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Objective: High quality obstetric anaesthetic care is integral to reducing preventable maternal deaths in Low-and-Middle-Income-Countries (LMICs). We applied behavioural science to evaluate SAFE Obstetrics, a 3-day Continuing Professional Development (CPD) course, on physician and non-physician anaesthetists' practice behaviours across 3 LMICs.Methods: Seven anaesthetist Fellows from Bangladesh, Nepal and Tanzania were trained in qualitative methods and behavioural science. Structured interviews were undertaken by Fellows and two UK behavioural scientists with course participants. Interviews were based on the Theoretical Domains Framework: a comprehensive framework of influences on behaviour change. Interviews were recorded, transcribed and analysed using content and thematic analysis.Results: 78 physician and non-physician anaesthetists participated (n = 26 Bangladesh, n = 24 Nepal and n = 28 Tanzania). Participants reported positive improvements in patient-centered working, safety, teamwork and confidence. Across countries, we found similar barriers and facilitators: environmental resources, a strong professional identity and positive social influences were key facilitators of change.Conclusion: This multi-country theory-based evaluation highlighted the impact of SAFE Obstetrics on participants' clinical practice. A supportive work environment was crucial for implementing learning following training; CPD courses in LMICs must furnish participants with skills and equipment to address training implementation challenges. Building local behavioural science capacity can strengthen LMIC health intervention evaluations.
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SummaryReducing maternal mortality remains a global priority, particularly in low- and middle-income countries (LMICs). The Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia (OB) course is a three-day refresher course for trained anaesthesia providers addressing common causes of maternal mortality in LMICs. This aim of this study was to investigate the impact of SAFE training for a cohort of anaesthesia providers in Ethiopia.We conducted a mixed methods longitudinal cohort study incorporating a behavioural questionnaire, multiple-choice questionnaires (MCQs), structured observational skills tests and structured interviews for anaesthesia providers who attended one of four SAFE-OB courses conducted in two regions of Ethiopia from October 2017 to May 2018.Some 149 participants from 60 facilities attended training. Behavioural questionnaires were completed at baseline (n = 101, 69% response rate). Pre- and post-course MCQs (n = 121, n = 123 respectively) and pre- and post-course skills tests (n = 123, n = 105 respectively) were completed, with repeat MCQ and skills tests, and semi-structured interviews completed at follow-up (n = 88, n = 76, n = 49 respectively). The mean MCQ scores for all participants improved from 80.3% prior to training to 85.4% following training (P < 0.0001) and skills test scores improved from 56.5% to 83.2% (P < 0.0001). Improvements in MCQs and skills were maintained at follow-up 3-11 months post-training compared to baseline (P = 0.0006, < 0.0001 respectively). Participants reported improved confidence, teamwork and communication at follow-up.This study suggests that the SAFE-OB course can have a sustained impact on knowledge and skills and can improve the confidence of anaesthesia providers and communication within surgical teams.
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Anestesia Obstétrica , Anestesiología , Competencia Clínica , Estudios de Cohortes , Etiopía , Femenino , Humanos , Estudios Longitudinales , EmbarazoAsunto(s)
Servicio de Anestesia en Hospital/organización & administración , Infecciones por Coronavirus/transmisión , Infección Hospitalaria/prevención & control , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Servicio de Ginecología y Obstetricia en Hospital/organización & administración , Neumonía Viral/transmisión , Servicio de Cirugía en Hospital/organización & administración , África del Sur del Sahara/epidemiología , Betacoronavirus , COVID-19 , Infecciones por Coronavirus/terapia , Humanos , Cuerpo Médico de Hospitales , Pandemias , Equipo de Protección Personal/provisión & distribución , Neumonía Viral/terapia , SARS-CoV-2RESUMEN
OBJECTIVE: To assess the performance of reusable pulse oximeter probe and microprocessor box combinations, of varying price-points, in the context of a low-income pediatric setting. METHODS: A prospective, randomized cross-over study comparing time to biologically plausible oxygen saturation (SpO2 ) between: (1) Lifebox LB-01 probe with Masimo Rad-87 box (L + M) and (2) a weight-appropriate reusable Masimo probe with Masimo Rad-87 box (M + M). A post hoc secondary analysis comparison with historical usability testing data with the Lifebox LB-01 probe and Lifebox V1.5 box (L + L) was also conducted. Participants, children aged 0 to 35 months, were recruited from pediatric wards and outpatient clinics in the central region of Malawi. The primary outcome was time taken to achieve a biologically plausible SpO 2 measurement, compared using t tests for equivalence. RESULTS: We recruited 572 children. Plausible SpO2 measurements were obtained in less than 1 minute, 71%, 70%, and 63% for the M + M, L + M, and L + L combinations, respectively. A similar pattern was seen for less than 2 minutes, however, this effect disappeared at less than 5 minutes with 96%, 96%, and 95% plausible measurements. Using a ±10 second threshold for equivalence, we found L + M and M + M to be equivalent, but were under-powered to assess equivalence for L + L. CONCLUSIONS: The novel reusable pediatric Lifebox probe can achieve a quality SpO2 measurement within a pragmatic time range of weight-appropriate Masimo equivalent probes. Further research, which considers the cost of the devices, is needed to assess the added value of sophisticated motion tolerance software.
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Oximetría/instrumentación , Oxígeno/sangre , Preescolar , Estudios Cruzados , Humanos , Lactante , Recién NacidoRESUMEN
Hypoxemia measured by pulse oximetry predicts child pneumonia mortality in low-resource settings (LRS). Existing pediatric oximeter probes are prohibitively expensive and/or difficult to use, limiting LRS implementation. Using a human-centered design, we developed a low-cost, reusable pediatric oximeter probe for LRS health-care workers (HCWs). Here, we report probe usability testing. Fifty-one HCWs from Malawi, Bangladesh, and the United Kingdom participated, and seven experts provided reference measurements. Health-care workers and experts measured the peripheral arterial oxyhemoglobin saturation (SpO2) independently in < 5 year olds. Health-care worker measurements were classed as successful if recorded in 5 minutes (or shorter) and physiologically appropriate for the child, using expert measurements as the reference. All expert measurements were considered successful if obtained in < 5 minutes. We analyzed the proportion of successful SpO2 measurements obtained in < 1, < 2, and < 5 minutes and used multivariable logistic regression to predict < 1 minute successful measurements. We conducted four testing rounds with probe modifications between rounds, and obtained 1,307 SpO2 readings. Overall, 67% (876) of measurements were successful and achieved in < 1 minute, 81% (1,059) < 2 minutes, and 90% (1,181) < 5 minutes. Compared with neonates, increasing age (infant adjusted odds ratio [aOR]; 1.87, 95% confidence interval [CI]: 1.16, 3.02; toddler aOR: 4.33, 95% CI: 2.36, 7.97; child aOR; 3.90, 95% CI: 1.73, 8.81) and being asleep versus being calm (aOR; 3.53, 95% CI: 1.89, 6.58), were associated with < 1 minute successful measurements. In conclusion, we designed a novel, reusable pediatric oximetry probe that was effectively used by LRS HCWs on children. This probe may be suitable for LRS implementation.
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Hipoxia/diagnóstico , Ensayos de Aptitud de Laboratorios/estadística & datos numéricos , Oximetría/instrumentación , Oxígeno/sangre , Oxihemoglobinas/análisis , Neumonía/diagnóstico , Adulto , Bangladesh , Niño , Equipo Reutilizado , Personal de Salud , Humanos , Hipoxia/sangre , Hipoxia/economía , Lactante , Recién Nacido , Modelos Logísticos , Malaui , Oximetría/economía , Neumonía/sangre , Neumonía/economía , Reino UnidoRESUMEN
OBJECTIVE: To gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries. DESIGN: Focus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach. SETTING: Community, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care. PARTICIPANTS: Healthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors. RESULTS: We conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability. CONCLUSIONS: Pulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations. TRIAL REGISTRATION NUMBER: NCT02941237.
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Personal de Salud/educación , Oximetría/instrumentación , Oxígeno/sangre , Neumonía/sangre , Bangladesh , Países en Desarrollo , Grupos Focales , Humanos , Malaui , Neumonía/fisiopatología , Frecuencia Respiratoria , TermómetrosRESUMEN
The safety of anesthesia was dramatically improved by the introduction of pulse oximetry. This technology was rapidly adopted by anesthesiologists and made a standard of practice in many countries. In 2007, during development of the Surgical Safety Checklist, the World Health Organization recommended a pulse oximeter as a monitor for all patients undergoing anesthesia. However, clinicians in low- and middle-income countries lack access to basic anesthesia equipment, including pulse oximeters. The Lifebox Foundation was formed to determine how a suitable oximeter could be made available to anesthesia providers in these countries. Almost 11,000 oximeters have been delivered in 90 countries, with education courses completed in over 50 countries.
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Anestesiología/educación , Anestesiología/métodos , Salud Global/educación , Oximetría/métodos , Seguridad del Paciente , Anestesiología/economía , Salud Global/economía , Humanos , Oximetría/economía , Seguridad del Paciente/economía , Sociedades Médicas/economía , Organización Mundial de la Salud/economíaAsunto(s)
Anestesia/tendencias , Salud Global/tendencias , Accesibilidad a los Servicios de Salud/tendencias , Procedimientos Quirúrgicos Operativos/tendencias , Anestesia/economía , Sueños , Salud Global/economía , Accesibilidad a los Servicios de Salud/economía , Humanos , Procedimientos Quirúrgicos Operativos/economíaAsunto(s)
Anestesiología/organización & administración , Cirugía General/organización & administración , Publicaciones Periódicas como Asunto , Comunicación , Salud Global , Accesibilidad a los Servicios de Salud , Humanos , Agencias Internacionales , Cooperación Internacional , Objetivos Organizacionales , Pobreza , Sociedades MédicasRESUMEN
The physiology of the neonate is ideally suited to the transition to extrauterine life followed by a period of rapid growth and development. Intravenous fluids and electrolytes should be prescribed with care in the neonate. Sodium and water requirements in the first few days of life are low and should be increased after the postnatal diuresis. Expansion of the extracellular fluid volume prior to the postnatal diuresis is associated with poor outcomes, particularly in preterm infants. Newborn infants are prone to hypoglycemia and require a source of intravenous glucose if enteral feeds are withheld. Anemia is common, and untreated is associated with poor outcomes. Liberal versus restrictive transfusion practices are controversial, but liberal transfusion practices (accompanied by measures to minimize donor exposure) may be associated with improved long-term outcomes. Intravenous crystalloids are as effective as albumin to treat hypotension, and semi-synthetic colloids cannot be recommended at this time. Inotropes should be used to treat hypotension unresponsive to intravenous fluid, ideally guided by assessment of perfusion rather than blood pressure alone. Noninvasive methods of assessing cardiac output have been validated in neonates. More studies are required to guide fluid management in neonates, particularly in those with sepsis or undergoing surgery. A balanced salt solution such as Hartmann's or Plasmalyte should be used to replace losses during surgery (and blood or coagulation factors as indicated). Excessive fluid administration during surgery should be avoided.
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Líquidos Corporales/fisiología , Homeostasis/fisiología , Recién Nacido/fisiología , Adaptación Fisiológica/fisiología , Transfusión Sanguínea , Compartimentos de Líquidos Corporales/fisiología , Capilares/fisiología , Electrólitos/uso terapéutico , Endotelio Vascular/fisiología , Fluidoterapia , Glicocálix/fisiología , Humanos , Hipotensión/terapia , Cuidado Intensivo Neonatal , Necesidades Nutricionales , Pérdida Insensible de Agua/fisiología , Equilibrio Hidroelectrolítico/fisiologíaRESUMEN
BACKGROUND: No consensus exists on whether preoperative blood transfusions are beneficial in patients with sickle-cell disease. We assessed whether perioperative complication rates would be altered by preoperative transfusion. METHODS: We did a multicentre, randomised trial. Eligible patients were aged at least 1 year, had haemoglobin SS or Sß(0)thalassaemia sickle-cell-disease subtypes, and were scheduled for low-risk or medium-risk operations. Patients were randomly assigned no transfusion or transfusion no more than 10 days before surgery. The primary outcome was the proportion of clinically important complications between randomisation and 30 days after surgery. Analysis was by intention to treat. FINDINGS: 67 (96%) of 70 enrolled patients-33 no preoperative transfusion and 34 preoperative transfusion-were assessed. 65 (97%) of 67 patients had the haemoglobin SS subtype and 54 (81%) were scheduled to undergo medium-risk surgery. 13 (39%) of 33 patients in the no-preoperative-transfusion group had clinically important complications, compared with five (15%) in the preoperative-transfusion group (p=0.023). Of these, 10 (30%) and one (3%), respectively, had serious adverse events. The unadjusted odds ratio of clinically important complications was 3.8 (95% CI 1.2-12.2, p=0.027). 10 (91%) of 11 serious adverse events were acute chest syndrome (nine in the no-preoperative-transfusion group and one in the preoperative-transfusion group). Duration of hospital stay and readmission rates did not differ between study groups. INTERPRETATION: Preoperative transfusion was associated with decreased perioperative complications in patients with sickle-cell disease in this trial. This approach could, therefore, be beneficial for patients with the haemoglobin SS subtype who are scheduled to undergo low-risk and medium-risk surgeries. FUNDING: NHS Blood and Transplant.
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Síndrome Torácico Agudo/prevención & control , Anemia de Células Falciformes/terapia , Transfusión Sanguínea , Hemoglobina Falciforme/metabolismo , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Operativos , Síndrome Torácico Agudo/etiología , Adolescente , Adulto , Anemia de Células Falciformes/sangre , Anemia de Células Falciformes/complicaciones , Canadá , Niño , Preescolar , Europa (Continente) , Femenino , Humanos , Lactante , Masculino , Oportunidad Relativa , Periodo Perioperatorio , Procedimientos Quirúrgicos Operativos/efectos adversos , Resultado del Tratamiento , Talasemia beta/terapiaRESUMEN
Pediatric anesthesia is no longer a small subspecialty, but an important sector where developments in the new century have brought effective and safe management to children in the perioperative period. Unfortunately, what is common daily practice in the high-income countries with all the guidelines, checklists, instruments, and dedicated pediatric anesthesiologists is often only a dream in the low- and middle-income countries where the basic anesthesia services for improving the high rate of morbidity and mortality still are lacking. Anesthesia given by nonphysicians, with no monitoring, lack of elementary supplies, poor control of infections and hemorrhage, and no water or electricity are very often the 'usual' conditions. The World Health Organization is working hard to offer teams, basic equipments, and teaching and what is needed to offer children of these countries the same opportunities given in the industrialized countries. Other projects such as the Lifebox Project have a similar aim. This paper outlines some of what organizations are doing around the world, with different strategies all having the same target: safe pediatric anesthesia.
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Seguridad del Paciente/normas , Pediatría/normas , Atención Perioperativa/normas , Anestesia , Niño , Países Desarrollados , Países en Desarrollo , Cirugía General/normas , Humanos , Mejoramiento de la Calidad , Organización Mundial de la SaludRESUMEN
Checklists have established themselves as a key safety process in the operating room environment. This paper describes the background and context of how checklists have evolved in medicine. It also highlights ongoing challenges with particular attention to the importance of nontechnical skills or human factors training with relation to checklist design, testing and implementation and ongoing coaching.
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Lista de Verificación/métodos , Quirófanos/organización & administración , Anestesia , Lista de Verificación/normas , Cuidados Críticos , Humanos , Errores Médicos/prevención & control , Seguridad del Paciente , Control de Calidad , Administración de la SeguridadRESUMEN
OBJECTIVE: We introduced a fast-track program for our cardiac operations requiring adjustment in anaesthesia techniques to facilitate rapid extubation and discharge from the intensive care unit (ICU). Our objective was to investigate the quality of analgesia in fast-track paediatric cardiac patients. METHODS: We performed a retrospective review of the records of all patients who were fast-tracked in our institution between January 2006 and January 2007. Data collected included surgical procedure, anaesthesia technique, intra-operative opioids, ventilation time, intensive care stay, postoperative morphine consumption, pain scores, patient-controlled analgesia/nurse-controlled analgesia (PCA/NCA) duration, supplemental analgesia and incidence of vomiting. RESULTS: Fifty-four patients were studied, with a median age of 5.6 years (8 months-18 years), median weight 15.6 kg (range: 6.4-101 kg), median intensive care unit (ICU) ventilation time 1.1h (range: 0-8h) and median ICU stay of 4.1h (1-52 h). All patients received intra-operative fentanyl, median dose of 16.8 mcg kg⻹ (range: 15-20 mcg kg⻹). Twenty-three children received a bolus of morphine intra-operatively median dose of 102 mcg kg⻹ (range: 50-170 mcg kg⻹). Those patients who did not receive a morphine bolus intra-operatively, received a 100 mcg kg⻹ loading dose of morphine in the ICU. Twenty-four patients received intravenous paracetamol intra-operatively and five patients were given both paracetamol and diclofenac. Twenty-five children were not given either paracetamol or diclofenac intra-operatively. During the postoperative period, all patients received morphine by infusion administered via either PCA (18%) or NCA)(73%). The median PCA/NCA infusion time was 28.9h. Forty-eight patients received paracetamol and non-steroidal analgesics postoperatively, either diclofenac or ibuprofen. Five patients received only paracetamol and only one patient required no supplemental analgesia. The bedside nurse reported the pain scores on an hourly basis on a 10-point visual analogue score where 0=no pain and 10=strongest pain. Pain scores showed that most patients after day 0 (which was the day of surgery) had only mild pain. CONCLUSIONS: Our data showed that our program achieves high-quality analgesia in fast-track paediatric cardiac patients.
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Analgesia/normas , Procedimientos Quirúrgicos Cardíacos , Calidad de la Atención de Salud , Acetaminofén/administración & dosificación , Adolescente , Analgesia/efectos adversos , Analgesia/métodos , Analgesia Controlada por el Paciente/métodos , Analgésicos Opioides/administración & dosificación , Niño , Preescolar , Diclofenaco/administración & dosificación , Esquema de Medicación , Humanos , Lactante , Unidades de Cuidado Intensivo Pediátrico , Cuidados Intraoperatorios/métodos , Tiempo de Internación , Londres , Morfina/administración & dosificación , Manejo del Dolor/métodos , Manejo del Dolor/normas , Dimensión del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Cuidados Posoperatorios/métodos , Náusea y Vómito Posoperatorios/inducido químicamente , Evaluación de Programas y Proyectos de Salud , Estudios RetrospectivosRESUMEN
OBJECTIVE: to study paediatric surgery rates in south-western Uganda, compare them to rates in England, and determine if existing surgical facilities and workforce meet World Health Organization (WHO) standards. METHODS: to obtain information on surgical facilities and workforce, we conducted a cross-sectional survey of all hospitals performing major surgery in 14 districts of south-western Uganda in 2007-2008. Using theatre logbook data, we determined the surgical rates, types of surgery performed and in-theatre surgical outcomes. FINDINGS: of 72 hospitals surveyed, 29 were performing major surgery. None met WHO standards for essential surgery. There were 0.7 accredited surgeons per 100.000 population and no paediatric surgeons. Most anaesthetists were not physicians (accredited anaesthetist per 100.000 population: 1.1). The annual surgical rate for children aged ≤ 14 years was 180 operations per 100.000 population; most were emergency procedures. The annual surgical rate for patients of all ages was 652 operations per 100.000 population, with a median of 422 per operating theatre (range: 60-3497) and of 226 per surgeon (range: 60-1748). Mission or nongovernmental organization (NGO) hospitals, which had 44% of the hospital beds in the region, performed 3039 (55%) of the paediatric operations. Externally funded surgeons performed 80% of the 140 cleft lip and palate operations. Four in-theatre deaths occurred in children ≤ 14 years old (in-theatre mortality: 7.7 deaths per 10.000 operations). CONCLUSION: access to all surgery, including paediatric surgery, is poor in south-western Uganda and investment in basic health-care facilities and surgical workforce and training is urgently needed. Mission and NGO hospitals make a valuable contribution to elective surgery, and externally funded surgeons make an important contribution to specialist surgery. In-theatre mortality was lower than reported for similar settings.
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Anestesia/normas , Servicio de Cirugía en Hospital/normas , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Adolescente , Niño , Estudios Transversales , Inglaterra , Fuerza Laboral en Salud/normas , Humanos , Quirófanos/normas , Uganda , Organización Mundial de la SaludRESUMEN
OBJECTIVE: Fast-track patient pathways for cardiac surgery are used in adult practice and by necessity is a mainstay in the developing world. We aimed to introduce a fast-track protocol for uncomplicated paediatric open-heart surgery cases and to subsequently review the results of this change in practice. METHODS: A fast-track protocol co-ordinated by the Advanced Nurse Practitioners was introduced in January 2006 for children aged over 6 months undergoing uncomplicated open-heart procedures. We conducted a review of prospectively collected data on all included patients. The setting was a tertiary paediatric cardiac surgical centre in the UK. The outcome measures for audit were: patient fitness to leave the intensive care unit (ICU) on the day of surgery and hospital length of stay. RESULTS: Included children had a mean age 6 (standard deviation (SD) 4.9) years and mean weight 22.7 (SD 17.6) kg. Of the 194 patients included, 153 (79%) were fit to leave the ICU on the day of surgery. Patients undergoing surgery for ventricular septal defect: odds ratio (OR) 2.8 (95% CI: 1.2-5.6) P=0.01 and left ventricular outflow tract obstruction: OR 5.5 (95% CI: 1.4-21.2) P=0.01, were more likely to be unfit than atrial septal defect and right ventricular outflow tract obstruction. Patients undergoing surgery in the afternoon were more likely to be unfit than those undergoing surgery in the morning: OR 2.3 (95% CI: 1.2-4.8) P=0.03. No relationship was found between age or weight and fitness to fast track. Median length of hospital stay for the whole cohort was 3 (range: 2-11) days. After adjustment for case mix, there was significant evidence that length of hospital stay reduced as experience with the protocol increased over the series of patients RC -0.02 (95% CI: -0.01 to -0.03) P<0.01. CONCLUSION: A fast-track programme can be implemented safely and effectively if the appropriate support including a step-down ward area is put in place. Greater experience with this type of protocol leads to reductions in the length of hospital stay for children aged over 6 months undergoing uncomplicated open-heart surgery. Fast-track cases should be performed in the morning.