United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance

BACKGROUND

Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients.

METHODS

As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.

RESULTS

The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

CONCLUSIONS

Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.

Building workforce capacity for the surgical management of cervical cancer in a fragile, low-income African nation-Democratic Republic of the Congo

Objectives

Surgery is a cornerstone of the management of cervical cancer. Women diagnosed with cervical cancer in sub-Saharan Africa have very little access to specialised (gynaecologic oncology) surgical services. We describe our experiences and challenges of training local general gynaecologists to surgically treat early stage invasive cervical cancer at a private sector healthcare facility in a fragile, low-income African nation.

Methods

Implementation of the training curriculum began with assigned self-directed learning. It continued with on-site training which consisted of preoperative surgical video reviews, pre- and intra-operative assessment of disease status, deconstruction of the designated surgical procedure into its critical subcomponents and trainees orally communicating the steps of the surgical procedure with the master trainers. High-volume repetition of a single surgical procedure over a short time interval, intra-operative bedside mentoring, post-operative case review and mental narration were critical to the process of surgical skills transfer.

Results

Nineteen radical abdominal hysterectomies were successfully performed over four training visits; trainees were able to perform the procedure alone after eight cases; surgical complications decreased over time. The trainees have continued to perform the surgical procedures independently.

Conclusion

Life-saving surgical capacity for the treatment of cervical cancer has been established and sustained at a private sector healthcare facility in a fragile, low-income African setting, through an innovative model of surgical training.

The evolution of a novel approach to building surgical capacity for cervical cancer in Africa

The human, financial, and infrastructural resources required to effectively treat invasive cancer of the cervix are grossly inadequate in the African region, inclusive of a paucity of surgeons capable of performing life-saving radical pelvic surgery for early-stage disease, and the requisite medical ecosystem (blood banking, anesthesia, laboratory, imaging, diagnostics, etc.) Death without treatment, therefore, is a common sequela of cervical cancer in Africa. As African American gynaecologic oncology sub-specialists working in Africa and its Diaspora, we set out to find a way to alter these circumstances. Herein, we provide an overview of our efforts and how they evolved into a novel method of training that rapidly builds surgical capacity for the treatment of early-stage cervical cancer in resource-constrained environments.

Long-Term Impact of a Mission-Based Surgical Training Rotation on Plastic Surgery Capacity Building in Rwanda

OBJECTIVE

Short-term, high-volume surgical training experiences can lead to successful skills transfer and be an effective method of training surgical providers in low-resource settings. However, immediate skills acquisition does not guarantee long-term performance of surgical procedures by trainees. This study aims to determine the long-term impact of a short-term plastic surgery training rotation (STR) on general surgeon contribution to plastic surgery capacity building in Rwanda.

DESIGN

A retrospective survey study was conducted. Surveys were distributed to credentialed general surgeons who previously participated in the Operation Smile STR in Rwanda. Questions focused on exposure to procedures during the rotation and current practice demographics. The percentage of current practice volumes dedicated to plastic surgery was mapped to demonstrate participant contribution to plastic surgery capacity in the country.

SETTING

Surveys were distributed remotely. Surgeon respondents previously participated in the STR at the Rwinkwavu District Hospital, a primary level hospital in eastern Rwanda.

PARTICIPANTS

All 8 prior participants of the STR who completed residency and are currently practicing as general surgeons in Rwanda were included.

RESULTS

Six out of 8 prior participants completed the survey (75.0%). All respondents work as general surgeons in governmental hospitals around the country. Up to 75% of surgeon caseloads are dedicated to plastic surgery procedures. Half of respondents work in regions without a credentialed plastic surgeon. Exposure to cleft and congenital hand surgery during the rotation did not lead to durable performance in practice. All participants felt the rotation improved their performance in multiple core competencies.

CONCLUSION

Participation in a short-term plastic surgery training experience in Rwanda was associated with increased long-term surgical capacity in the country through a task-sharing model. A mission-based rotation may provide sufficient exposure for basic plastic surgery procedures, but does not provide enough volume or time to durably teach more complicated surgeries such as cleft repair. Further studies are needed to determine how longer durations of training exposure impacts long-term performance of plastic surgery procedures.

Building safe surgery knowledge and capacity in Cambodia: a mixed-methods evaluation of an innovative training and mentorship intervention

BACKGROUND

Working in partnership with the Cambodian Ministry of Health, the Safe Surgery 2020 initiative (SS2020) supports the prioritization of surgery and mobilization of resources to target limited workforce capacity. An evaluation study was conducted to assess the impact of SS2020 on intervention hospitals in Cambodia.

OBJECTIVE

To understand the impact of the SS2020 program on intervention hospitals in Cambodia by assessing the changes in key surgical performance indicators before and after the intervention, identifying key barriers and facilitators to adoption of learnings, and discovering lessons on the uptake and diffusion of this initiative in Cambodia and other similar contexts.

METHODS

This study is a convergent mixed-methods evaluation of a one-year multicomponent SS2020 intervention. Surgical observations were conducted in 8 intervention hospitals at baseline and endline to evaluate pre and post adherence to 20 safety, teamwork, and communication items. Fifteen focus groups were conducted in all intervention sites at endline to assess key facilitators and barriers to positive impact.

RESULTS

There was significant improvement in 19 of 20 indicators assessed during surgical observations. Among the highest performing indicators were safety items; among the lowest were communication items. Participants self-reported improved knowledge and positive behavior change after the intervention. Institutional change and direct patient impact were not widely reported. Most participants had favorable views of the mentorship model and were eager for the program to continue implementation.

CONCLUSIONS

The results provide evidence that change in surgical ecosystems can be achieved on a short timeline with limited resources. The hub-and-spoke mentorship model can be successful in improving knowledge and changing behavior in surgical safety. Workforce development is important to improving surgical systems, but greater financial and human resources are needed. Ministry support in adopting, leading, and scaling is crucial to the continued success of safe surgery interventions in Cambodia.