Improving the implementation of the WHO Surgical Safety Checklist in a Sierra Leone teaching hospital: Experiences from a multi-faceted patient safety improvement project.

BACKGROUND AND OBJECTIVE: Improving the safety of surgical care is an area of growing interest in Sierra Leona, a low resource setting where health outcomes remain poor. One tool shown to improve outcomes is the WHO Surgical Safety Checklist. We report an approach for optimising adherence in a public referral hospital in Freetown, Sierra Leone. METHODS: A multi-faceted series of interventions was proposed. Planning involved service evaluation, discussion with key stakeholders and formation of a working group to develop tailored interventions. Implementation involved reformatting the local checklist, formal classroom and simulation training and introduction of protocols and visual aids. Analysis of impact was performed by prospective observation of safety processes both pre- and post-intervention. RESULTS: Following the intervention, there was a significant increase in the total number of intraoperative safety processes performed (38.1% pre vs 73.0% post, p < 0.001). A significant improvement was noted in the performance of airway evaluation, correct administration of antibiotics, marking of the surgical site and preoperative team briefing. CONCLUSION: This project describes a series of interventions taken to improve the performance of the WHO Surgical Safety Checklist in a low resource setting. We highlight the importance of local partnership working and stakeholder engagement in implementing successful change.

What is the minimum number of specialist anaesthetists needed in low-income and middle-income countries?

INTRODUCTION: The number of specialist anaesthetists in most low-income and middle-income countries is below what is needed to provide a safe quality anaesthesia service. There are no estimates of the optimal number; therefore, we estimated the minimum density of specialist anaesthetists to achieve a reasonable standard of healthcare as indicated by the maternal mortality ratio (MMR). METHODS: Utilising existing country-level data of the number of physician anaesthesia providers (PAPs), MMR and Human Development Index (HDI), we developed best-fit curves to describe the relationship between MMR and PAPs, controlling for HDI. The aim was to use this relationship to estimate the number of PAPs associated with achieving the median MMR. RESULTS: We estimated that, in order to achieve a reasonable standard of healthcare, as indicated by the global median MMR, countries should aim to have at least four PAPs per 100 000 population. Existing data show that currently 80 countries have fewer than this number. CONCLUSION: Four PAPs per 100 000 population is a modest target, but there is a need to increase training of doctors in many countries in order to train more specialist anaesthetists. It is important that this target is considered during the development of national workforce plans, even if a stepwise approach to workforce planning is chosen.

Collecting data for global surgical indicators: a collaborative approach in the Pacific Region.

In 2015, the Lancet Commission on Global Surgery (LCoGS) recommended six surgical metrics to enable countries to measure their surgical and anaesthesia care delivery. These indicators have subsequently been accepted by the World Bank for inclusion in the World Development Indicators. With support from the Royal Australasian College of Surgeons and the Pacific Islands Surgical Association, 14 South Pacific countries collaborated to collect the first four of six LCoGS indicators. Thirteen countries collected all four indicators over a 6-month period from October 2015 to April 2016. Australia and New Zealand exceeded the recommended LCoGS target for all four indicators. Only 5 of 13 countries (38%) achieved 2-hour access for at least 80% of their population, with a range of 20% (Papua New Guinea and Solomon Islands) to over 65% (Fiji and Samoa). Five of 13 (38%) countries met the target surgical volume of 5000 procedures per 100 000 population, with six performing less than 1600. Four of 14 (29%) countries had at least 20 surgical, anaesthesia and obstetric providers in their workforce per 100 000 population, with a range of 0.9 (Timor Leste) to 18.5 (Tuvalu). Perioperative mortality rate was reported by 13 of 14 countries, and ranged from 0.11% to 1.0%. We believe it is feasible to collect global surgery indicators across the South Pacific, a diverse geographical region encompassing high-income and low-income countries. Such metrics will allow direct comparison between similar nations, but more importantly provide baseline data that providers and politicians can use in advocacy national health planning.

Surgical capacity building in Timor-Leste: a review of the first 15 years of the Royal Australasian College of Surgeons-led Australian Aid programme.

BACKGROUND: Timor-Leste suffered a destructive withdrawal by the Indonesian military in 1999, leaving only 20 Timorese-based doctors and no practising specialists for a population of 700 000 that has now grown to 1.2 million. METHODS: This article assesses the outcomes and impact of Royal Australasian College of Surgeons (RACS) specialist medical support from 2001 to 2015. Three programmes were designed collaboratively with the Timor-Leste Ministry of Health and Australian Aid. The RACS team began to provide 24/7 resident surgical and anaesthesia services in the capital, Dili, from July 2001. The arrival of the Chinese and Cuban Medical Teams provided a medical workforce, and the Cubans initiated undergraduate medical training for about 1000 nationals both in Cuba and in Timor-Leste, whilst RACS focused on specialist medical training. RESULTS: Australian Aid provided AUD$20 million through three continuous programmes over 15 years. In the first 10 years over 10 000 operations were performed. Initially only 10% of operations were done by trainees but this reached 77% by 2010. Twenty-one nurse anaesthetists were trained in-country, sufficient to cover the needs of each hospital. Seven Timorese doctors gained specialist qualifications (five surgery, one ophthalmology and one anaesthesia) from regional medical schools in Papua New Guinea, Fiji, Indonesia and Malaysia. They introduced local specialist and family medicine diploma programmes for the Cuban graduates. CONCLUSIONS: Timor-Leste has developed increasing levels of surgical and anaesthetic self-sufficiency through multi-level collaboration between the Ministry of Health, Universidade Nacional de Timor Lorosa'e, and sustained, consistent support from external donors including Australian Aid, Cuba and RACS.