Regional anesthesia training model for resource-limited settings: a prospective single-center observational study with pre-post evaluations.

BACKGROUND AND OBJECTIVES: Educational initiatives are a sustainable means to address provider shortages in resource-limited settings (RLS), yet few regional anesthesia curricula for RLS have been described. We sought to design a reproducible training model for RLS called Global Regional Anesthesia Curricular Engagement (GRACE), implement GRACE at an RLS hospital in Ghana, and measure training and practice-based outcomes associated with GRACE implementation. METHODS: Fourteen of 15 physician anesthesiologists from the study location and three from an outside orthopedic specialty hospital consented to be trainees and trainers, respectively, for this prospective single-center observational study with pre-post evaluations. We conducted an initial needs assessment to determine current clinical practices, participants' learning preferences, and available resources. Needs assessment findings, expert panel recommendations, and investigator consensus were then used to generate a site-specific curriculum that was implemented during two 3-week periods. We evaluated trainee satisfaction and changes in knowledge, clinical skill, and peripheral nerve block (PNB) utilization using the Kirkpatrick method. RESULTS: The curriculum consisted of didactic lectures, simulations, and clinical instruction to teach ultrasound-guided PNB for limb injuries. Pre-post evaluations showed trainees were satisfied with GRACE, median knowledge examination score improved from 62.5% (15/24) to 91.7% (22/24) (p<0.001), clinical examination pass rate increased from 28.6% (4/14) to 85.7% (12/14) (p<0.01), and total PNB performed in 3 months grew from 48 to 118. CONCLUSIONS: GRACE applied in an RLS hospital led to the design, implementation, and measurement of a regional anesthesia curriculum tailored to institutional specifications that was associated with positive Kirkpatrick outcomes.

Anesthesia Capacity in Ghana: A Teaching Hospital's Resources, and the National Workforce and Education.

BACKGROUND: Quality anesthetic care is lacking in low- and middle-income countries (LMICs). Global health leaders call for perioperative capacity reports in limited-resource settings to guide improved health care initiatives. We describe a teaching hospital's resources and the national workforce and education in this LMIC capacity report. METHODS: A prospective observational study was conducted at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, during 4 weeks in August 2016. Teaching hospital data were generated from observations of hospital facilities and patient care, review of archival records, and interviews with KATH personnel. National data were obtained from interviews with KATH personnel, correspondence with Ghana's anesthesia society, and review of public records. RESULTS: The practice of anesthesia at KATH incorporated preanesthesia clinics, intraoperative management, and critical care. However, there were not enough physicians to consistently supervise care, especially in postanesthesia care units (PACUs) and the critical care unit (CCU). Clean water and electricity were usually reliable in all 16 operating rooms (ORs) and throughout the hospital. Equipment and drugs were inventoried in detail. While much basic infrastructure, equipment, and medications were present in ORs, patient safety was hindered by hospital-wide oxygen supply failures and shortage of vital signs monitors and working ventilators in PACUs and the CCU. In 2015, there were 10,319 anesthetics administered, with obstetric and gynecologic, general, and orthopedic procedures comprising 62% of surgeries. From 2011 to 2015, all-cause perioperative mortality rate in ORs and PACUs was 0.65% or 1 death per 154 anesthetics, with 99% of deaths occurring in PACUs. Workforce and education data at KATH revealed 10 anesthesia attending physicians, 61 nurse anesthetists (NAs), and 7 anesthesia resident physicians in training. At the national level, 70 anesthesia attending physicians and 565 NAs cared for Ghana's population of 27 million. Providers were heavily concentrated in urban areas, and NAs frequently practiced independently. Two teaching hospitals provided accredited postgraduate training modeled after European curricula to 22 anesthesia resident physicians. CONCLUSIONS: While important limitations to capacity exist in Ghana, the overall situation is good compared to other LMICs. Many of the challenges encountered resulted from insufficient PACU and CCU provisions and few providers. Inadequate outcomes reporting made analysis and resolution of problem areas difficult. While many shortcomings stemmed from limited funding, strengthening physician commitment to overseeing care, ensuring oxygen supplies are uninterrupted, keeping ventilators in working order, and making vital signs monitors ubiquitously available are feasible ways to increase patient safety with the tools currently in place.

Orthopedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United States.

BACKGROUND: Musculoskeletal disease is a growing burden in low- and middle-income countries (LMICs), yet little research exists to describe the problem. The purposes of this study were to characterize orthopedic surgery in an LMIC and compare the findings to those from a developed country. METHODS: The study location was the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Orthopedic surgeon, resident, and postgraduate training program numbers were compared to analogous data from a developed nation, the United States. Annual surgical volumes were compared to those at a level I trauma center in the United States, the San Francisco General Hospital (SFGH). RESULTS: There were 24 surgeons in Ghana compared to 23,956 in the United States. There were 7 orthopedic residents and 1 residency program in Ghana versus 3,371 residents and 155 residencies in the United States. Annual case volume was 2,161 at KATH and 2,132 at SFGH. Trauma accounted for 95 % of operations at KATH compared to 65 % at SFGH. The proportion of surgeries devoted to severe fractures was 29 % at KATH compared to 12 % at SFGH. Infections comprised 15 % of procedures at KATH and 5 % at SFGH. CONCLUSIONS: Annual case volume at a referral hospital in an LMIC is equivalent to that of a level I trauma center in an industrialized country. Total case volume is similar, but the LMIC institution manages a disproportionately large number of trauma cases, severe fractures, and infections. There is a large burden of orthopedic disease in the developing nation, and there are too few providers and training programs to address these conditions.