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Objective: The objective of this study was to examine the impact of the introduction of the Universal Anaesthesia Machine (UAM), a device designed for use in clinical environments with limited clinical perioperative resources, on the choice of general anesthesia technique and safe anesthesia practice in a tertiary-care hospital in Sierra Leone. Methods: We introduced an anesthesia machine (UAM) into Connaught Hospital, Freetown, Sierra Leone. We conducted a prospective observational study of anesthesia practice and an examination of perioperative clinical parameters among surgical patients at the hospital to determine the usability of the device, its impact on anesthesia capacity, and changes in general anesthesia technique. Findings: We observed a shift from the use of ketamine total intravenous anesthesia to inhalational anesthesia. This shift was most demonstrable in anesthesia care for appendectomies and surgical wound management. In 10 of 17 power outages that occurred during inhalational general anesthesia, anesthesia delivery was uninterrupted because inhalational anesthesia was being delivered with the UAM. Conclusion: Anesthesia technologies tailored to overcome austere environmental conditions can support the delivery of safe anesthesia care while maintaining fidelity to recommended international anesthesia practice standards.
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Dexmedetomidine's unique sedative properties have led to its widespread use. Dexmedetomidine has a beneficial pharmacologic profile including analgesic sparing effects, anxiolysis, sympatholysis, organ-protective effects against ischemic and hypoxic injury, and sedation which parallels natural sleep. An understanding of predictable side effects, effects of age-related physiologic changes, and pharmacokinetic and pharmacodynamic effects of dexmedetomidine is crucial to maximize its safe administration in adults and children. This review focuses on the growing body of literature examining advances in applications of dexmedetomidine in children and adults.
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Anestesia , Dexmedetomidina , Criança , Adulto , Humanos , Dexmedetomidina/uso terapêutico , Dexmedetomidina/farmacologia , Hipnóticos e Sedativos/uso terapêutico , Cuidados CríticosRESUMO
BACKGROUND: Anesthesia providers in low- and middle-income countries face many challenges, including poor availability of functioning equipment designed to meet their environmental, organizational, and resource constraints. These are serious global health disparities which threaten access to care and patient safety for those who receive surgical care. In this study, we conducted a simulation-based human factors analysis of the Universal Anaesthesia Machine (UAM®), a device designed to support anesthesia providers in austere medical settings. Our team anticipated the introduction of the UAM® to the two major referral hospitals in Freetown, Sierra Leone. A prior observational study had identified these two hospitals as having environmental conditions consistent with an austere environment: an unstable electrical grid, as well as limited access to compressed oxygen, biomedical support, and consumables. Although the Baltimore simulation environment cannot reproduce all of the challenges present in a resource-constrained environment such as Sierra Leone, the major impediments to standard anesthesia machine functionality and human factors-associated use can be reproduced with the use of high-fidelity simulation. Using anesthesia care providers who have limited UAM® familiarity, this study allowed for the examination of machine-user issues in a controlled environment in preparation for further field studies concerning equipment introduction, training and device deployment in Sierra Leone. The goals of this study were: 1. to assess the usability of the UAM® (machine-user interface, simulated patient use, symbology, etc.) across different provider user groups during simulation of use in scenarios depicting routine use in healthy patients, use in clinically challenging patients and use in environmentally-challenging scenarios in a controlled setting devoid of patient risk, and 2. To gather feedback on available UAM manuals and cognitive aides and UAM usability issues in order to guide development of curricula for training providers on use of the UAM® in the intended austere clinical environments. METHODS: Residents, fellows, attending physician anesthesiologists, student nurse anesthetists, and nurse anesthetists participated in a variety of simulations involving the Universal Anaesthesia Machine® at the Johns Hopkins Medicine Simulation Center between September 2012 and July 2013. Data collected included participant demographics, performance during simulation scenarios captured with critical action checklists, workload ratings captured with the National Aeronautics and Space Administration Task Load Index (NASA TLX), and participant reactions to UAM® use captured through a post-session survey and semi-structured usability debriefing. The scenarios were: 1. normal use (machine check, induction, and maintenance of an uneventful case), 2. use in a challenging clinical condition (acute onset of bronchospasm) and 3.use in an adverse environmental event (power failure). Critical action checklists and workload ratings were analyzed by Analysis of Covariance (ANCOVA) to control for participant demographics. Usability debriefings were analyzed qualitatively. RESULTS: Thirty-five anesthesia providers participated in the study. Overall participant ratings, observations of performance in simulation scenarios, and usability debriefings indicated a high level of usability for the UAM®. Mean participant ratings were high for ease of use (5.4 ± 0.96) and clarity of instruction (6.2 ± 0.87) on a 7-point scale in which higher ratings indicate more positive perceptions. After adjusting for clinical experience, workload ratings were significantly higher in the bronchospasm scenario than in the normal/routine use (P = 0.046; 95% CI, 0.33-34.7) or power failure scenarios (P = 0.012; 95% CI, 5.24-37.9). Thirty-two specific usability issues were identified and grouped into five themes: device design and labeling, machine use during simulation scenarios, user-anticipated errors or hazards, curriculum issues, and overall impressions of the UAM®. CONCLUSIONS: The UAM® design addresses many of the key challenges facing anesthesia providers in resource-constrained settings. The simulation-based human factors evaluation described here successfully identified opportunities for continued refinement of the initial device design as well as issues to be addressed in future curricula and cognitive aides.
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Anestesia Geral/instrumentação , Atitude do Pessoal de Saúde , Países em Desenvolvimento , Carga de Trabalho , Adulto , Anestesiologia/educação , Anestesiologia/instrumentação , Baltimore , Espasmo Brônquico/terapia , Lista de Checagem , Simulação por Computador , Currículo , Desenho de Equipamento , Ergonomia , Humanos , Sistemas Homem-Máquina , Pessoa de Meia-Idade , Simulação de Paciente , Serra LeoaRESUMO
BACKGROUND: Maternal mortality and morbidity are major causes of death in low-resource countries, especially those in Sub-Saharan Africa. Healthcare workforce scarcities present in these locations result in poor perioperative care access and quality. These scarcities also limit the capacity for progressive development and enhancement of workforce training, and skills through continuing medical education. Newly available low-cost, in-situ simulation systems make it possible for a small cadre of trainers to use simulation to identify areas needing improvement and to rehearse best practice approaches, relevant to the context of target environments. METHODS: Nurse anesthetists were recruited throughout Sierra Leone to participate in simulation-based obstetric anesthesia scenarios at the country's national referral maternity hospital. All subjects participated in a detailed computer assisted training program to familiarize themselves with the Universal Anesthesia Machine (UAM). An expert panel rated the morbidity/mortality risk of pre-identified critical incidents within the scenario via the Delphi process. Participant responses to critical incidents were observed during these scenarios. Participants had an obstetric anesthesia pretest and post-test as well as debrief sessions focused on reviewing the significance of critical incident responses observed during the scenario. RESULTS: 21 nurse anesthetists, (20% of anesthesia providers nationally) participated. Median age was 41 years and median experience practicing anesthesia was 3.5 years. Most participants (57.1%) were female, two-thirds (66.7%) performed obstetrics anesthesia daily but 57.1% had no experience using the UAM. During the simulation, participants were observed and assessed on critical incident responses for case preparation with a median score of 7 out of 13 points, anesthesia management with a median score of 10 out of 20 points and rapid sequence intubation with a median score of 3 out of 10 points. CONCLUSION: This study identified substantial risks to patient care and provides evidence to support the feasibility and value of in-situ simulation-based performance assessment for identifying critical gaps in safe anesthesia care in the low-resource settings. Further investigations may validate the impact and sustainability of simulation based training on skills transfer and retention among anesthesia providers low resource environments.
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Anestesia Obstétrica/normas , Países em Desenvolvimento , Treinamento com Simulação de Alta Fidelidade , Enfermeiros Anestesistas/educação , Complicações do Trabalho de Parto/terapia , Adulto , Anestesia Obstétrica/instrumentação , Anestesia Obstétrica/métodos , Competência Clínica , Tomada de Decisão Clínica , Emergências , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Serra Leoa , Análise e Desempenho de TarefasRESUMO
BACKGROUND: Anesthesia in West Africa is associated with high mortality rates. Critical shortages of adequately trained personnel, unreliable electrical supply, and lack of basic monitoring equipment are a few of the unique challenges to surgical care in this region. This study aims to describe the anesthesia practice at 2 tertiary care hospitals in Sierra Leone. METHODS: We conducted an observational study of anesthesia care at Connaught Hospital and Princess Christian Maternity Hospital in Freetown, Sierra Leone. Twenty-five percent of the anesthesia workforce in Sierra Leone, resident at both hospitals, was observed from June 2012 to February 2013. Perioperative assessments, anesthetic techniques, and intraoperative clinical and environmental irregularities were noted and analyzed. The postoperative status of observed cases was ascertained for morbidity and mortality. RESULTS: Between the 2 hospitals, 754 anesthesia cases and 373 general anesthetics were observed. Ketamine was the predominant IV anesthetic used. Both hospitals experienced infrastructural and environmental constraints to the delivery of anesthesia care during the observation period. Vital sign monitoring was irregular and dependent on age and availability of monitors. Perioperative mortality during the course of the study was 11.9 deaths/1000 anesthetics. CONCLUSIONS: We identified gaps in the application of internationally recommended anesthesia practices at both hospitals, likely caused by lack of available resources. Mortality rates were similar to those in other resource-limited countries.
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Serviço Hospitalar de Anestesia/tendências , Anestesia/tendências , Anestesiologistas/tendências , Prestação Integrada de Cuidados de Saúde/tendências , Enfermeiros Anestesistas/tendências , Padrões de Prática Médica/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , Centros de Atenção Terciária/tendências , Adolescente , Adulto , Anestesia/efeitos adversos , Anestesia/mortalidade , Criança , Pré-Escolar , Feminino , Fidelidade a Diretrizes/tendências , Mortalidade Hospitalar , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Fatores de Risco , Serra Leoa , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
QUALITY PROBLEM OR ISSUE: Inadequate observance of basic processes in patient care such as patient monitoring and documentation practices are potential impediments to the timely diagnoses and management of patients. These gaps exist in low resource settings such as Sierra Leone and can be attributed to a myriad of factors such as workforce and technology deficiencies. INITIAL ASSESSMENT: In the study site, only 12.4% of four critical vital signs were documented in the pre-intervention period. CHOICE OF SOLUTION: Implement a failure mode and effects analysis (FMEA) to improve documentation of four patient vital signs: temperature, blood pressure, pulse rate and respiratory rate. IMPLEMENTATION: FMEA was implemented among a subpopulation of health workers who are involved in monitoring and documenting patient vital signs. Pre- and post-FMEA monitoring and documentation practice were compared with a control site. EVALUATION: Participants identified a four-step process to monitoring and documenting vital signs, three categories of failure modes and four potential solutions. Based on 2100 patient days of documentation compliance data from 147 patients between July and November 2012, staff members at the study site were 1.79 times more likely to document all four patient vital signs in the post-implementation period (95% CI [1.35, 2.38]). LESSONS LEARNED: FMEA is a feasible and effective strategy for improving quality and safety in an austere medical environment. Documentation compliance improved at the intervention facility. To evaluate the scalability and sustainability of this approach, programs targeting the development of these types of process improvement skills in local staff should be evaluated.
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Recursos Humanos de Enfermagem Hospitalar , Segurança do Paciente , Melhoria de Qualidade , Estudos de Casos e Controles , Países em Desenvolvimento , Documentação/métodos , Documentação/normas , Humanos , Recursos Humanos de Enfermagem Hospitalar/educação , Recursos Humanos de Enfermagem Hospitalar/normas , Melhoria de Qualidade/organização & administração , Serra Leoa , Centros de Atenção Terciária/normas , Sinais VitaisRESUMO
IMPORTANCE: Strengthening workforce capacity to deliver essential surgical and anesthesia care has been identified as a strategy for addressing the unmet burden of morbidity and mortality in under-resourced countries. Sierra Leone is one of the poorest countries in the world and faces the challenge of stretching limited resources to provide appropriate health care for a population of 6 million. OBJECTIVES: To investigate the training of surgical and anesthesia staff in Sierra Leone and to build an evidence base for future health care policy and training programs tailored to local needs. DESIGN, SETTING, AND PARTICIPANTS: Health care professionals who conduct surgery or deliver anesthesia at 10 of the 23 government hospitals in Sierra Leone were surveyed regarding training and clinical practices. This study surveyed 36 of 70 surgical staff (51%) and 38 of 68 nurse specialists (56%) nationally. MAIN OUTCOMES AND MEASURES: Descriptive analysis of demographic details, training levels, and reported needs for future development. RESULTS: Thirty-six surgeons were surveyed in study hospitals, of whom the majority had limited surgical specialization training, whereas most anesthesia was provided by 47 nurse specialists. All consultants had postgraduate qualifications, but 4 of 6 medical superintendents (67%) and all medical officers lacked postgraduate surgical qualifications or formal surgical specialist training. The number of trained anesthesia staff increased after the introduction of the Nurse Anesthesia Training Program in 2008, funded by the United Nations Fund for Population Activities, increasing the number from 2 to 47 anesthesia staff based at the study hospitals. Although 32 of 37 nurse anesthetists (86%) reported having attended training workshops, 30 of 37 (>80%) described anesthesia resources as "poor," reporting a critical need for anesthesia machines and continual oxygen supply. Of the 37, 25 specifically mentioned the need for a better-functioning anesthesia machine and 16 mentioned the need for oxygen. CONCLUSIONS AND RELEVANCE: To address unmet surgical need in the long term, accredited local surgical specialization programs are required; training of nonphysician surgical practitioners may offer a short-term solution. To develop safe anesthesia care, governments and donors should focus on providing health care professionals with essential equipment and resources.
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Anestesiologia/educação , Cirurgia Geral/educação , Hospitais Públicos , Corpo Clínico Hospitalar/educação , Adulto , Atitude do Pessoal de Saúde , Competência Clínica , Feminino , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Masculino , Corpo Clínico Hospitalar/provisão & distribuição , Pessoa de Meia-Idade , Avaliação das Necessidades , Serra Leoa , Inquéritos e Questionários , Recursos HumanosRESUMO
OBJECTIVE: Medical technology designed for Western settings frequently does not function adequately or as intended when placed in an austere clinical environment because of issues such as the instability of the electrical grid, environmental conditions, access to replacement parts, level of provider training and general absence of biomedical engineering support. The purpose of this study was to demonstrate the feasibility of applying failure mode and effects analysis as part of an implementation strategy for medical devices in austere medical settings. DESIGN: Observational case-study. SETTING/PARTICIPANTS/INTERVENTION: We conducted failure mode and effects analysis sessions with 16 biomedical engineering technicians at two tertiary-care hospitals in Freetown, Sierra Leone. The sessions focused on maintenance and repair processes for the Universal Anaesthesia Machine. Participating biomedical engineers detailed local maintenance and repair processes and failure modes, including resource availability, communication challenges, use errors and physical access to the machine. MAIN OUTCOME MEASURE(S): Qualitative descriptive themes in barriers perceived and solutions generated by biomedical engineers. RESULTS: Solutions generated involved redesigned work processes to increase the efficiency of identifying machine malfunctions, clinician engagement strategies, a formal plan for acquiring spare parts and plans for improving access to the machine. Follow-up interviews indicated solutions generated were implemented and perceived to be effective. CONCLUSIONS: This study demonstrates the feasibility of using the failure mode and effects analysis approach to improve implementation of technology in austere medical environments.
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Anestesiologia/instrumentação , Meio Ambiente , Comunicação , Falha de Equipamento , Humanos , Manutenção , Erros Médicos , Serra Leoa , Centros de Atenção TerciáriaRESUMO
HYPOTHESIS: Surgical and obstetrics-gynecology (Ob-Gyn) workload of medical officers (MOs) is substantial and may inform policies for training investment and surveillance to strengthen surgical care at district hospitals in Ghana. DESIGN: Observational study. SETTING: Academic research. PARTICIPANTS: Using standardized criteria, 12 trained on-site observers assessed the surgical and Ob-Gyn workload of MOs at 10 district hospitals in each of 10 administrative regions in Ghana, West Africa. The number of patients seen by MOs and the time spent managing each patient were recorded. According to each patient's diagnosis, the encounters were categorized as medical/nonsurgical, Ob-Gyn, or surgical. MAIN OUTCOME MEASURES: The proportions of patients having Ob-Gyn and surgical conditions and the time expended providing care to Ob-Gyn and surgical patients. RESULTS: Of the observed patient encounters, 1600 (64.5%) were classified as medical or nonsurgical, 514 (20.7%) as Ob-Gyn, and 368 (14.8%) as surgical (9.0% nontrauma and 5.8% trauma). The most common diagnosis among Ob-Gyn patients was obstetric complication requiring cesarean section. The most common diagnosis among surgical patients was inguinal hernia. Medical officers devoted 24.8% of their time to managing Ob-Gyn patients and 18.9% to managing surgical patients (which included 5.4% for the management of traumatic injuries). CONCLUSIONS: Surgical and Ob-Gyn patients represent a substantial proportion of the workload among MOs at district hospitals in Ghana. Strategies to increase surgical capacity at these facilities must include equipping MOs with the appropriate training and resources to address the significant surgical and Ob-Gyn workload they face.