Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone.

BACKGROUND: Surgical task-sharing may be central to expanding the provision of surgical care in low-resource settings. The aims of this paper were to describe the set-up of a new surgical task-sharing training programme for associate clinicians and junior doctors in Sierra Leone, assess its productivity and safety, and estimate its future role in contributing to surgical volume. METHODS: This prospective observational study from a consortium of 16 hospitals evaluated crude in-hospital mortality over 5 years and productivity of operations performed during and after completion of a 3-year surgical training programme. RESULTS: Some 48 trainees and nine graduated surgical assistant community health officers (SACHOs) participated in 27 216 supervised operations between January 2011 and July 2016. During training, trainees attended a median of 822 operations. SACHOs performed a median of 173 operations annually. Caesarean section, hernia repair and laparotomy were the most common procedures during and after training. Crude in-hospital mortality rates after caesarean sections and laparotomies were 0·7 per cent (13 of 1915) and 4·3 per cent (7 of 164) respectively for operations performed by trainees, and 0·4 per cent (5 of 1169) and 8·0 per cent (11 of 137) for those carried out by SACHOs. Adjusted for patient sex, surgical procedure, urgency and hospital, mortality was lower for operations performed by trainees (OR 0·47, 95 per cent c.i. 0·32 to 0·71; P < 0·001) and SACHOs (OR 0·16, 0·07 to 0·41; P < 0·001) compared with those conducted by trainers and supervisors. CONCLUSION: SACHOs rapidly and safely achieved substantial increases in surgical volume in Sierra Leone.

Learning Curve Characteristics for Caesarean Section Among Associate Clinicians: A Prospective Study from Sierra Leone.

BACKGROUND: In response to the high maternal mortality ratio, Sierra Leone has adopted an associate clinician postgraduate surgical task-sharing training programme. Little is known about learning curve characteristics for caesarean sections among associate clinicians. The aim of this study is to evaluate the number of caesarean sections needed to be performed by associate clinicians until there is no further significant reduction in operation time. METHODS: This prospective study evaluates the first 50 caesarean sections performed by trainees between January 2011 and June 2016. Primary outcome was total operating time in minutes (incision to suturing time). Secondary outcomes were length of hospital stay, surgical site infections, estimated operative bloodloss and in-hospital postoperative mortality. RESULTS: A total of 1174 caesarean sections performed by 24 trainees were analysed. Total operation time significantly reduced during the first 15 operations from mean (SD) operation time 72 (27)-51 (18) min after 15 procedures (p < 0.001). Estimated bloodloss did not significantly vary among the first 50 caesarean sections. Surgical site infections were reported in 3.7% of the operations, which was higher during the first 15 operations (6.8%) compared to the following 35 operations (2.3%). Length of stay reduced from median (range) 9 (2-39)-6 (2-127) days after 15 operations, but there was no reduction in maternal mortality. CONCLUSION: While gaining experience, the operation time of associate clinicians significantly reduced during the first 15 caesarean sections. Estimated bloodloss is not related to trainees experience.