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1.
Anesth Analg ; 2020 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-33264116

RESUMO

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

2.
Indian J Anaesth ; 63(12): 965-971, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31879420

RESUMO

The increasing focus on and importance of surgical care in achieving universal health coverage requires the development of safe and accessible anaesthesia services. Increasing access to care by supporting the necessary inputs to the anaesthesia system, including medications, equipment and personnel, must be accompanied by processes that support high-quality care, including support for education, and guidelines for standards, and training. As safe, high-quality care requires an integrated approach, each element must be supported together, i.e., in an integrated manner to ensure that anaesthesia care reaches those who need it, and in the safest possible manner. Several important efforts have been undertaken globally to address and foster these elements, and resources to guide these processes exist for low- and middle-income countries to improve them. This review highlights both the needs and resources for safe and high-quality care that patients deserve.

3.
Anesth Analg ; 129(3): 839-846, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31425228

RESUMO

BACKGROUND: In Africa, most countries have fewer than 1 physician anesthesiologist (PA) per 100,000 population. Nonphysician anesthesia providers (NPAPs) play a large role in the workforce of many low- and middle-income countries (LMICs), but little information has been systematically collected to describe existing human resources for anesthesia care models. An understanding of existing PA and NPAP training pathways and roles is needed to inform anesthesia workforce planning, especially for critically underresourced countries. METHODS: Between 2016 and 2018, we conducted electronic, phone, and in-person surveys of anesthesia providers in Africa. The surveys focused on the presence of anesthesia training programs, training program characteristics, and clinical scope of practice after graduation. RESULTS: One hundred thirty-one respondents completed surveys representing data for 51 of 55 countries in Africa. Most countries had both PA and NPAP training programs (57%; mean, 1.6 pathways per country). Thirty distinct training pathways to become an anesthesia provider could be discriminated on the basis of entry qualification, duration, and qualification gained. Of these 30 distinct pathways, 22 (73%) were for NPAPs. Physician and NPAP program durations were a median of 48 and 24 months (ranges: 36-72, 9-48), respectively. Sixty percent of NPAP pathways required a nursing background for entry, and 60% conferred a technical (eg, diploma/license) qualification after training. Physicians and NPAPs were trained to perform most anesthesia tasks independently, though few had subspecialty training (such as regional or cardiac anesthesia). CONCLUSIONS: Despite profound anesthesia provider shortages throughout Africa, most countries have both NPAP and PA training programs. NPAP training pathways, in particular, show significant heterogeneity despite relatively similar scopes of clinical practice for NPAPs after graduation. Such heterogeneity may reflect the varied needs and resources for different settings, though may also suggest lack of consensus on how to train the anesthesia workforce. Lack of consistent terminology to describe the anesthesia workforce is a significant challenge that must be addressed to accelerate workforce research and planning efforts.


Assuntos
Anestesia/métodos , Anestesiologistas/educação , Enfermeiras Anestesistas/educação , Inquéritos e Questionários , África/epidemiologia , Humanos
4.
Artigo em Inglês | MEDLINE | ID: mdl-27296199

RESUMO

BACKGROUND: There is no systematic assessment of available evidence on effectiveness and comparative effectiveness of balloon dilatation and stenting for aortic coarctation. METHODS AND RESULTS: We systematically searched 4 online databases to identify and select relevant studies of balloon dilatation and stenting for aortic coarctation based on a priori criteria (PROSPERO 2014:CRD42014014418). We quantitatively synthesized results for each intervention from single-arm studies and obtained pooled estimates for relative effectiveness from pairwise and network meta-analysis of comparative studies. Our primary analysis included 15 stenting (423 participants) and 12 balloon dilatation studies (361 participants), including patients ≥10 years of age. Post-treatment blood pressure gradient reduction to ≤20 and ≤10 mm Hg was achieved in 89.5% (95% confidence interval, 83.7-95.3) and 66.5% (44.1-88.9%) of patients undergoing balloon dilatation, and in 99.5% (97.5-100.0%) and 93.8% (88.5-99.1%) of patients undergoing stenting, respectively. Odds of achieving ≤20 mm Hg were lower with balloon dilatation as compared with stenting (odds ratio, 0.105 [0.010-0.886]). Thirty-day survival rates were comparable. Numerically more patients undergoing balloon dilatation experienced severe complications during admission (6.4% [2.6-10.2%]) compared with stenting (2.6% [0.5-4.7%]). This was supported by meta-analysis of head-to-head studies (odds ratio, 9.617 [2.654-34.845]) and network meta-analysis (odds ratio, 16.23, 95% credible interval: 4.27-62.77) in a secondary analysis in patients ≥1 month of age, including 57 stenting (3397 participants) and 62 balloon dilatation studies (4331 participants). CONCLUSIONS: Despite the limitations of the evidence base consisting predominantly of single-arm studies, our review indicates that stenting achieves superior immediate relief of a relevant pressure gradient compared with balloon dilatation.


Assuntos
Angioplastia com Balão/instrumentação , Aorta/fisiopatologia , Coartação Aórtica/terapia , Pressão Arterial , Stents , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Aorta/anormalidades , Aorta/efeitos dos fármacos , Coartação Aórtica/diagnóstico por imagem , Coartação Aórtica/mortalidade , Coartação Aórtica/fisiopatologia , Humanos , Metanálise em Rede , Razão de Chances , Fatores de Risco , Resultado do Tratamento
5.
Dynamics ; 23(4): 18-24, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23342934

RESUMO

OBJECTIVES: Delirium in critically ill patients is common and is associated with increased morbidity and mortality. Routine delirium screening is recommended by the Society of Critical Care Medicine. The Intensive Care Delirium Screening Checklist (ICDSC) is one validated and commonly-used tool, but little is known about nurses'perceptions of using the ICDSC, and of barriers to delirium assessment and treatment. DESIGN: A survey was administered to 189 critical care-trained nurses working on four oncology inpatient units, where the ICDSC has been used for greater than five years. RESULTS: Eighty-four nurses (44%) responded to the survey. Respondents indicated that they had knowledge of delirium, confidence in the ICDSC, and that the ICDSC was useful. Respondents perceived that physicians did not value the ICDSC results. Similar to prior nurse surveys for other delirium screening tools, physicians were the most frequently identified barrier to both delirium assessment and treatment, with other frequent barriers being lack of time, feedback on performance, and knowledge of delirium. CONCLUSIONS: The ICDSC is viewed favourably by nurses with experience using the tool. Future delirium screening programs should encourage physician engagement early in the planning process to help address perceived barriers to delirium assessment and treatment.


Assuntos
Lista de Checagem , Cuidados Críticos/normas , Delírio/diagnóstico , Delírio/enfermagem , Conhecimentos, Atitudes e Prática em Saúde , Avaliação em Enfermagem , Distribuição de Qui-Quadrado , Humanos , Inquéritos e Questionários
6.
Crit Care Med ; 39(2): 371-9, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20959786

RESUMO

OBJECTIVES: As critical care advances and intensive care unit mortality declines, the number of survivors of critical illness is increasing. These survivors frequently experience long-lasting complications of critical care. As a result, it is important to understand these complications and implement evidence-based practices to minimize them. DATA SOURCES: Database searches and review of relevant medical literature. DATA SYNTHESIS: Critical illness and intensive care unit care influence a wide range of long-term patient outcomes, with some impairments persisting for 5-15 yrs. Impaired pulmonary function, greater healthcare utilization, and increased mortality are observed in intensive care survivors. Neuromuscular weakness and impairments in both physical function and related aspects of quality of life are common and may be long-lasting. These complications may be reduced by multidisciplinary physical rehabilitation initiated early and continued throughout the intensive care unit care stay and by providing patient education for self-rehabilitation after hospital discharge. Common neuropsychiatric complications, including cognitive impairment and symptoms of depression and posttraumatic stress disorder, are frequently associated with intensive care unit sedation, delirium or delusional memories, and long-term impairments in quality of life. CONCLUSIONS: Survivors of critical illness are frequently left with a legacy of long-term physical, neuropsychiatric, and quality of life impairments. Understanding patient and intensive care risk factors can help identify patients who are most at risk of these complications. Furthermore, modifiable risk factors and beneficial interventions are increasingly being identified to help inform practical management recommendations to reduce the prevalence and impact of these long-term complications.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/terapia , Avaliação da Deficiência , Qualidade de Vida , Transtornos Cognitivos/epidemiologia , Transtornos Cognitivos/etiologia , Continuidade da Assistência ao Paciente , Estado Terminal/mortalidade , Delírio/epidemiologia , Delírio/etiologia , Feminino , Seguimentos , Humanos , Incidência , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Transtornos Mentais/epidemiologia , Transtornos Mentais/etiologia , Monitorização Fisiológica/métodos , Doenças Neuromusculares/epidemiologia , Doenças Neuromusculares/etiologia , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Medição de Risco , Sobreviventes , Tempo
7.
Soc Sci Med ; 70(12): 1933-1942, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20378228

RESUMO

Donor funding for health systems financing (HSF) research is inadequate and often poorly aligned with national priorities. This study aimed to generate consensus about a core set of research issues that urgently require attention in order to facilitate policy development. There were three key inputs into the priority setting process: key-informant interviews with health policy makers, researchers, community and civil society representatives across twenty-four low- and middle-income countries in four regions; an overview of relevant reviews to identify research completed to date; and inputs from 12 key informants (largely researchers) at a consultative workshop. Nineteen priority research questions emerged from key-informant interviews. The overview of reviews was instructive in showing which health financing topics have had comparatively little written about them, despite being identified as important by key informants. The questions ranked as most important at the consultative workshop were: It is hoped that this work on HSF research priorities will complement calls for increased health systems research and evaluation by providing specific suggestions as to where new and existing research resources can best be invested. The list of high priority HSF research questions is being communicated to research funders and researchers in order to seek to influence global patterns of HSF research funding and activity. A "bottom up" approach to setting global research priorities such as that employed here should ensure that priorities are more sensitive to user needs.


Assuntos
Países em Desenvolvimento , Política de Saúde , Prioridades em Saúde/economia , Apoio à Pesquisa como Assunto , Participação da Comunidade , Humanos , Formulação de Políticas
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