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Fitzgerald TN, Zambeli-Ljepović A, Olatunji BT, Saleh A, Ameh EA. Gaps and priorities in innovation for children's surgery. Semin Pediatr Surg 2023; 32:151352. [PMID: 37976896 DOI: 10.1016/j.sempedsurg.2023.151352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.
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Affiliation(s)
- Tamara N Fitzgerald
- Department of Surgery, Duke University, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA
| | - Alan Zambeli-Ljepović
- Philip R. Lee Institute for Health Policy Studies, University of California San Fransisco, USA
| | | | | | - Emmanuel A Ameh
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria.
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Graham HR, Bakare AA, Ayede AI, Eleyinmi J, Olatunde O, Bakare OR, Edunwale B, Neal EFG, Qazi S, McPake B, Peel D, Gray AZ, Duke T, Falade AG. Cost-effectiveness and sustainability of improved hospital oxygen systems in Nigeria. BMJ Glob Health 2022; 7:bmjgh-2022-009278. [PMID: 35948344 PMCID: PMC9379491 DOI: 10.1136/bmjgh-2022-009278] [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: 04/06/2022] [Accepted: 06/19/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Improving hospital oxygen systems can improve quality of care and reduce mortality for children, but we lack data on cost-effectiveness or sustainability. This study evaluated medium-term sustainability and cost-effectiveness of the Nigeria Oxygen Implementation programme. Methods Prospective follow-up of a stepped-wedge trial involving 12 secondary-level hospitals. Cross-sectional facility assessment, clinical audit (January–March 2021), summary admission data (January 2018–December 2020), programme cost data. Intervention: pulse oximetry introduction followed by solar-powered oxygen system installation with clinical and technical training and support. Primary outcomes: (i) proportion of children screened with pulse oximetry; (ii) proportion of hypoxaemic (SpO2 <90%) children who received oxygen. Comparison across three time periods: preintervention (2014–2015), intervention (2016–2017) and follow-up (2018–2020) using mixed-effects logistic regression. Calculated cost-effectiveness of the intervention on child pneumonia mortality using programme costs, recorded deaths and estimated counterfactual deaths using effectiveness estimates from our effectiveness study. Reported cost-effectiveness over the original 2-year intervention period (2016–2017) and extrapolated over 5 years (2016–2020). Results Pulse oximetry coverage for neonates and children remained high during follow-up (83% and 81%) compared with full oxygen system period (94% and 92%) and preintervention (3.9% and 2.9%). Oxygen coverage for hypoxaemic neonates/children was similarly high (94%/88%) compared with full oxygen system period (90%/82%). Functional oxygen sources were present in 11/12 (92%) paediatric areas and all (8/8) neonatal areas; three-quarters (15/20) of wards had a functional oximeter. Of 32 concentrators deployed, 23/32 (72%) passed technical testing and usage was high (median 10 797 hours). Estimated 5-year cost-effectiveness US$86 per patient treated, $2694–4382 per life saved and $82–125 per disability-adjusted life year-averted. We identified practical issues for hospitals and Ministries of Health wishing to adapt and scale up pulse oximetry and oxygen. Conclusion Hospital-level improvements to oxygen and pulse oximetry systems in Nigerian hospitals have been sustained over the medium-term and are a highly cost-effective child pneumonia intervention.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia .,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Nigeria.,Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Adejumoke Idowu Ayede
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria.,Department of Paediatrics, School of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Joseph Eleyinmi
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Oyaniyi Olatunde
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Oluwabunmi R Bakare
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Blessing Edunwale
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Eleanor F G Neal
- Infection and Immunity, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Shamim Qazi
- Independent Consultant Paediatrician, Geneva, Switzerland
| | - Barbara McPake
- Nossal Institute for Global Health, Melbourne, Victoria, Australia
| | | | - Amy Z Gray
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria.,Department of Paediatrics, School of Medicine, University of Ibadan, Ibadan, Nigeria
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3
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Affiliation(s)
- Angela Enright
- From the Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia.,Department of Anesthesiology, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Alan F Merry
- Department of Anaesthesiology, University of Auckland New Zealand, Auckland City Hospital, Auckland, New Zealand
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Holmaas G, Abate A, Woldetsadik A, Hevrøy O. Establishing a sustainable training programme in anaesthesia in Ethiopia. Acta Anaesthesiol Scand 2022; 66:1016-1023. [PMID: 35749233 PMCID: PMC9541354 DOI: 10.1111/aas.14106] [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: 05/13/2022] [Revised: 06/09/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
Background Lack of qualified staff is a major hindrance for quality and safety improvements in anaesthesia and critical care in many low‐income countries. Support in specialist training may enhance perioperative treatment and have a positive downstream impact on other hospital services, which may improve the overall standard of care. Methods Between 2011 and 2019, consultant anaesthetists from Haukeland University Hospital in Norway supported a postgraduate anaesthesia‐training programme at Addis Ababa University/Tikur Anbessa Specialised Hospital in Ethiopia. The aim of the programme was to build a self‐sustainable work force of anaesthetists across the country who could perform high quality anaesthesia within the confinement of limited local resources. Over the course of 10 years, an almost continuous rotation of experienced anaesthetists and intensivists assisted training of Ethiopian residents in anaesthesia and critical care. Local specialists organised the programme; however, external support was necessary during this period to establish a sustainable training programme. Results Since the programme's commencement at Addis Ababa University in 2011, 159 residents have entered the programme and 71 have graduated. As the number of qualified anaesthetists increased, Ethiopian specialists gradually obtained responsibility for the programme. Candidates are recruited from various regions and from neighbouring countries. Five other Ethiopian training sites have been established. To date (May 2022), 112 residents have completed their training in Ethiopia, and 195 residents expect to graduate within 3 years. Conclusion Nearly 11 years after establishment of the programme, locally trained highly qualified anaesthetists work in Ethiopia's major hospitals throughout the country.
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Affiliation(s)
- Gunhild Holmaas
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
| | - Ananya Abate
- Department of Anesthesiology, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | | | - Olav Hevrøy
- Department of Surgical Services, Haukeland University Hospital, Bergen, Norway
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Odinkemelu DS, Sonah AK, Nsereko ET, Dahn BT, Martin MH, Moon TD, Niconchuk JA, Walters CB, Kynes JM. An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola. Anesth Analg 2021; 132:1727-1737. [PMID: 33844659 DOI: 10.1213/ane.0000000000005456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). METHODS Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible. RESULTS Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided. CONCLUSIONS Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.
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Affiliation(s)
- Didi S Odinkemelu
- From the Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Aaron K Sonah
- Phebe Nurse Anesthesia Program, Phebe Paramedical Training Program and School of Nursing, Suakoko, Liberia
| | - Etienne T Nsereko
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Bernice T Dahn
- College of Health Sciences, University of Liberia, Monrovia, Liberia
| | - Marie H Martin
- Vanderbilt Institute of Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Troy D Moon
- Vanderbilt Institute of Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jonathan A Niconchuk
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Camila B Walters
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Matthew Kynes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Walker PJB, Bakare AA, Ayede AI, Oluwafemi RO, Olubosede OA, Olafimihan IV, Tan K, Duke T, Falade AG, Graham H. Using intermittent pulse oximetry to guide neonatal oxygen therapy in a low-resource context. Arch Dis Child Fetal Neonatal Ed 2020; 105:316-321. [PMID: 31462405 PMCID: PMC7363784 DOI: 10.1136/archdischild-2019-317630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/31/2019] [Accepted: 08/08/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of intermittent pulse oximetry in guiding oxygen therapy in neonates in a low-resource setting. DESIGN AND SETTING Prospective validation study at three hospitals in southwest Nigeria. We performed concealed continuous pulse oximetry on participants to evaluate intermittent SpO2 monitoring. PATIENTS We recruited all preterm or low birthweight neonates, and all term neonates who required oxygen therapy, who were admitted to the neonatal ward(s) of the study hospitals during the study period. MAIN OUTCOME MEASURES Proportion of time preterm/low birthweight neonates on oxygen spent within, above and below the target SpO2 range of 90%-95%; and the proportion of time term neonates and neonates not on oxygen spent within and below the target range of 90%-100%. RESULTS Preterm/low birthweight neonates receiving oxygen therapy (group A) spent 15.7% (95% CI 13.3 to 18.9) of time in the target SpO2 range of 90%-95%. They spent 75.0% (63.6-81.1) of time above 95%, and 2.7% (1.7-5.6) of time below 85%. Term neonates and all neonates not receiving oxygen (group B) spent 97.3% (95% CI 96.4 to 98.6) of time within the target range of 90%-100%, and 0.9% (0.3-1.4) of time below 85%. Guidelines recommended SpO2 monitoring 3 times per day for all patients, however neonates in groups A and B were monitored an average of 4.7 and 5.3 times per day, respectively. CONCLUSIONS To better maintain SpO2 within the target range, preterm/low birthweight neonates on oxygen should have their SpO2 monitored more frequently than the current 4.7 times per day. In all other neonates, however, monitoring SpO2 5.3 times per day appears suitable.
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Affiliation(s)
- Patrick James Berkeley Walker
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia .,Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Ayobami Adebayo Bakare
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria,University College Hospital Ibadan, Ibadan, Nigeria
| | | | | | | | | | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Trevor Duke
- Intensive Care Unit and University of Melbourne Department of Paediatrics, Royal Children's Hospital, Parkville, Victoria, Australia,Department of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Adegoke Gbadegesin Falade
- College of Medicine, University of Ibadan, Ibadan, Nigeria,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Hamish Graham
- Centre for International Child Health, University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia
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Graham H, Bakare AA, Ayede AI, Oyewole OB, Gray A, Peel D, McPake B, Neal E, Qazi SA, Izadnegahdar R, Duke T, Falade AG. Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals. EClinicalMedicine 2019; 16:51-63. [PMID: 31832620 PMCID: PMC6890969 DOI: 10.1016/j.eclinm.2019.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria. METHODS We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not). FINDINGS Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming ∼3500 L of oxygen per admission. INTERPRETATION Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children.
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Affiliation(s)
- Hamish Graham
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Corresponding author at: Centre for International Child Health, Department of Paediatrics, Level 2 East, 50 Flemington Road, Parkville, VIC 3052, Australia.
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | | | - Barbara McPake
- Nossal Institute of Global Health, University of Melbourne, Parkville, Australia
| | - Eleanor Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Pneumococcal Research, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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Chellam S, Ganbold L, Gadgil A, Orgoi S, Lonnee H, Roy N, Gelb AW. Contributions of academic institutions in high income countries to anesthesia and surgical care in low- and middle-income countries: are they providing what is really needed? Can J Anaesth 2018; 66:255-262. [PMID: 30460603 DOI: 10.1007/s12630-018-1258-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
| | - Lundeg Ganbold
- Department of Critical Care and Anesthesia, Mongolian, National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Anita Gadgil
- Department of Surgery and WHO Collaborating Centre for Research on Surgical Care Delivery in LMICS, BARC Hospital, Mumbai, India
| | - Sergelen Orgoi
- Department of Surgery, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Herman Lonnee
- Department of Anesthesia, St. Olavs' Hospital, Trondheim, Norway
| | - Nobhojit Roy
- General Surgeon and Health Systems Consultant, Mumbai, India
| | - Adrian W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
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Graham HR, Bakare AA, Gray A, Ayede AI, Qazi S, McPake B, Izadnegahdar R, Duke T, Falade AG. Adoption of paediatric and neonatal pulse oximetry by 12 hospitals in Nigeria: a mixed-methods realist evaluation. BMJ Glob Health 2018; 3:e000812. [PMID: 29989086 PMCID: PMC6035503 DOI: 10.1136/bmjgh-2018-000812] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction Pulse oximetry is a life-saving tool for identifying children with hypoxaemia and guiding oxygen therapy. This study aimed to evaluate the adoption of oximetry practices in 12 Nigerian hospitals and identify strategies to improve adoption. Methods We conducted a mixed-methods realist evaluation to understand how oximetry was adopted in 12 Nigerian hospitals and why it varied in different contexts. We collected quantitative data on oximetry use (from case notes) and user knowledge (pretraining/post-training tests). We collected qualitative data via focus groups with project nurses (n=12) and interviews with hospital staff (n=11). We used the quantitative data to describe the uptake of oximetry practices. We used mixed methods to explain how hospitals adopted oximetry and why it varied between contexts. Results Between January 2014 and April 2017, 38 525 children (38% aged ≤28 days) were admitted to participating hospitals (23 401 pretraining; 15 124 post-training). Prior to our intervention, 3.3% of children and 2.5% of neonates had oximetry documented on admission. In the 18 months of intervention period, all hospitals improved oximetry practices, typically achieving oximetry coverage on >50% of admitted children after 2-3 months and >90% after 6-12 months. However, oximetry adoption varied in different contexts. We identified key mechanisms that influenced oximetry adoption in particular contexts. Conclusion Pulse oximetry is a simple, life-saving clinical practice, but introducing it into routine clinical practice is challenging. By exploring how oximetry was adopted in different contexts, we identified strategies to enhance institutional adoption of oximetry, which will be relevant for scale-up of oximetry in hospitals globally. Trial registration number ACTRN12617000341325.
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Affiliation(s)
- Hamish R Graham
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adejumoke Idowu Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Shamim Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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11
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Abstract
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.
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13
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White MC, Baxter LS, Close KL, Ravelojaona VA, Rakotoarison HN, Bruno E, Herbert A, Andean V, Callahan J, Andriamanjato HH, Shrime MG. Evaluation of a countrywide implementation of the world health organisation surgical safety checklist in Madagascar. PLoS One 2018; 13:e0191849. [PMID: 29401465 PMCID: PMC5798831 DOI: 10.1371/journal.pone.0191849] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/08/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The 2009 World Health Organisation (WHO) surgical safety checklist significantly reduces surgical mortality and morbidity (up to 47%). Yet in 2016, only 25% of East African anesthetists regularly use the checklist. Nationwide implementation of the checklist is reported in high-income countries, but in low- and middle-income countries (LMICs) reports of successful implementations are sparse, limited to single institutions and require intensive support. Since checklist use leads to the biggest improvements in outcomes in LMICs, methods of wide-scale implementation are needed. We hypothesized that, using a three-day course, successful wide-scale implementation of the checklist could be achieved, as measured by at least 50% compliance with six basic safety processes at three to four months. We also aimed to determine predictors for checklist utilization. MATERIALS AND METHODS Using a blended educational implementation strategy based on prior pilot studies we designed a three-day dynamic educational course to facilitate widespread implementation of the WHO checklist. The course utilized lectures, film, small group breakouts, participant feedback and simulation to teach the knowledge, skills and behavior changes needed to implement the checklist. In collaboration with the Ministry of Health and local hospital leadership, the course was delivered to 427 multi-disciplinary staff at 21 hospitals located in 19 of 22 regions of Madagascar between September 2015 and March 2016. We evaluated implementation at three to four months using questionnaires (with a 5-point Likert scale) and focus groups. Multivariate linear regression was used to test predictors of checklist utilization. RESULTS At three to four months, 65% of respondents reported always using the checklist, with another 13% using it in part. Participant's years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with counting instruments (p< 0.05), but not with verifying: patient identity, difficult intubation risk, risk of blood loss, prophylactic antibiotic administration, or counting needles and sponges. CONCLUSION Use of a multi-disciplinary three-day course for checklist implementation resulted in 78% of participants using the checklist, at three months; and an increase in counting surgical instruments. Successful checklist implementation was not predicted by participant length of medical service, hospital size or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.
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Affiliation(s)
- Michelle C. White
- Department of Medical Capacity Building, Mercy Ships, Port of Toamasina, Madagascar
- Department of Medical Capacity Building, Mercy Ships, Africa Bureau, Cotonou, Benin
- * E-mail:
| | - Linden S. Baxter
- Department of Medical Capacity Building, Mercy Ships, Port of Toamasina, Madagascar
| | - Kristin L. Close
- Department of Medical Capacity Building, Mercy Ships, Port of Toamasina, Madagascar
- Department of Medical Capacity Building, Mercy Ships, Africa Bureau, Cotonou, Benin
| | | | | | - Emily Bruno
- Department of Medical Capacity Building, Mercy Ships, Port of Toamasina, Madagascar
- University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States of America
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston MA, United States of America
| | - Alison Herbert
- Department of Medical Capacity Building, Mercy Ships, Port of Toamasina, Madagascar
| | - Vanessa Andean
- Department of Medical Capacity Building, Mercy Ships, Port of Toamasina, Madagascar
- The Austin Hospital, Melbourne, Australia
| | - James Callahan
- Department of Medical Capacity Building, Mercy Ships, Port of Toamasina, Madagascar
| | | | - Mark G. Shrime
- Department of Medical Capacity Building, Mercy Ships, Africa Bureau, Cotonou, Benin
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston MA, United States of America
- Department of Otolaryngology, Harvard Medical School, Boston, MA, United States of America
- Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, United States of America
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14
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15
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Albert V, Mndolo S, Harrison EM, O'Sullivan E, Wilson IH, Walker IA. Lifebox pulse oximeter implementation in Malawi: evaluation of educational outcomes and impact on oxygen desaturation episodes during anaesthesia. Anaesthesia 2017; 72:686-693. [DOI: 10.1111/anae.13838] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - S. Mndolo
- Department of Anaesthesia; Queen Elizabeth Central Hospital; Blantyre Malawi
| | - E. M. Harrison
- University of Edinburgh; Royal Infirmary of Edinburgh; UK
| | - E. O'Sullivan
- Department of Anaesthesia; St James’ Hospital; Dublin Ireland
| | | | - I. A. Walker
- Department of Anaesthesia; Great Ormond Street Hospital NHS Foundation Trust; UCL Great Ormond Street Institute of Child Health; London UK
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16
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International Anesthesia Workforce Development. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0196-7] [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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17
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Affiliation(s)
- Elizabeth T Drum
- From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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18
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Affiliation(s)
- Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Dr.E.Borges Marg, Parel, Mumbai, Maharashtra, India E-mail:
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