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Peterson ME, Docter S, Ruiz-Betancourt DR, Alawa J, Arimino S, Weiser TG. Pulse oximetry training landscape for healthcare workers in low- and middle-income countries: A scoping review. J Glob Health 2023; 13:04074. [PMID: 37736848 PMCID: PMC10514743 DOI: 10.7189/jogh.13.04074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
Background Pulse oximetry has been used in medical care for decades. Its use quickly became standard of care in high resource settings, with delayed widespread availability and use in lower resource settings. Pulse oximetry training initiatives have been ongoing for years, but a map of the literature describing such initiatives among health care workers in low- and middle-income countries (LMICs) has not previously been conducted. Additionally, the coronavirus disease 2019 (COVID-19) pandemic further highlighted the inequitable distribution of pulse oximetry use and training. We aimed to characterise the landscape of pulse oximetry training for health care workers in LMICs prior to the COVID-19 pandemic as described in the literature. Methods We systematically searched six databases to identify studies reporting pulse oximetry training among health care workers, broadly defined, in LMICs prior to the COVID-19 pandemic. Two reviewers independently assessed titles and abstracts and relevant full texts for eligibility. Data were charted by one author and reviewed for accuracy by a second. We synthesised the results using a narrative synthesis. Results A total of 7423 studies were identified and 182 screened in full. A total of 55 training initiatives in 42 countries met inclusion criteria, as described in 66 studies since some included studies reported on different aspects of the same training initiative. Five overarching reasons for conducting pulse oximetry training were identified: 1) anaesthesia and perioperative care, 2) respiratory support programme expansion, 3) perinatal assessment and monitoring, 4) assessment and monitoring of children and 5) assessment and monitoring of adults. Educational programmes varied in their purpose with respect to the types of patients being targeted, the health care workers being instructed, and the depth of pulse oximetry specific training. Conclusions Pulse oximetry training initiatives have been ongoing for decades for a variety of purposes, utilising a multitude of approaches to equip health care workers with tools to improve patient care. It is important that these initiatives continue as pulse oximetry availability and knowledge gaps remain. Neither pulse oximetry provision nor training alone is enough to bolster patient care, but sustainable solutions for both must be considered to meet the needs of both health care workers and patients.
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Affiliation(s)
| | - Shgufta Docter
- School of Medicine, University of Limerick, Limerick, Ireland
| | | | - Jude Alawa
- Stanford University School of Medicine, Stanford, California, USA
| | - Sedera Arimino
- CHRR (Regional Hospital Centre of Reference) Vakinankaratra, Madagascar
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA
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Rapolti D, Kisa P, Situma M, Nico E, Lobe T, Sims T, Ozgediz D, Klazura G. The Creation of a Pediatric Surgical Checklist for Adult Providers. RESEARCH SQUARE 2023:rs.3.rs-3269257. [PMID: 37790469 PMCID: PMC10543282 DOI: 10.21203/rs.3.rs-3269257/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Purpose To address the need for a pediatric surgical checklist for adult providers. Background Pediatric surgery is unique due to the specific needs and many tasks that are employed in the care of adults require accommodations for children. There are some resources for adult surgeons to perform safe pediatric surgery and to assist such surgeons in pediatric emergencies, we created a straightforward checklist based on current literature. We propose a surgical checklist as the value of surgical checklists has been validated through research in a variety of applications. Methods Literature review on PubMed to gather information on current resources for pediatric surgery, all papers on surgical checklists describing their outcomes as of October 2022 were included to prevent a biased overview of the existing literature. Interviews with multiple pediatric surgeons were conducted for the creation of a checklist that is relevant to the field and has limited bias. Results 42 papers with 8529061 total participants were included. The positive impact of checklists was highlighted throughout the literature in terms of outcomes, financial cost and team relationship. Certain care checkpoints emerged as vital checklist items: antibiotic administration, anesthetic considerations, intraoperative hemodynamics and postoperative resuscitation. The result was the creation of a checklist that is not substitutive for existing WHO surgery checklists but additive for adult surgeons who must operate on children in emergencies. Conclusion The outcomes measured throughout the literature are varied and thus provide both a nuanced view of a variety of factors that must be taken into account and are limited in the amount of evidence for each outcome. We hope to implement the checklist developed to create a standard of care for pediatric surgery performed in low resource settings by adult surgeons and further evaluate its impact on emergency pediatric surgery outcomes. Funding Fulbright Fogarty Fellowship, GHES NIH FIC D43 TW010540.
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Affiliation(s)
- Diana Rapolti
- University of Illinois Hospital and Health Sciences System
| | | | | | - Elsa Nico
- University of Illinois Hospital and Health Sciences System
| | - Thom Lobe
- University of Illinois Hospital and Health Sciences System
| | - Thomas Sims
- University of Illinois Hospital and Health Sciences System
| | | | - Greg Klazura
- University of Illinois Hospital and Health Sciences System
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Leversedge C, McCullough M, Appiani LMC, Đình MP, Kamal RN, Shapiro LM. Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist. World J Surg 2023; 47:50-60. [PMID: 36210361 PMCID: PMC9726663 DOI: 10.1007/s00268-022-06760-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent. METHODS We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain. RESULTS A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience. CONCLUSION As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.
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Affiliation(s)
- Chelsea Leversedge
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA USA
| | - Meghan McCullough
- Department of Plastic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA USA
| | - Luis Miguel Castro Appiani
- Department of Orthopaedic Surgery, Hospital Clinica Biblica, Aveinda 14 Calle 1 Y Central, San José, Costa Rica
| | - Mùng Phan Đình
- Orthropaedic Institute, 175 Military Hospital, Ho Chi Minh City, Vietnam
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street MC: 6342, Redwood City, CA USA
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, University of California, 1500 Owens St., San Francisco, CA USA
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White MC, Ahuja S, Peven K, McLean SR, Hadi D, Okonkwo I, Clancy O, Turner M, Henry JCA, Sevdalis N. Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness. BMJ Glob Health 2022; 7:bmjgh-2022-010649. [PMID: 36288819 PMCID: PMC9615995 DOI: 10.1136/bmjgh-2022-010649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory. METHODS Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported. RESULTS We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced. CONCLUSION Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.
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Affiliation(s)
- Michelle C White
- Department of Anaesthesia, Manchester Children’s Hospital, Manchester, UK
| | - Shalini Ahuja
- Methodologies Research Division, Faculty of Nursing Midwifery and Pallative Care, London, UK,Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, UK
| | - Kimberly Peven
- Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, UK
| | - Susanna Ritchie McLean
- Department of Anesthesia, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Dina Hadi
- Department of Anesthesia, Whittington Hospital, London, UK
| | - Ijeoma Okonkwo
- Department of Anaesthesia, Alder Hey Children’s Hospital, London, UK
| | - Olivia Clancy
- Department of Anaesthesia, Manchester Children’s Hospital, Manchester, UK
| | - Maryann Turner
- Department of Anaesthesia, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | | | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Girma T, Mude LG, Bekele A. Utilization and Completeness of Surgical Safety Checklist with Associated Factors in Surgical Units of Jimma University Medical Center, Ethiopia. Int J Gen Med 2022; 15:7781-7788. [PMID: 36258800 PMCID: PMC9572490 DOI: 10.2147/ijgm.s378260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Surgical safety checklist is used for every patient undergoing a surgical procedure and is now employed by a majority of surgical providers around the world, but the utilization and completion of surgical safety checklists were low in lower- and middle-income countries. Objective The objective of this study was to evaluate the utilization and completeness of the surgical safety checklist in surgical units of Jimma University Medical Center, Ethiopia. Methods Hospital-based prospective cross-sectional study was conducted from October 1 to 30, 2020. A total of 384 surgical cases were included in the study. Checklists were kept as part of each patient's medical record, and consecutive post-operative patient charts were included in the study. The data were collected using the modified version of the WHO checklist constituted of 27 items. The collected data were cleaned, coded, and entered into EpiData version 3.1 and exported to SPSS version 20 for analysis. Binary and multiple logistic regression analyses were computed, and the level of statistical significance was determined at p < 0.05. Results The use of a surgical safety checklist was 93.5%. The checklist was completed 17.3% of the time, with sign-in, time-out, and sign-out being completed 83%, 25%, and 35% of the time, respectively. Utilization of the surgical safety checklist was 87.4%, which is lower in elective surgeries (AOR = 0.126 95% CI (0.039-0.414)) compared with the emergency procedure. Once more, the completeness of the safety checklist was 63.3%, which is lower in elective surgery (AOR = 0.367 95% CI (0.208-0.65)) than in emergency procedures. Conclusion The use of a surgical safety checklist was promising, while the completeness of the checklist was poor that demands further improvement. Time-out was the least completed section of the checklist. Completion of the checklist was high in the first case on the positions of the theatre list.
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Affiliation(s)
- Tadesse Girma
- Department of Surgery, Faculty of Medicine, Institute of Health, Jimma University, Jimma, Ethiopia,Correspondence: Tadesse Girma, Department of Surgery, Faculty of Medicine, Institute of Health, Jimma University, Jimma, Ethiopia, Email
| | - Lidya Gemechu Mude
- Department of Surgery, Faculty of Medicine, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Azmeraw Bekele
- Department of Social and Administrative Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
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Brima N, Morhason-Bello IO, Charles V, Davies J, Leather AJ. Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions. BMJ Open 2022; 12:e062616. [PMID: 36220318 PMCID: PMC9557325 DOI: 10.1136/bmjopen-2022-062616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to evaluate the impact of the intervention and implementation learning. DESIGN We conducted a systematic literature review and narrative synthesis. SETTING Literature on hospital-based quality improvement studies in sub-Saharan Africa reviewed until 31 December 2021. PARTICIPANTS MEDLINE, EMBASE, Global Health, CINAHL, Web of Science databases and grey literature were searched. INTERVENTION We extracted data on intervention characteristics and how the intervention was delivered and evaluated. PRIMARY AND SECONDARY OUTCOME MEASURES Importantly, we assessed whether clinical, process and implementation outcomes were collected and separately categorised the outcomes under the Institute of Medicine quality domains. Risk of bias was not assessed. RESULTS Of 1573 articles identified, 49 were included from 17/48 sub-Saharan African countries, 16 of which were low-income or lower middle-income countries. Almost two-thirds of the studies took place in East Africa (31/49, 63.2%). The most common intervention focus was reduction of surgical site infection (12/49, 24.5%) and use of a surgical safety checklist (14/49, 28.6%). Use of implementation and quality improvement science methods were rare. Over half the studies measured clinical outcomes (29/49, 59.2%), with the most commonly reported ones being perioperative mortality (13/29, 44.8%) and surgical site infection rate (14/29, 48.3%). Process and implementation outcomes were reported in over two thirds of the studies (34/49, 69.4% and 35, 71.4%, respectively). The most studied quality domain was safety (44/49, 89.8%), with efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) the least studied domains. CONCLUSIONS There are few hospital-based studies that focus on improving the quality of surgical and anaesthesia care in sub-Saharan Africa. Use of implementation and quality improvement methodologies remain low, and some quality domains are neglected. PROSPERO REGISTRATION NUMBER CRD42019125570.
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Affiliation(s)
- Nataliya Brima
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King's College London, London, UK
| | - Imran O Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine/University College Hospital, University of Ibadan, University of Ibadan College of Medicine, Ibadan, Oyo, Nigeria
| | | | - Justine Davies
- University of Birmingham Institute of Applied Health Research, Birmingham, UK
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Munthali J, Pittalis C, Bijlmakers L, Kachimba J, Cheelo M, Brugha R, Gajewski J. Barriers and enablers to utilisation of the WHO surgical safety checklist at the university teaching hospital in Lusaka, Zambia: a qualitative study. BMC Health Serv Res 2022; 22:894. [PMID: 35810290 PMCID: PMC9271243 DOI: 10.1186/s12913-022-08257-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/16/2022] [Indexed: 12/04/2022] Open
Abstract
Background Surgical perioperative deaths and major complications are important contributors to preventable morbidity, globally and in sub-Saharan Africa. The surgical safety checklist (SSC) was developed by WHO to reduce surgical deaths and complications, by utilising a team approach and a series of steps to ensure the safe transit of a patient through the surgical operation. This study explored barriers and enablers to the utilisation of the Checklist at the University Teaching Hospital (UTH) in Lusaka, Zambia. Methods A qualitative case study was conducted involving members of surgical teams (doctors, anaesthesia providers, nurses and support staff) from the UTH surgical departments. Purposive sampling was used and 16 in-depth interviews were conducted between December 2018 and March 2019. Data were transcribed, organised and analysed using thematic analysis. Results Analysis revealed variability in implementation of the SSC by surgical teams, which stemmed from lack of senior surgeon ownership of the initiative, when the SSC was introduced at UTH 5 years earlier. Low utilisation was also linked to factors such as: negative attitudes towards it, the hierarchical structure of surgical teams, lack of support for the SSC among senior surgeons and poor teamwork. Further determinants included: lack of training opportunities, lack of leadership and erratic availability of resources. Interviewees proposed the following strategies for improving SSC utilisation: periodic training, refresher courses, monitoring of use, local adaptation, mobilising the support of senior surgeons and improvement in functionality of the surgical teams. Conclusion The SSC has the potential to benefit patients; however, its utilisation at the UTH has been patchy, at best. Its full benefits will only be achieved if senior surgeons are committed and managers allocate resources to its implementation. The study points more broadly to the factors that influence or obstruct the introduction and effective implementation of new quality of care initiatives. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08257-y.
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Affiliation(s)
- Judith Munthali
- University Teaching Hospital, Nationalist Rd, Lusaka, Zambia.
| | - Chiara Pittalis
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leon Bijlmakers
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - John Kachimba
- Department of Surgery, Surgical Society of Zambia, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Mweene Cheelo
- Department of Surgery, Surgical Society of Zambia, University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Ruairi Brugha
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Does timing and type of surgery influence the WHO surgical checklist compliance? Indian J Surg 2022. [DOI: 10.1007/s12262-022-03476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Cheng L, Cheng H, Parker G. Global Surgery and Mercy Ships. J Oral Biol Craniofac Res 2021; 12:121-153. [PMID: 34840943 DOI: 10.1016/j.jobcr.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
Two-thirds of the world population do not have access to safe, affordable and timely surgery. This global surgical crisis largely affects low and middle-income countries, and it will surpass the challenges created by communicable diseases. The barriers of access to surgery range from cost of surgery and patient transportation to availability and quality of surgical infrastructure and providers. Mercy Ships is a Non-Governmental Organisation (NGO) providing free world-class life-saving and life-transforming surgery to the poorest of the poor in West Africa. In order to address barriers to access surgical assessment and care, Mercy Ships switched from centralised patient selection mainly in port cities or capitals to decentralised selection strategy staffed by experienced nursing teams travelling to remote locations nearer to patients' homes. In this way, the under-served rural population is given equal opportunity to access Mercy Ships' free specialised surgical services. In each country served by the Mercy Ships, a 5 year country engagement program is created to focus on improving the quality of life for people living with disease, disfigurement and disability through free direct medical service to reduce the burden of unmet surgical needs. Moreover, our Medical Capacity Building teams concentrate in improving infrastructure and quality control, equipment donation and maintenance. Lastly, Mercy Ships partner with government and policy makers to improve and strengthen their local surgical care delivery system as an indispensable part of the healthcare system. In this vast sea of global surgical crisis, the vision of the Mercy Ships is to eradicate the 'disease of poverty' and effectively do itself out of a job. Mercy Ships' new and the world's largest (37,000 ton) purpose-built hospital ship, the Global Mercy, is joining our current ship, the Africa Mercy (16,500 ton) to save lives and to strengthen local surgical care service. This will more than double our capacity and impact in sub-Saharan Africa following COVID-19 pandemic. Moreover our state-of-art on-board simulation laboratories and traditional practical training of local healthcare providers will further enhance and build their medical capacity. The Global Mercy will become the largest floating and training platform to train next generation African medical and health care professionals so that they can save countless lives by training others in the future. We therefore invite you to partner with us in bringing hope and healing to the forgotten poor in West Africa.
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Affiliation(s)
- Leo Cheng
- Consultant Oral, Maxillofacial, Head and Neck Surgeon, St Bartholomew's, The Royal London and Homerton University Hospitals, London, UK.,Volunteer Maxillofacial, Thyroid and Reconstructive Surgeon, M/V The Africa Mercy, The Mercy Ships, West Africa
| | - Hilary Cheng
- Minister of the Forest Circuit, The Methodist Church, UK.,Volunteer Ward Chaplain, M/V The Africa Mercy, The Mercy Ships, West Africa
| | - Gary Parker
- Chief Medical Officer & Volunteer Maxillofacial, Head and Neck Surgeon, M/V The Africa Mercy, The Mercy Ships, West Africa
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GÜRKAN A, KIRTIL İ, DİKMEN Y. Surgical Teams’ Attitudes and Views Concerning the Surgical Safety ChecklistTR. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2021. [DOI: 10.33808/clinexphealthsci.937745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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11
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Trang K, Wick EC. Getting started and sustaining change. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis. Ann Surg 2021; 273:e196-e205. [PMID: 33064387 DOI: 10.1097/sla.0000000000003944] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact. BACKGROUND The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood. METHODS We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034). RESULTS We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52). CONCLUSIONS The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community.
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Jin J, Akau Ola S, Yip CH, Nthumba P, Ameh EA, de Jonge S, Mehes M, Waiqanabete HI, Henry J, Hill A. The Impact of Quality Improvement Interventions in Improving Surgical Infections and Mortality in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis. World J Surg 2021; 45:2993-3006. [PMID: 34218314 DOI: 10.1007/s00268-021-06208-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Morbidity and mortality in surgical systems in low- and middle-income countries (LMICs) remain high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to improve peri-operative outcomes. METHODS A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country surgical systems was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC, occurred in a surgical setting, and measured the effect of an implementation and its impact. The primary outcome was mortality, and secondary outcomes were rates of rates of hospital-acquired infection (HAI) and surgical site infections (SSI). Prospero Registration: CRD42020171542. RESULT Of 38,273 search results, 31 studies were included in a qualitative synthesis, and 28 articles were included in a meta-analysis. Implementation of multimodal bundled interventions reduced the incidence of HAI by a relative risk (RR) of 0.39 (95%CI 0.26 to 0.59), the effect of hand hygiene interventions on HAIs showed a non-significant effect of RR of 0.69 (0.46-1.05). The WHO Safe Surgery Checklist reduced mortality by RR 0.68 (0.49 to 0.95) and SSI by RR 0.50 (0.33 to 0.63) and antimicrobial stewardship interventions reduced SSI by RR 0.67 (0.48-0.93). CONCLUSION There is evidence that a number of quality improvement processes, interventions and structural changes can improve mortality, HAI and SSI outcomes in the peri-operative setting in LMICs.
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Affiliation(s)
- James Jin
- Department of Surgery, The University of Auckland, Auckland, 1010, New Zealand
| | - Salesi Akau Ola
- Surgery, Fiji National University, samabula fiji Lakeba Street Samabula, Suva, Fiji
| | - Cheng-Har Yip
- Surgery, University of Malaya, Subang Jaya Medical Centre, 50603, Kuala Lumpur, Malaysia
| | - Peter Nthumba
- AIC Kijabe Hospital Surgery, Kijabe Road Kijabe Lari Kiambu KE, Kijabe, Kenya
| | - Emmanuel A Ameh
- Division of Paediatric Surgery, Northcentral University, 8667 E Hartford Dr Ste 100, Scottsdale, AZ, 85255, USA
| | - Stijn de Jonge
- Department of Surgery, Amsterdam UMC Locatie AMC, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
| | | | | | - Jaymie Henry
- Department of Surgery, Florida Atlantic University, Boca Raton, USA.
| | - Andrew Hill
- Department of Surgery, University of Auckland, Auckland, 1010, New Zealand
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Bari S, Incorvia J, Iverson KR, Bekele A, Garringer K, Ahearn O, Drown L, Emiru AA, Burssa D, Workineh S, Sheferaw ED, Meara JG, Beyene A. Surgical data strengthening in Ethiopia: results of a Kirkpatrick framework evaluation of a data quality intervention. Glob Health Action 2021; 14:1855808. [PMID: 33357164 PMCID: PMC7782003 DOI: 10.1080/16549716.2020.1855808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background: One key challenge in improving surgical care in resource-limited settings is the lack of high-quality and informative data. In Ethiopia, the Safe Surgery 2020 (SS2020) project developed surgical key performance indicators (KPIs) to evaluate surgical care within the country. New data collection methods were developed and piloted in 10 SS2020 intervention hospitals in the Amhara and Tigray regions of Ethiopia. Objective: To assess the feasibility of collecting and reporting new surgical indicators and measure the impact of a surgical Data Quality Intervention (DQI) in rural Ethiopian hospitals. Methods: An 8-week DQI was implemented to roll-out new data collection tools in SS2020 hospitals. The Kirkpatrick Method, a widely used mixed-method evaluation framework for training programs, was used to assess the impact of the DQI. Feedback surveys and focus groups at various timepoints evaluated the impact of the intervention on surgical data quality, the feasibility of a new data collection system, and the potential for national scale-up. Results: Results of the evaluation are largely positive and promising. DQI participants reported knowledge gain, behavior change, and improved surgical data quality, as well as greater teamwork, communication, leadership, and accountability among surgical staff. Barriers remained in collection of high-quality data, such as lack of adequate human resources and electronic data reporting infrastructure. Conclusions: Study results are largely positive and make evident that surgical data capture is feasible in low-resource settings and warrants more investment in global surgery efforts. This type of training and mentorship model can be successful in changing individual behavior and institutional culture regarding surgical data collection and reporting. Use of the Kirkpatrick Framework for evaluation of a surgical DQI is an innovative contribution to literature and can be easily adapted and expanded for use within global surgery.
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Affiliation(s)
- Sehrish Bari
- Program in Global Surgery and Social Change, Harvard Medical School , Boston, MA, USA
| | - Joseph Incorvia
- Program in Global Surgery and Social Change, Harvard Medical School , Boston, MA, USA
| | - Katherine R Iverson
- Program in Global Surgery and Social Change, Harvard Medical School , Boston, MA, USA.,University of California, Davis Medical Center , Sacramento, CA, USA
| | - Abebe Bekele
- University of Global Health Equity, School of Medicine , Kigali, Rwanda
| | - Kaya Garringer
- Program in Global Surgery and Social Change, Harvard Medical School , Boston, MA, USA
| | - Olivia Ahearn
- Program in Global Surgery and Social Change, Harvard Medical School , Boston, MA, USA
| | - Laura Drown
- Program in Global Surgery and Social Change, Harvard Medical School , Boston, MA, USA
| | - Amanu Aragaw Emiru
- College of Medicine and Health Sciences, School of Public Health, Department of Reproductive Health and Population Studies, Bahir Dar University , Bahir Dar, Ethiopia
| | - Daniel Burssa
- Ethiopian Federal Ministry of Health, State Minister's Office , Addis Ababa, Ethiopia
| | | | | | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School , Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital , Boston, MA, USA
| | - Andualem Beyene
- Department of Surgery, Addis Ababa University School of Medicine , Addis Ababa, Ethiopia
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Clinical Outcome and Predictors of Intestinal Obstruction Surgery in Ethiopia: A Cross-Sectional Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7826519. [PMID: 33299875 PMCID: PMC7704150 DOI: 10.1155/2020/7826519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
Background Despite the advancement in the healthcare system, the impact of surgical interventions on public health systems will continue to grow. But predicting the outcome is challenging. Concerns related to unexpected outcomes and delays in the diagnosis of postoperative complications are the major issue. Intestinal obstruction is a common life-threatening surgical condition followed by fatal and nonfatal postoperative complications. This study was aimed at assessing results after surgery for intestinal obstruction in a hospital of Ethiopia. Methodology. An institutional-based cross-sectional study was conducted among 254 postoperative patients admitted with intestinal obstruction from January 1, 2014, to December 31, 2017. Data were coded and entered into EpiData 4.2.0.0 software and exported to the Statistical Package for the Social Sciences version 22 for analysis. A binary logistic regression model was used for analysis. All variables with a p value < 0.25 during bivariable analysis were considered for multivariable logistic regression analysis. Results The magnitude of poor surgical outcome of intestinal obstruction was 21.3% for patients enrolled into this investigation. The age group of ≥55 years (adjusted odds ratio (AOR) = 2.9, 95% CI: 1.03, 8.4), duration of illness of ≥24 hrs (AOR = 3.1, 95% CI: 1.03, 9.4), preoperative diagnosis of a gangrenous large bowel (AOR = 3.6, 95% CI: 1.3, 9.8), and a gangrenous small bowel (AOR = 4.2, 95% CI: 1.3, 13.7) were significantly associated with poor surgical outcome. Conclusions The magnitude of poor surgical outcome was high. Age, late presentation of illness, and gangrenous bowel obstructions were significantly associated with poor outcomes. So, concern should be given in early detection and follow-up of patients who came late and older patients.
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White MC, Daya L, Karel FKB, White G, Abid S, Fitzgerald A, Mballa GAE, Sevdalis N, Leather AJM. Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon. Anesth Analg 2020; 130:1425-1434. [PMID: 31856007 PMCID: PMC7147425 DOI: 10.1213/ane.0000000000004586] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Surgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings. This study uses an implementation framework, knowledge to action, to examine a model of nationwide World Health Organization (WHO) Surgical Safety Checklist implementation in Cameroon. Cameroon is a lower-middle-income country, and based on data from high- and low-income countries, we hypothesized that more than 50% of participants would be using the checklist (penetration) in the correct manner (fidelity) 4 months postintervention. METHODS A collaboration of 3 stakeholders (Ministry of Health, academic institution, and nongovernmental organization) used a prospective observational design. Based on knowledge to action, there were 3 phases to the study implementation: problem identification (lack of routine checklist use in Cameroonian hospitals), multifaceted implementation strategy (3-day multidisciplinary training course, coaching, facilitated leadership engagement, and support networks), and outcome evaluation 4 months postintervention. Validated implementation outcomes were assessed. Primary outcomes were checklist use (penetration) and fidelity; secondary outcomes were perioperative teams' reactions, learning and behavior change; and tertiary outcomes were perioperative teams' acceptability of the checklist. RESULTS Three hundred and fifty-one operating room staff members from 25 hospitals received training. Median time to evaluation was 4.5 months (interquartile range [IQR]: 4.5-5.5, range 3-7); checklist use (penetration) increased from 20% (95% confidence interval [CI], 16-25) to 56% (95% CI, 49-63); fidelity for adherence to 6 basic safety processes was high: verification of patient identification was 91% (95% CI, 87-95); risk assessment for difficult intubation was 79% (95% CI, 73-85): risk assessment for blood loss was 88% (95% CI, 83-93) use of pulse oximetry was 93% (95% CI, 90-97); antibiotic administration was 95% (95% CI, 91-98); surgical counting was 89% (95% CI, 84-93); and fidelity for nontechnical skills measured by the WHO Behaviorally Anchored Rating Scale was 4.5 of 7 (95% CI, 3.5-5.4). Median scores for all secondary outcomes were 10/10, and 7 acceptability measures were consistently more than 70%. CONCLUSIONS This study shows that a multifaceted implementation strategy is associated with successful checklist implementation in a lower-middle-income country such as Cameroon, and suggests that a theoretical framework can be used to practically drive nationwide scale-up of checklist use.
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Affiliation(s)
- Michelle C White
- From the Centre for Global Health and Health Partnerships, King's College London, London, United Kingdom.,Department of Anaesthesia, Great Ormond Street Hospital, London, United Kingdom.,Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Leonid Daya
- Department of Anaesthesia and Intensive Care, Faculty of Medicine and Biomedical Sciences of Yaounde, Yaounde, Cameroon
| | | | - Graham White
- Department of Anaesthesia, Royal Alexandra Hospital, Paisley, United Kingdom.,Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Sonia Abid
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin.,Imperial School of Anaesthesia, London, United Kingdom
| | - Aoife Fitzgerald
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin.,Department of Intensive Care, Oxford University Hospitals, Oxford, United Kingdom
| | - G Alain Etoundi Mballa
- Ministry of Public Health, Cameroon.,Faculty of Medicine and Biomedical Sciences of Yaounde, Yaounde, Cameroon
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, United Kingdom
| | - Andrew J M Leather
- From the Centre for Global Health and Health Partnerships, King's College London, London, United Kingdom
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17
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Brouillette MA, Aidoo AJ, Hondras MA, Boateng NA, Antwi-Kusi A, Addison W, Singh S, Laughlin PT, Johnson B, Pakala SR. Regional anesthesia training model for resource-limited settings: a prospective single-center observational study with pre-post evaluations. Reg Anesth Pain Med 2020; 45:528-535. [PMID: 32447288 DOI: 10.1136/rapm-2020-101550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Educational initiatives are a sustainable means to address provider shortages in resource-limited settings (RLS), yet few regional anesthesia curricula for RLS have been described. We sought to design a reproducible training model for RLS called Global Regional Anesthesia Curricular Engagement (GRACE), implement GRACE at an RLS hospital in Ghana, and measure training and practice-based outcomes associated with GRACE implementation. METHODS Fourteen of 15 physician anesthesiologists from the study location and three from an outside orthopedic specialty hospital consented to be trainees and trainers, respectively, for this prospective single-center observational study with pre-post evaluations. We conducted an initial needs assessment to determine current clinical practices, participants' learning preferences, and available resources. Needs assessment findings, expert panel recommendations, and investigator consensus were then used to generate a site-specific curriculum that was implemented during two 3-week periods. We evaluated trainee satisfaction and changes in knowledge, clinical skill, and peripheral nerve block (PNB) utilization using the Kirkpatrick method. RESULTS The curriculum consisted of didactic lectures, simulations, and clinical instruction to teach ultrasound-guided PNB for limb injuries. Pre-post evaluations showed trainees were satisfied with GRACE, median knowledge examination score improved from 62.5% (15/24) to 91.7% (22/24) (p<0.001), clinical examination pass rate increased from 28.6% (4/14) to 85.7% (12/14) (p<0.01), and total PNB performed in 3 months grew from 48 to 118. CONCLUSIONS GRACE applied in an RLS hospital led to the design, implementation, and measurement of a regional anesthesia curriculum tailored to institutional specifications that was associated with positive Kirkpatrick outcomes.
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Affiliation(s)
- Mark A Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Alfred J Aidoo
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Maria A Hondras
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nana A Boateng
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Akwasi Antwi-Kusi
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - William Addison
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Sanjeev Singh
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Patrick T Laughlin
- Department of Anesthesiology, US Anesthesia Partners, Denver, Colorado, USA
| | - Benjamin Johnson
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Swetha R Pakala
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
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Hellar A, Tibyehabwa L, Ernest E, Varallo J, Betram MM, Fitzgerald L, Giiti G, Kihundrwa A, Kapologwe N, Drake M, Zoungrana J, Troxel A, Lemwayi R, Alidina S, Maongezi S, Makuwani A, Varallo J. A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania. World J Surg 2019; 44:689-695. [DOI: 10.1007/s00268-019-05292-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Enhanced recovery program implementation: an evidence-based review of the art and the science. Surg Endosc 2019; 33:3833-3841. [PMID: 31451916 DOI: 10.1007/s00464-019-07065-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered "on pathway" are unlikely to be exposed to a majority of recommended ERP elements. METHODS To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. RESULTS The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the "soft" skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. CONCLUSIONS To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.
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White MC, Randall K, Capo-Chichi NFE, Sodogas F, Quenum S, Wright K, Close KL, Russ S, Sevdalis N, Leather AJM. Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist. Br J Surg 2019; 106:e91-e102. [PMID: 30620076 PMCID: PMC6519364 DOI: 10.1002/bjs.11034] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 01/19/2023]
Abstract
Background The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low‐income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally. Methods This study had a longitudinal embedded mixed‐methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty‐six hospitals received 3‐day multidisciplinary training and 4‐month follow‐up. Seventeen hospitals were sampled purposively for evaluation at 12–18 months. The primary outcome was sustainability of checklist use at 12–18 months measured by questionnaire. Secondary outcomes were CFIR‐derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups. Results At 12–18 months, 86·0 per cent of participants (86 of 100) reported checklist use compared with 31·1 per cent (169 of 543) before training and 88·8 per cent (158 of 178) at 4 months. There was high‐fidelity use (median WHOBARS score 5·0 of 7; use of basic safety processes ranged from 85·0 to 99·0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76·7, 81·1 and 82·2 per cent before, and at 4 and 12–18 months after training respectively; P < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6–9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully. Conclusion This study shows successfully sustained nationwide checklist implementation using a validated implementation framework. Implementation works
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Affiliation(s)
- M C White
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin.,Centre for Global Health and Health Partnerships, King's College London, London, UK.,Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - K Randall
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - N F E Capo-Chichi
- Department of Paediatric Surgery, Centre National Hospitalier Universitaire Hubert Koutoukou Manga, Cotonou, Benin
| | - F Sodogas
- Faculté des Sciences de la Santé de Cotonou, Université d'Abomey Calavi, Cotonou, Benin
| | - S Quenum
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - K Wright
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - K L Close
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - S Russ
- Centre for Implementation Science, King's College London, London, UK
| | - N Sevdalis
- Centre for Implementation Science, King's College London, London, UK
| | - A J M Leather
- Centre for Global Health and Health Partnerships, King's College London, London, UK
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21
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Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy. Br J Surg 2019; 106:e103-e112. [PMID: 30620059 PMCID: PMC6492154 DOI: 10.1002/bjs.11051] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/04/2018] [Accepted: 10/15/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. METHODS In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. RESULTS Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -9·4 (95 per cent c.i. -11·9 to -6·9) per cent; P < 0·001), but the relationship was reversed in low-HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. CONCLUSION Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.
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White MC, Randall K, Ravelojaona VA, Andriamanjato HH, Andean V, Callahan J, Shrime MG, Russ S, Leather AJM, Sevdalis N. Sustainability of using the WHO surgical safety checklist: a mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar. BMJ Glob Health 2018; 3:e001104. [PMID: 30622746 PMCID: PMC6307586 DOI: 10.1136/bmjgh-2018-001104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/24/2018] [Accepted: 10/28/2018] [Indexed: 01/05/2023] Open
Abstract
Background The WHO Surgical Safety Checklist reduces postoperative complications by up to 50% with the biggest gains in low-income and middle-income countries (LMICs). However in LMICs, checklist use is sporadic and widespread implementation has hitherto been unsuccessful. In 2015/2016, we partnered with the Madagascar Ministry of Health to undertake nationwide implementation of the checklist. We report a longitudinal evaluation of checklist use at 12-18 months postimplementation. Methods Hospitals were identified from the original cohort using purposive sampling. Using a concurrent triangulation mixed-methods design, the primary outcome was self-reported checklist use. Secondary outcomes included use of basic safety processes, assessment of team behaviour, predictors of checklist use, impact on individuals and organisational culture and identification of barriers. Data were collected during 1-day hospital visits using validated questionnaires, WHO Behaviourally Adjusted Rating Scale (WHOBARS) assessment tool and focus groups and analysed using descriptive statistics, multivariate linear regression and thematic analysis. Results 175 individuals from 14 hospitals participated. 74% reported sustained checklist use after 15 months. Mean WHOBARS scores were high, indicating good team engagement. Sustained checklist use was associated with an improved overall understanding of patient safety but not with WHOBARS, hospital size or surgical volume. 87% reported improved understanding of patient safety and 83% increased job satisfaction. Thematic analysis identified improvements in hospital culture (teamwork and communication, preparation and organisation, trust and confidence) and hospital practice (pulse oximetry, timing of antibiotic prophylaxis, introduction of a surgical count). Lack of time in an emergency and obstructive leadership were the greatest implementation barriers. Conclusion 74% of participants reported sustained checklist use 12-18 months following nationwide implementation in Madagascar, with associated improvements in job satisfaction, culture and compliance with safety procedures. Further work is required to examine this implementation model in other countries.
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Affiliation(s)
- Michelle C White
- Centre for Global Health and Health Partnerships, King’s College London, London, UK
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Kirsten Randall
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | | | - Hery H Andriamanjato
- Directeur du Partenariat, Ministère de la Santé Publique, Antananarivo, Madagascar
| | - Vanessa Andean
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - James Callahan
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Mark G Shrime
- Centre for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Stephanie Russ
- Centre for Implementation Science, King’s College London, London, UK
| | - Andrew J M Leather
- Centre for Global Health and Health Partnerships, King’s College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King’s College London, London, UK
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23
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Affiliation(s)
- Haile T Debas
- UCSF Institute for Global Health, University of California, San Francisco, San Francisco, California, USA
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