Quality Measures to Deliver Safe, High-Quality Care on Hand Surgery Outreach Trips to Low and Middle-Income Countries.

BACKGROUND: The burden of hand surgery in low and middle-income countries (LMICs) is immense and growing. Although outreach trips to LMICs have been increasing, there has remained a gap regarding assessment of quality of care on outreach trips. We developed quality measures to assess hand surgery outreach trips to LMICs. METHODS: We followed the recommendations set forth by the World Health Organization for practice guideline development. We used the results of a systematic review to inform the development of quality measures. Eight hand and upper-extremity surgeons with extensive global outreach experience (mean surgical outreach experience of >15 years, completed >3,000 surgeries in 24 countries) completed a modified RAND/UCLA (University of California Los Angeles) Delphi process to evaluate the importance, the feasibility, the usability, and the scientific acceptability of 83 measures. Validity was defined according to established methods. RESULTS: A tiering system that was based on the resources available at an outreach site (essential, intermediate, and advanced) was developed to classify the application of the measures since care delivery in LMICs often is constrained by local resources. Twenty-two (27%) of 83 measures were validated. All 22 (100%) were classified as essential (e.g., availability of interpretation services for the visiting team); no measures that were classified as intermediate or advanced were validated. CONCLUSIONS: Field-testing and implementation of quality measures served to identify the safety and the quality of hand surgical care that was provided on outreach trips to LMICs and inform improvement efforts. Tiers of care can be applied to quality measures to incorporate resource and capacity limitations when assessing their performance. CLINICAL RELEVANCE: Ensuring safety and high-quality care on hand surgical outreach trips to LMICs is foundational to all participating organizations and physicians. Valid quality measures can be implemented by organizations undertaking outreach trips to LMICs.

Challenges to Implementing Total Joint Replacement Programs in Developing Countries.

In this review article, the authors present the many challenges that orthopedic surgeons in developing countries face when implementing arthroplasty programs. The issues of cost, sterility, and patient demographics are specifically addressed. Despite the many challenges, developing countries are beginning to offer hip and knee reconstructive surgery to respond to the increasing demand for such elective operations as the prevalence of osteoarthritis continues to increase. The authors shed light on these nascent arthroplasty programs.

When International Humanitarian or Medical Missions Go Wrong: An Ethical Analysis.

Recent decades have seen a significant increase in physicians participating in international short-term missions to regions with limited or no access to health care by virtue of natural disaster or lack of resources. Recent publications in the ethics literature have explored the potential of these missions for unintentional harm to the intended beneficiaries. Less has been discussed about how to respond when harm actually occurs. The authors review the ethical issues raised by short-term medical and humanitarian missions and the literature on responding to unintended error to provide guidelines for avoiding harm to the intended beneficiaries of missions and an appropriate response when harm occurs. Two cases demonstrating an analysis and response to unintended harm are presented.

Reducing Surgical Site Infections During Otolaryngology Surgical Missions.

OBJECTIVES: To determine what measures an otolaryngology-head and neck surgery team might adopt to decrease the incidence of surgical site infection (SSI) on a short-term surgical mission. Despite concerns about safety and efficacy, short-term surgical missions remain the predominant structure for humanitarian surgical care in low- and middle-income countries (LMIC). Hospitals in high-income countries strive to improve surgical outcomes through implementation of World Health Organization (WHO) safe surgery guidelines. Reduction of SSI risk is a key part of this effort. METHODS: Literature review and practical experience. RESULTS: WHO recommendations for reducing SSI are based largely on research done in the North America and Europe. LMIC populations are younger; comorbidities are fewer; infectious disease and trauma are prevalent; and delays in access to care are common. SSI are much more frequent in resource-limited settings. Recommendations regarding preoperative assessment, operating room environment, instrument sterilization, surgical antibiotic prophylaxis, surgical site preparation, gloving, draping, and postsurgical care are reviewed in the context of a surgical mission at a typical LMIC government hospital. CONCLUSION: Many of the WHO guidelines on reduction of SSI are logical and applicable to the short-term surgical missions; others may need to be modified. Careful prospective data collection and clinical trials are needed to learn which interventions are valid and which should be changed. LEVEL OF EVIDENCE: 5 Laryngoscope, 130:1388-1395, 2020.

Applying global standards to short-term global health clinical experiences: the case of Project Salud y Paz.

This case study was extracted from an administrative report generated for Project Salud y Paz (SYP), a non-governmental organization (NGO) that supports short term global health clinical experiences (STGHCE) in Guatemala. As a basis to generate criticisms and offer recommendations, the analysis used the shared themes of two sets of standards recently published by Globalization and Health (GH) and the American College of Physicians (ACP). These standards respectively address the ethical responsibilities of organizations and of physicians in the conduct of STGHCE. Information used in the original quality analysis and quality improvement consultation for SYP was gathered from interviews, medical committee minutes, output statistics, and observations in the course of a real-time trip. This case study describes how the standards served as a useful lens to assess SYP and as a platform from which to make recommendations for improved compliance with global conventions. Additionally, the standards provide SYP a body of consensus wisdom for holding itself accountable to patients, host communities, volunteers, and the donor community on a continuing basis. While the shared themes of these standards are intentionally broad and require context in their application, NGOs that support STGHCE may find it instructive to benchmark them to assure their own compliance with global standards for both the organization and their volunteer physicians.

A survey of international medical volunteers' experiences of working with Voluntary Service Overseas in Ethiopia.

Many skilled medical professionals from high-income countries volunteer to work in poor-resource settings. There is, however, little research to assess the views and experiences of such healthcare providers. Our study sought to explore this among Voluntary Service Overseas volunteers working in Ethiopia for one year. An online survey was distributed to all returned international medical volunteers one year after their return to their base country. Most felt that they had impacted the local community in which they worked and reported a positive experience, recommending this to friends or family, but there was a small subgroup whose experience was otherwise. We believe there is a need for more comprehensive, systematic and robust monitoring in order to evaluate the outcomes of medical volunteers' placements.

A Sustainable and Scalable Approach to the Provision of Cleft Care: A Focus on Safety and Quality.

BACKGROUND: A global health model based on partnering with local hospitals and surgical teams, providing education and training for local providers, and mandating adherence to safety and quality standards to ensure safe surgery and anesthesia care can build local surgical capacity and strengthen existing health care systems in low- and middle-income countries. Smile Train uses this sustainable partnership model to provide responsible humanitarian aid while maintaining a bidirectional exchange with its international partners. METHODS: A voluntary online survey is administered annually to Smile Train's global partners. One portion of this survey focuses on how Smile Train can best support providers' adherence to the Smile Train Safety and Quality Protocol and Anesthesia Guidelines for cleft care. RESULTS: In 2014 and 2015, 1132 health care providers responded to Smile Train's annual partner survey (77 percent response rate). When asked how Smile Train could best support partners to continually meet the safety and quality standards, most partners reported that they could benefit from additional financial support (59.6 percent) and medical professional education and training opportunities (59.2 percent). CONCLUSIONS: The results from the partner survey yield important insights into the programmatic needs of Smile Train partners. Smile Train uses this information to efficiently allocate and distribute resources and to strategically plan and implement training opportunities where needed. The partner survey helps to ensure that Smile Train patients around the world consistently receive safe and high-quality cleft surgery and anesthesia care.

Short-Term Medical Missions: Toward an Ethical Approach.

Projects must have clearly stated intentions and sustainability plans.

Guidelines for responsible short-term global health activities: developing common principles.

BACKGROUND: Growing concerns about the value and effectiveness of short-term volunteer trips intending to improve health in underserved Global South communities has driven the development of guidelines by multiple organizations and individuals. These are intended to mitigate potential harms and maximize benefits associated with such efforts. METHOD: This paper analyzes 27 guidelines derived from a scoping review of the literature available in early 2017, describing their authorship, intended audiences, the aspects of short term medical missions (STMMs) they address, and their attention to guideline implementation. It further considers how these guidelines relate to the desires of host communities, as seen in studies of host country staff who work with volunteers. RESULTS: Existing guidelines are almost entirely written by and addressed to educators and practitioners in the Global North. There is broad consensus on key principles for responsible, effective, and ethical programs--need for host partners, proper preparation and supervision of visitors, needs assessment and evaluation, sustainability, and adherence to pertinent legal and ethical standards. Host country staff studies suggest agreement with the main elements of this guideline consensus, but they add the importance of mutual learning and respect for hosts. CONCLUSIONS: Guidelines must be informed by research and policy directives from host countries that is now mostly absent. Also, a comprehensive strategy to support adherence to best practice guidelines is needed, given limited regulation and enforcement capacity in host country contexts and strong incentives for involved stakeholders to undertake or host STMMs that do not respect key principles.

Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group.

INTRODUCTION: Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries (HICs) are increasingly engaged in resource-limited areas, with short-term missions (STMs) as the most common form of involvement. However, consensus recommendations currently do not exist for STMs in pediatric general surgery and associated perioperative care. METHODS: The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for STMs based on extensive experience with STMs. RESULTS: Three distinct, but related areas were identified: 1) Broad goals of surgical partnerships between HICs- and low and middle-income countries (LMICs). A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN), was endorsed by all groups; 2) Guidelines for the conduct of STMs were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; 3) travel and safety considerations critical to STM success were enumerated. CONCLUSION: A diverse group of stakeholders developed these guidelines for STMs in LMICs. These guidelines may be a useful tool to ensure safe, responsible, and ethical STMs given increasing engagement of HIC providers in this work. LEVEL OF EVIDENCE: 5.

Why do patients receive care from a short-term medical mission? Survey study from rural Guatemala.

BACKGROUND: Hospital de la Familia was established to serve the indigent population in the western highlands of Guatemala and has a full-time staff of Guatemalan primary care providers supplemented by short-term missions of surgical specialists. The reasons for patients seeking surgical care in this setting, as opposed to more consistent care from local institutions, are unclear. We sought to better understand motivations of patients seeking mission-based surgical care. METHODS: Patients presenting to the obstetric and gynecologic, plastic, ophthalmologic, general, and pediatric surgical clinics at the Hospital de la Familia from July 27 to August 6, 2015 were surveyed. The surveys assessed patient demographics, surgical diagnosis, location of home, mode of travel, and reasons for seeking care at this facility. RESULTS: Of 252 patients surveyed, 144 (59.3%) were female. Most patients reported no other medical condition (67.9%, n = 169) and no consistent income (83.9%, n = 209). Almost half (44.9%, n = 109) traveled >50 km to receive care. The most common reasons for choosing care at this facility were reputation of high quality (51.8%, n = 130) and affordability (42.6%, n = 102); the least common reason was a lack of other options (6.4%, n = 16). CONCLUSIONS: Despite long travel distances and the availability of other options, reputation and affordability were primarily cited as the most common reasons for choosing to receive care at this short-term surgical mission site. Our results highlight that although other surgical options may be closer and more readily available, reputation and cost play a large role in choice of patients seeking care.

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis.

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broad training, ability to work quickly and effectively in high-pressure, austere settings, and their inherent flexibility. While emergency medicine training is helpful to support the needs of crisis-affected and displaced populations, it is not in itself sufficient. In this article we review what an EP should carefully consider prior to deployment.

Contribución de la mujer en misiones internacionales de las Fuerzas Armadas / Contribution of women on Armed Forces’ international missions

ANTECEDENTES: Hasta hace apenas una década, las mujeres han estado generalmente excluidas para participar en la guerra como sujetos activos. Después de la Resolución 1325 del Consejo de Seguridad de las Naciones Unidas (UN) de Octubre del 2000, se ha generalizado su incorporación a los ejércitos en procesos de paz y reconstrucción posconflicto; siendo el principal objetivo del Plan de Acción del Gobierno de España aprobado en 2007 «Potenciar la participación de mujeres en misiones y órganos de toma de decisiones». OBJETIVO: Determinar el nivel de cumplimiento con respecto a la participación de las mujeres del ejército español en procesos de paz y reconstrucción posconflicto. MATERIAL Y MÉTODO: DISEÑO: se trata de un estudio observacional descriptivo longitudinal retrospectivo. Ámbito: Fuerzas Armadas Españolas, durante el periodo comprendido entre enero de 1993 y diciembre de 2015. Población: Mujeres que han ingresado en las Fuerzas Armadas Españolas durante el periodo de estudio y que han participado en misiones internacionales. RESULTADOS: durante el periodo de estudio se observó un incremento de mujeres en los diferentes ejércitos que participaron en misiones internacionales, siendo el año 2014 el de máxima participación con un 12,5% de mujeres. CONCLUSIONES: Se observó un incremento en la proporción de mujeres participantes en misiones internacionales (FAS), así como su acceso a los cargos de mayor responsabilidad

BACKGROUND: Until just a decade, women have been largely excluded from participating in war as active subjects. After the 1325 Resolution of the UN Security Council in October 2000, incorporation of women to armies in peace-keeping missions and post-conflict reconstruction has been generalized, being the main objective of the «Action Plan of Government of Spain» approved in 2007 to «Enhance Women's Participation in Missions and Decision-Making Bodies». OBJECTIVE: To determine the level of compliance in relation to the participation of women in the Spanish army in peace-keeping processes and post-conflict reconstruction. MATERIALS AND METHODS: DESIGN: It is an observational, retrospective, descriptive and longitudinal study. Ambit: Spanish army, during the period between January 1993 and December 2015. Population: women who have joined the Spanish army during the studied period and have participated in international tours of duty. RESULTS: During the studied period, an increase of women in the different armies that participated in international missions has been observed, being 2014 the year with maximum participation of women, 12.5%. CONCLUSIONS: An increase in the proportion of women participating in international missions (FAS), as well as their access to positions of greater responsibility has been observed

International short-term medical missions: a systematic review of recommended practices.

OBJECTIVES: To identify practices for conducting international short-term medical missions (STMMs) recommended in the literature and examine how these link STMMs to recipient countries' existing health systems. METHODS: Systematic review of PubMed-indexed articles on STMMs and their bibliographies using preferred reporting items for systematic reviews and meta-analyses guidelines. Recommendations were organized using the World Health Organization Health Systems Framework. RESULTS: In 92 publications, 67 % offered at least one recommendation that would link STMMs to the recipient country's health system. Among these recommendations, most focused on service delivery and few on health financing and governance. There is a lack of consensus around a proper standard of care, patient selection, and trip duration. CONCLUSIONS: Comprehensive global standards are needed for STMM work to ensure that services are beneficial both to patients and to the broader healthcare systems of recipient countries. By providing an overview of the current recommendations and important gaps where practice recommendations are needed, this study can provide relevant input into the development of global standards for STMMs.

The Need for Formal Surgical Global Health Programs and Improved Mission Trip Coordination.

BACKGROUND: There is a dire need for more surgical services as part of improving global health. Conditions treatable with surgery account for 11% of the global burden of disease, with a disproportionate burden affecting low- and middle-income countries (LMICs). Less than 6% of the world's operations are performed in LMICs, with relief organizations performing nearly 250,000 operations annually in LMICs in addition to each country's domestic surgical capacity. Currently, surgical needs are not adequately met by the existing patchwork of federal and nongovernmental organizations' surgical services and surgical mission trips. Improving coordination between mission trips may have synergistic benefits for maximizing the efficacy of the individual trips and improving the overall quality of care. OBJECTIVES: To establish whether cooperation between surgical mission trips can lead to operational efficiency and to identify obstacles to cooperation. METHODS: In order to establish the veracity of cooperation translating into efficiency and to identify obstacles that prevent cooperation, a 50-question survey was created (see Supplement 1). The survey was sent to surgical program directors of the 147 major surgical programs in the United States and Canada with a follow-up telephone survey of 18 randomly selected programs. FINDINGS: The survey response rate was 14%. Although 90% of respondent programs mount at least 1 mission trip per year, only one-third confirmed the existence of global health or surgical global health programs at their institution (33%). There was significant interest in cooperating with programs at other institutions (80%). When asked why they do not communicate with humanitarian aid organizations doing similar work, 53% of respondents reported a "lack of knowledge of how to find similar organizations to mine doing similar work." An additional 21% of respondents were "unaware that coordination is possible." CONCLUSIONS: A minority of respondent surgery programs host formal, organized surgical global health programs with a structured leadership based at academic medical centers. Although most institutions have individuals leading international humanitarian missions to LMICs, these leaders do not function in an integrated fashion with their departments, institutions, or other academic medical programs. The majority of respondents were interested in coordinating their surgical trips with other groups. Respondents suggested the creation of a central database that would allow trip organizers to share information about upcoming trips, site logistics, and personnel or supply needs.

Survey of patient perceptions towards short-term mobile medical aid for those living in a medically underserved area of Swaziland.

BACKGROUND: An increasing number of short-term medical missions (STMMs) are being dispatched to provide humanitarian healthcare; however, extensive investigations on how recipient patients perceive STMMs are lacking. The current study evaluated the perceptions of patients toward medical services provided by a Taiwanese STMM in a resource-poor area of Swaziland. METHODS: A structured questionnaire survey was completed by patients who had received medical services from the medical mission of Taipei Medical University in Swaziland in July 2014. RESULTS: In total, 349 questionnaires were valid for the analysis. More respondents were female than male (69.6% vs 30.4%). The most common chief complaint was musculoskeletal problems (45.8%), followed by respiratory symptoms (35.0%). Most of the patients stated that their overall experience with the medical services was excellent (91.4%). Universal patients would like to see the service provided in the future (99.7%). Nearly 90% of the patients were aware of how to take care of the medical problem they were diagnosed with. A majority of the patients comprehended what their medical providers said. Only a few patients did not understand what physicians said (5.2%). CONCLUSION: Medical services provided by the STMM were helpful in resolving patients' problems. The data have crucial implications for evaluating overseas mobile medical aid from the viewpoint of patients.