

Cross-sectional survey.

SETTING

Hospitals and health facilities in PNG.

PARTICIPANTS

21 facilities including 3 national/provincial hospitals, 11 district/rural hospitals, and 7 health centres.

OUTCOME MEASURES

The WHO Situational Analysis Tool to Assess Emergency and Essential Surgical Care (WHO-SAT) was used to measure each participating facility's capacity to deliver essential surgery and anaesthesia services, including 108 items related to relevant infrastructure, human resources, interventions and equipment.

RESULTS

While major surgical procedures were provided at each hospital, fewer than 30% had uninterrupted access to oxygen, and 57% had uninterrupted access to resuscitation bag and mask. Most hospitals reported capacity to provide general anaesthesia, though few hospitals reported having at least one certified surgeon, obstetrician and anaesthesiologist. Access to anaesthetic machines, pulse oximetry and blood bank was severely limited. Many non-hospital health centres providing basic surgical procedures, but almost none had uninterrupted access to electricity, running water, oxygen and basic supplies for resuscitation, airway management and obstetric services.

CONCLUSIONS

Capacity for essential surgery and anaesthesia services is severely limited in PNG due to shortfalls in physical infrastructure, human resources, and basic equipment and supplies. Achieving post-2015 sustainable development goals, including universal healthcare, will require significant investment in surgery and anaesthesia capacity in PNG.