Pediatric anesthesia outreach in low and middle-income countries: Models, motives, and moral misalignments.

BACKGROUND: A lack of anesthesia and surgical capacity leaves approximately 1.7 billion children per annum without access to surgical and anesthetic care. REVIEW: Over the past 50 years, the predominant strategy to address this lack of access has been to provide surgical capacity primarily from high-income countries (HICs) to low and middle-income countries (LMICs) in the form of short-term surgical missions. More recently, the international medical community has recognized the need to build sustainable surgical capacity in resource-constrained settings. This article reviews three models of surgical aid: the vertical model (short-term surgical missions); the horizontal model (system-wide capacity building); and the diagonal model, which is a hybrid of the first two. At their core, medical aid interventions exist on a spectrum ranging from providing surgical capacity to building surgical capacity. DISCUSSION: The skills, attitudes, and behaviors that drive success in providing medical capacity are fundamentally different from those that drive success in building medical capacity. The root cause of this difference is a shift in the moral duty of the visiting physician from a duty solely to the patient in front of them (based on the primacy of the doctor-patient relationship) to include a duty to the local physicians and the local medical system, and by extension to the next 10 000 patients in need of care. CONCLUSION: Failure to address the conflicts engendered by this fundamental moral shift risks undermining capacity-building efforts in all models of medical aid.

Transfusion Camp Rwanda 2023: A train-the-trainer workshop establishing locally driven leadership in knowledge translation and sustainability in transfusion medicine education.

BACKGROUND AND OBJECTIVES: Blood transfusion is performed daily in hospitals. Gaps exist between transfusion guidelines and day-to-day clinical care. These gaps are prevalent in resource-limited settings due to scarce continuing medical education. Transfusion Camp Rwanda aims to bridge this gap by (1) delivering context-appropriate up-to-date education, (2) teaching participants how to independently deliver a case-based curriculum and (3) identifying strategies to promote change in transfusion practice in Rwanda. MATERIALS AND METHODS: In May 2023, a multidisciplinary team from Canada and Rwanda carried out a Transfusion Camp train-the-trainer workshop for clinicians from all five provinces in Rwanda. Participants attended in-person lectures, seminars and workshop group discussions on the implementation of the Rwanda National Directives on Rational Use of Blood and Blood Components. Course feedback was based on the Kirkpatrick Model of Training and Evaluation. RESULTS: Fifty-one physicians and laboratory technicians participated in the course. Confidence in caring for patients based on transfusion guidelines was self-rated as 'excellent' by 23% of participants before and 77% after, while 84% reported they planned to teach Transfusion Camp to others and 100% responded that they will apply course content to clinical practice. Workshop groups recommended strategies to improve transfusion medicine practice in Rwanda in four domains: Communication, Institutional Approval, Practice Audits and Education. CONCLUSION: Transfusion medicine education in Rwanda using a train-the-trainer approach was well-received by participants and allowed for a more detailed understanding of the local medical and educational environment. These observations can inform the further expansion of the Transfusion Camp Rwanda project.

Perioperative Anesthesia-Related Complications and Risk Factors in Children: A Cross-Sectional Observation Study in Rwanda.

BACKGROUND: Despite an increasing awareness of the unmet burden of surgical conditions, information on perioperative complications in children remains limited especially in low-income countries such as Rwanda. The objective of this study was to estimate the prevalence of perioperative anesthesia-related adverse events and to explore potential risk factors associated with them among pediatric surgical patients in public referral hospitals in Rwanda. METHODS: Data were collected for all patients under 5 years of age undergoing surgery in 3 public referral hospitals in Rwanda from June to December 2015. Patient and family history, type of surgery, comorbidities, anesthesia technique, intraoperative adverse events and postoperative events in the postanesthesia care unit (PACU) were recorded. The incidence of perioperative adverse events was assessed and associated risk factors analyzed with univariate logistic regression. RESULTS: Of 354 patients enrolled in this study 11 children had a cardiac arrest. Six (1.7%) suffered an intraoperative cardiac arrest, 2 of whom (0.6%) died intraoperatively. In the PACU, 6 (1.8%) suffered a postoperative cardiac arrest, 5 of whom (1.5%) died in the PACU. One child had both an intraoperative cardiac arrest and then a cardiac arrest in PACU but survived. Eighty-nine children (25.1%) had an intraoperative adverse event, whereas 67 (20.6%) had an adverse event in PACU. A review of the cases where cardiac arrest or death occurred indicated that there were significant lapses in the expected standard of care. Age <1 week was associated with cardiac arrest or death. CONCLUSIONS: The rate of perioperative complications, including death, for children undergoing surgery in tertiary care hospitals in Rwanda was high. Quality improvement measures are needed to decrease this rate among surgical pediatric patients in this low resource setting.

Transfusion Camp Rwanda: A prospective feasibility study evaluating the delivery of Transfusion Camp to a multidisciplinary group of postgraduate medical trainees in Rwanda.

BACKGROUND: Safe blood transfusion is an increasing priority in global health equity. The Global Health 2030 commission lists access to a safe blood supply as essential for all surgical and nonoperative patients. The objective of this study was to determine if Transfusion Camp, when modified through a collaborative partnership between experts in Canada and Rwanda, results in improved knowledge and confidence among trainees in a resource-limited setting in sub-Saharan Africa. METHODS: This prospective study took place at The University Teaching Hospital of Kigali in Rwanda. Participants were postgraduate medical trainees from departments where blood transfusion is frequent. Participants watched five prerecorded lectures and then attended a 5-hour team-based learning seminar to consolidate learning. Pre- and post-data were analyzed on transfusion knowledge and trainee confidence. A Rasch analysis investigated the performance of individual questions in assessing respondent knowledge. RESULTS: Of 31 trainees from surgery, anesthesia, internal medicine, and pediatrics invited to the course, 27 trainees attended the in-person team-based learning and 24 trainees completed the pre- and post-course analysis. Trainee knowledge assessment improved from (mean ± SD) 7.7/20 ± 1.95 to 10.4/20 ± 2.4 (p < .0001) and this knowledge was maintained by 12 trainees on a 3-month follow-up with a mean score of 9.3/20 ± 2.3. Trainees reported increased confidence in managing transfusion medicine-related patient issues. CONCLUSION: This pilot study demonstrated that Transfusion Camp education content modified to the local context can result in increased knowledge and confidence in managing transfusion-related issues. These results will inform future planning of Transfusion Camp in resource-limited settings.

Transfusion medicine education delivery in Rwanda: Adapting Transfusion Camp to a resource-limited setting.

BACKGROUND: Due to few teaching faculty, resource-limited settings may lack the education curricula providers need for safe practice. As safe surgery becomes an increasing priority worldwide, it is essential to improve access to critical education content including in transfusion medicine. Transfusion Camp is a longitudinal curriculum, shown to increase knowledge in postgraduate trainees. The objective was to develop a sustainable bilateral partnership between Rwanda and Canada, and to integrate Transfusion Camp into the existing curriculum of the School of Medicine and Pharmacy at University of Rwanda. METHODS: A Transfusion Camp pilot course was initiated through collaboration of experts in Rwanda and Canada. Planning occurred over 6 months via online and in-person meetings. Canadian teaching faculty adapted course content via iterative discussion with Rwandan faculty. Final content was delivered through online pre-recorded lectures by Canadian Faculty, and in-person small-group seminars by Rwandan Faculty. Project feasibility was assessed through structured evaluation and informal debriefing. RESULTS: Twenty-seven postgraduate trainees were present for the pilot course, of whom 21 (78%) submitted evaluation forms. While the structure and content of the adapted Transfusion Camp curriculum were well-received, the majority of respondents indicated a preference for in-person rather than pre-recorded lectures. Debriefing determined that future courses should focus on continuing education initiatives aimed at physicians entering or already in independent practice. CONCLUSION: A partnership between universities and blood operators in high-resource and resource-limited countries results in a transfusion medicine curriculum that is locally applicable, multidisciplinary, and supportive of learning benefitting the learners and educators alike.

An audit of the carbon footprint of travel for the Canadian Anesthesiologists' Society International Education Foundation partnerships.

PURPOSE: International partnerships have an important role in capacity building in global health, but frequently involve travel and its associated carbon footprint. The environmental impact of global health partnerships has not previously been quantified. METHODS: We conducted a retrospective internal audit of the environmental impact of air travel for the international education programs of the Canadian Anesthesiology Society's International Education Fund (CASIEF). We compiled a comprehensive list of volunteer travel routes and used the International Civil Aviation Organization Carbon Emissions Calculator, which considers travel distance, passenger numbers, and average operational data for optimized estimates. Comparisons were made with average Canadian household emissions and disability adjusted life years (DALYs) lost from climate change consequences. RESULTS: The total carbon dioxide emitted (CO2-e) for the Rwanda, Ethiopia, and Guyana CASIEF partnerships were 268.2, 60.7, and 52.0 tons, respectively. The DALYs cost of these programs combined is estimated to be as high as 1.1 years of life lost due to the effects of CO2-e. The mean daily carbon cost of the average Rwanda partnership was equivalent to daily emissions of 2.2 Canadians (or 383 Rwandans), for the Guyana partnership was equivalent to 1.6 Canadians (or 7.6 Guyanese people), and for the Ethiopia partnership was equivalent to 2.4 Canadians (or 252 Ethiopian people). CONCLUSIONS: Air travel from these CASIEF partnerships resulted in 380.9 tons CO2-e but also enabled 5,601 volunteer days-in-country since 2014. The estimated environmental cost needs to be balanced against the impact of the programs. Regardless, carbon-reduction remains a priority, whether by discouraging premium class travel, organizing longer trips to reduce daily emissions, prioritizing remote support and virtual education, or developing partnerships closer to home.

RéSUMé: OBJECTIF: Les partenariats internationaux jouent un rôle important dans le renforcement des capacités en santé mondiale, mais impliquent souvent des voyages et une empreinte carbone qui y est associée. L'impact environnemental des partenariats pour la santé mondiale n'a pas encore été quantifié. MéTHODE: Nous avons réalisé un audit interne rétrospectif de l'impact environnemental du transport aérien pour les programmes de formation internationale du Fonds d'éducation internationale de la Société canadienne des anesthésiologistes (FÉI SCA). Nous avons compilé une liste complète des itinéraires de voyage des bénévoles et utilisé le Calculateur d'émissions de carbone de l'Organisation de l'aviation civile internationale, qui prend en compte la distance parcourue, le nombre de passagers et les données opérationnelles moyennes pour des estimations optimisées. Des comparaisons ont été faites avec les émissions moyennes des ménages canadiens et les années de vie corrigées de l'incapacité (AVCI) perdues en raison des conséquences des changements climatiques. RéSULTATS: Le dioxyde de carbone total émis (CO2-e) dans le cadre des partenariats de la FÉI SCA avec le Rwanda, l'Éthiopie et le Guyana, étaient de 268,2, 60,7 et 52,0 tonnes, respectivement. Le coût combiné des AVCI de ces programmes est estimé à 1,1 année de vie perdue en raison des effets du CO2-e. Le coût quotidien moyen du carbone du partenariat moyen avec le Rwanda équivalait aux émissions quotidiennes de 2,2 Canadiens (ou 383 Rwandais); pour le partenariat avec le Guyana, cela équivalait à 1,6 Canadien (ou 7,6 Guyanais) et pour le partenariat avec l'Éthiopie, à 2,4 Canadiens (ou 252 Éthiopiens). CONCLUSION: Les voyages aériens des partenariats de la FÉI SCA ont entraîné la production de 380,9 tonnes de CO2-e mais ils ont également permis 5601 journées de bénévolat dans les pays partenaires depuis 2014. Le coût environnemental estimé doit être mis en perspective avec l'impact des programmes. Quoi qu'il en soit, la réduction des émissions de carbone reste une priorité, que ce soit en décourageant les voyages en première classe, en organisant des voyages plus longs pour réduire les émissions quotidiennes, en donnant la priorité à l'assistance à distance et à l'éducation virtuelle, ou en développant des partenariats plus près de chez soi.

Global critical care: a call to action.

Critical care is underprioritized. A global call to action is needed to increase equitable access to care and the quality of care provided to critically ill patients. Current challenges to effective critical care in resource-constrained settings are many. Estimates of the burden of critical illness are extrapolated from common etiologies, but the true burden remains ill-defined. Measuring the burden of critical illness is epidemiologically challenging but is thought to be increasing. Resources, infrastructure, and training are inadequate. Millions die unnecessarily due to critical illness. Solutions start with the implementation of first-step, patient care fundamentals known as Essential Emergency and Critical Care. Such essential care stands to decrease critical-illness mortality, augment pandemic preparedness, decrease postoperative mortality, and decrease the need for advanced level care. The entire healthcare workforce must be trained in these fundamentals. Additionally, physician and nurse specialists trained in critical care are needed and must be retained as leaders of critical care initiatives, researchers, and teachers. Context-specific research is mandatory to ensure care is appropriate for the patient populations served, not just duplicated from high-resourced settings. Governments must increase healthcare spending and invest in capacity to treat critically ill patients. Advocacy at all levels is needed to achieve universal health coverage for critically ill patients.

Barriers and facilitators to implementing a regional anesthesia service in a low-income country: a qualitative study.

INTRODUCTION: Regional anesthesia is a safe alternative to general anesthesia. Despite benefits for perioperative morbidity and mortality, this technique is underutilized in low-resource settings. In response to an identified need, a regional anesthesia service was established at the University Teaching Hospital of Kigali (CHUK), Rwanda. This qualitative study investigates the factors influencing implementation of this service in a low-resource tertiary-level teaching hospital. METHODS: Following service establishment, we recruited 18 local staff at CHUK for in-depth interviews informed by the "Consolidated Framework for Implementation Research" (CFIR). Data were coded using an inductive approach to discover emergent themes. RESULTS: Four themes emerged during data analysis. Patient experience and outcomes: where equipment failure is frequent and medications unavailable, regional anesthesia offered clear advantages including avoidance of airway intervention, improved analgesia and recovery and cost-effective care. Professional satisfaction: morale among healthcare providers suffers when outcomes are poor. Participants were motivated to learn techniques that they believe improve patient care. Human and material shortages: clinical services are challenged by high workload and human resource shortages. Advocacy is required to solve procurement issues for regional anesthesia equipment. Local engagement for sustainability: participants emphasized the need for a locally run, sustainable service. This requires broad engagement through education of staff and long-term strategic planning to expand regional anesthesia in Rwanda. CONCLUSION: While the establishment of regional anesthesia in Rwanda is challenged by human and resource shortages, collaboration with local stakeholders in an academic institution is pivotal to sustainability.