Curriculum Development for the South African Essential Steps in Managing Obstetric Emergencies (ESMOE) Anesthesiology Training Module: A Delphi Study.

BACKGROUND: The United Nations Sustainable Development Goal 3 (SDG3) for 2030 aims at <70 maternal deaths per 100,000 live births. South Africa (SA) falls short of this goal and most deaths occur in district and regional hospitals. Due to low anesthesiologist (specialist anesthetist) numbers in the public sector, the anesthetic workforce in these hospitals consists mainly of nonspecialist (general practitioner) junior doctors with limited supervision. The Essential Steps in Managing Obstetric Emergencies (ESMOE) training program for interns was introduced in 2008 to reduce maternal deaths in SA. Training is not consistently offered at all intern-training institutions and it has not been recently revised. This study sought expert suggestions to guide a revision of the regulation, pedagogy, and content of the ESMOE anesthetic module. METHODS: A 3-round consensus-seeking modified Delphi technique was used whereby experts rated current and suggested learning outcomes as well as pedagogical- and regulatory aspects of the ESMOE anesthetic module in an anonymous, online, Likert-scale questionnaire. Consensus was defined as ≥70% agreement. Open-ended questions sought motivations for decisions and further suggestions for program improvement. RESULTS: Between March 4, 2021 and August 18, 2021, a total of 17/24 (71%), 16/17 (94%), and 15/16 (94%) consenting experts completed the first, second, and third rounds, respectively. During the 3 rounds, the panel achieved consensus on all but 2 questionnaire items. The panel agreed that ESMOE anesthesia training should be mandatory and that it should be offered through a blended learning model. They further concurred that the current learning outcomes should be retained, and suggested additional outcomes based on the most common causes of maternal mortality in SA. CONCLUSIONS: Attendance of the ESMOE anesthesia module should be mandatory. Its pedagogy should be updated to a blended learning style to benefit the current digital native intern generation. The content should be updated to address the main causes of maternal mortality in SA in line with SDG3. A national obstetric anesthesia guideline should be considered, and lea-dership and collaboration are required to improve the alignment of undergraduate, internship, and junior doctor anesthesia training in SA. The content, process, and stakeholder engagement suggestions in this study can assist short-course-based anesthesia workforce training in similar global contexts.

Undergraduate Anesthesia Skills for a Global Surgery Agenda: Students' Self-Reported Competence.

BACKGROUND: Safe anesthesia is imperative for the Global Surgery agenda and Sustainable Development Goal 3. Due to a shortage of specialists in South Africa (SA), anesthetic services are often provided by nonspecialist doctors, often newly qualified and frequently without immediate supervision. The burden of disease in the developing world demands fit-for-purpose, day-one medical graduates. Although undergraduate anesthesia training is mandatory for medical students in SA, no outcomes are specified, and these are decided autonomously at each medical school. This study describes the current self-perceived anesthetic competence of medical students in SA as a needs assessment directed at achieving the goals of Global Surgery in SA and other developing countries. METHODS: In this cross-sectional observational study, 1689 students (89% participation rate), representing all medical schools in SA, rated their self-perceived competence at graduation in 54 anesthetic-related Likert scale items in 5 themes: patient evaluation, patient preparation for anesthesia, practical skills performance, administration of anesthesia, and the management of intraoperative complications. Medical schools were divided into clusters A (≥25 days of anesthetic training) and B (<25 days). Descriptive statistics, Fisher exact test, and a mixed-effects regression model were used in the statistical analysis. RESULTS: Students felt more prepared for history-taking and patient examination than for managing emergencies and complications. The self-perceived competence of students at cluster A schools was higher across all 54 items and all 5 themes. The same was observed for general medical skills and skills relating to maternal mortality in SA. CONCLUSIONS: Time-on-task, capacity for repetition, and student maturity might have impacted self-efficacy and should be considered in curriculum development. Students felt less prepared for emergencies. Focused training and assessment aimed at emergency management should be considered. Students did not feel competent in general medical areas, in which anesthetists are experts, including resuscitation, fluid management, and analgesia. Anesthetists should take ownership of this training at the undergraduate level. Cesarean delivery is the most performed surgical procedure in sub-Saharan Africa. The Essential Steps in Managing Obstetric Emergencies (ESMOE) program was designed for internship training but can be introduced at undergraduate level. This study suggests that curriculum reform is required. The achievement of an agreed-upon set of standardized national undergraduate anesthetic competencies may ensure fit-for-purpose practitioners. Undergraduate and internship training should align to form part of a continuum of basic anesthetics training in SA. The findings of this study might benefit curriculum development in other regions with similar contexts.

A Cognitive Load Theory Perspective of the Undergraduate Anesthesia Curricula in South Africa.

BACKGROUND: Safe anesthesia is indispensable to achieve global safe surgery and equitable health care access. The disease burden and lack of specialists in South Africa (SA) require junior, nonspecialist doctors to be fit-for-purpose from day 1 when they provide anesthetic services in peripheral hospitals with limited supervision. Graduating students report low self-perceived preparedness for administering anesthesia, but it is not known how their curricular experiences influence their learning. Cognitive load theory defines intrinsic, extraneous, and germane cognitive loads (subtypes). Intrinsic load relates to learning tasks, extraneous load to distractions, and germane load to students' learning processes. This study used a cognitive load theory lens to explore SA students' experiences of their undergraduate anesthesia training. METHODS: In a constructivist cross-sectional descriptive study, we explored the qualitative factors that influenced students' curricular experience of undergraduate anesthesia training in SA. Two investigators analyzed the data independently in an initial coding round. An emerging theme of lack of time to achieve the expected outcomes, prompted the use of cognitive load theory as a conceptual framework for further analysis by the 3 authors. The subsequent analysis informed the development and refinement of a final cognitive load theory framework for anesthesia training, the COLOAD (COgnitive LOad in Anesthesia eDucation) framework. RESULTS: Data were collected between November 2017 and February 2019. The 1336 respondents (79% participation) reported a variety of determinants of learning pertaining to all 3 cognitive load subtypes. Participants were novices in an inherently complex environment and experienced a high cognitive load during anesthesia training. The number-, complexity-, and interactivity of tasks influenced intrinsic load, while extraneous load was affected by ineffective instructional methods, external- and internal distractors. Program design, metacognition, and learner motivation impacted germane load. CONCLUSIONS: Cognitive load theory provided a useful theoretical basis for understanding students' curricular experiences. The COLOAD framework suggests a microlevel interrelatedness of the constituting elements of the 3 cognitive load subtypes. This has implications for curriculum design, pedagogy, and student support. Learning outcomes development and curriculum mapping are important to ensure a lean curriculum, but measures to enhance germane cognitive load might be equally important to achieve competence. Attention to the hidden curriculum and active promotion of reflective practice might reduce cognitive load in complex learning environments such as anesthesia training.

Development of a Clinical Prediction Model for In-hospital Mortality from the South African Cohort of the African Surgical Outcomes Study.

BACKGROUND: Data on the factors that influence mortality after surgery in South Africa are scarce, and neither these data nor data on risk-adjusted in-hospital mortality after surgery are routinely collected. Predictors related to the context or setting of surgical care delivery may also provide insight into variation in practice. Variation must be addressed when planning for improvement of risk-adjusted outcomes. Our objective was to identify the factors predicting in-hospital mortality after surgery in South Africa from available data. METHODS: A multivariable logistic regression model was developed to identify predictors of 30-day in-hospital mortality in surgical patients in South Africa. Data from the South African contribution to the African Surgical Outcomes Study were used and included 3800 cases from 51 hospitals. A forward stepwise regression technique was then employed to select for possible predictors prior to model specification. Model performance was evaluated by assessing calibration and discrimination. The South African Surgical Outcomes Study cohort was used to validate the model. RESULTS: Variables found to predict 30-day in-hospital mortality were age, American Society of Anesthesiologists Physical Status category, urgent or emergent surgery, major surgery, and gastrointestinal-, head and neck-, thoracic- and neurosurgery. The area under the receiver operating curve or c-statistic was 0.859 (95% confidence interval: 0.827-0.892) for the full model. Calibration, as assessed using a calibration plot, was acceptable. Performance was similar in the validation cohort as compared to the derivation cohort. CONCLUSION: The prediction model did not include factors that can explain how the context of care influences post-operative mortality in South Africa. It does, however, provide a basis for reporting risk-adjusted perioperative mortality rate in the future, and identifies the types of surgery to be prioritised in quality improvement projects at a local or national level.

Adapted full-face snorkel masks as an alternative for COVID-19 personal protection during aerosol generating procedures in South Africa: A multi-centre, non-blinded in-situ simulation study.

INTRODUCTION: SARS-CoV-2 has resulted in increased worldwide demand for personal protective equipment (PPE). With pressure from ongoing epidemic and endemic episodes, we assessed an adapted snorkel mask that provides full-face protection for healthcare workers (HCWs), particularly during aerosol-generating procedures. These masks have a custom-made adaptor which allows the fitment of standard medical respiratory filters. The aim of this study was to evaluate the fit, seal and clinical usability of these masks. METHODS: This multicentre, non-blinded in-situ simulation study recruited fifty-two HCWs to don and doff the adapted snorkel mask. Negative pressure seal checks and a qualitative fit test were performed. The HCWs completed intubation and extubation of a manikin in a university skills training laboratory, followed by a web-based questionnaire on the clinical usability of the masks. RESULTS: Whilst fit and usability data were generally satisfactory, two of the 52 participants (3.8%) felt that the mask did not span the correct distance from the nose to the chin, and 3 of 34 participants (8.8%) who underwent qualitative testing with a Bitrex test failed. The majority of users reported no fogging, humidity or irritation. It was reportedly easy to speak while wearing the mask, although some participants perceived that they were not always understood. Twenty-one participants (40%) experienced a subjective physiological effect from wearing the mask; most commonly a sensation of shortness of breath. DISCUSSION: A fit-tested modified full-face snorkel mask may offer benefit as a substitute for N95 respirators and face shields. It is, however, important to properly select the correct mask based on size, fit testing, quality of the three-dimensional (3D) printed parts and respiratory filter to be used. Additionally, HCWs should be trained in the use of the mask, and each mask should be used by a single HCW and not shared.