Anesthesia Patient Safety: Next Steps to Improve Worldwide Perioperative Safety by 2030.

Patient safety is a core principle of anesthesia care worldwide. The specialty of anesthesiology has been a leader in medicine for the past half century in pursuing patient safety research and implementing standards of care and systematic improvements in processes of care. Together, these efforts have dramatically reduced patient harm associated with anesthesia. However, improved anesthesia patient safety has not been uniformly obtained worldwide. There are unique differences in patient safety outcomes between countries and regions in the world. These differences are often related to factors such as availability, support, and use of health care resources, trained personnel, patient safety outcome data collection efforts, standards of care, and cultures of safety and teamwork in health care facilities. This article provides insights from national anesthesia society leaders from 13 countries around the world. The countries they represent are diverse geographically and in health care resources. The authors share their countries' current and future initiatives in anesthesia patient safety. Ten major patient safety issues are common to these countries, with several of these focused on the importance of extending initiatives into the full perioperative as well as intraoperative environments. These issues may be used by anesthesia leaders around the globe to direct collaborative efforts to improve the safety of patients undergoing surgery and anesthesia in the coming decade.

Addressing the Challenge of Pain Education in Low-Resource Countries: Essential Pain Management in Papua New Guinea.

Papua New Guinea (PNG) is a low-resource country in the South-West Pacific with considerable health care challenges, including a high burden of painful disease. The Essential Pain Management (EPM) educational program was developed to address the challenge of inadequate pain education in PNG and the first workshop was held in 2010. The aims of EPM are to improve pain knowledge, teach a simple system for managing pain, and address local pain management barriers. It is usually delivered as an interactive, multidisciplinary 1-day workshop with an emphasis on developing local solutions to local problems. The program includes an instructor workshop to encourage early handover to local health care workers. Between 2010 and 2018, a total of 42 one-day workshops and 6 instructor workshops were held throughout PNG, and 783 health care workers were trained, as well as 60 instructors. Over two-thirds of the 1-day workshops were taught entirely by local instructors. A shorter version of the workshop, called EPM Lite, was used to train 109 medical and nursing students. Program evaluation has included participant feedback (reaction) and preworkshop and postworkshop tests (knowledge) since inception. Evaluation of behavioral and organizational change has proved more challenging; however, a survey of past participants suggests some important behavioral changes and points to areas for formal research. The uptake of the EPM program in PNG is encouraging and suggests that there is a need for a pain management education program that is simple and easily adopted by local health care workers. There are still significant challenges, including a lack of funding, limited uptake at undergraduate level, the need for more formal evaluation of clinical impact, and the requirement for an all-of-system approach to improve pain management in PNG. Worldwide, EPM has now been taught in more than 60 countries. Our priorities for coming years include support for embedding EPM into health care systems and teaching programs, increased mentorship for instructors, assistance with overcoming local pain management barriers, and development of specific projects that will assess the impact of EPM education on patient outcomes.

Education: The Heart of the Matter.

There are inadequate numbers of anesthesia providers in many parts of the world. Good quality educational programs are needed to increase provider numbers, train leaders and teachers, and increase knowledge and skills. In some countries, considerable external support may be required to develop self-sustaining programs. There are some key themes related to educational programs in low- and middle-income countries:(1) Programs must be appropriate for the local environment-there is no "one-size-fits-all" program. In some countries, nonuniversity programs may be appropriate for training providers.(2) It is essential to train local teachers-a number of short courses provide teacher training. Overseas attachments may also play an important role in developing leadership and teaching capacity.(3) Interactive teaching techniques, such as small-group discussions and simulation, have been incorporated into many educational programs. Computer learning and videoconferencing offer additional educational possibilities.(4) Subspecialty education in areas such as obstetric anesthesia, pediatric anesthesia, and pain management are needed to develop leadership and increase capacity in subspecialty areas of practice. Examples include short subspecialty courses and clinical fellowships.(5) Collaboration and coordination are vital. Anesthesiologists need to work with ministries of health and other organizations to develop plans that are matched to need. External organizations can play an important role.(6) Excellent education is required at all levels. Training guidelines could help to standardize and improve training. Resources should be available for research, as well as monitoring and evaluation of educational programs.

World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia.

The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a nonprofit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.

World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia.

The International Standards for a Safe Practice of Anesthesia were developed on behalf of the World Federation of Societies of Anaesthesiologists (WFSA), a non-profit organization representing anesthesiologists in 150 countries, and the World Health Organization (WHO). The recommendations have been approved by WHO and the membership of WFSA. These Standards are applicable to all anesthesia providers throughout the world. They are intended to provide guidance and assistance to anesthesia providers, their professional organizations, hospital and facility administrators, and governments for maintaining and improving the quality and safety of anesthesia care. The Standards cover professional aspects; facilities and equipment; medications and intravenous fluids; monitoring; and the conduct of anesthesia. HIGHLY RECOMMENDED standards, the functional equivalent of mandatory standards, include (amongst other things): the continuous presence of a trained and vigilant anesthesia provider; continuous monitoring of tissue oxygenation and perfusion by clinical observation and a pulse oximeter; intermittent monitoring of blood pressure; confirmation of correct placement of an endotracheal tube (if used) by auscultation and carbon dioxide detection; the use of the WHO Safe Surgery Checklist; and a system for transfer of care at the end of an anesthetic. The International Standards represent minimum standards and the goal should always be to practice to the highest possible standards, preferably exceeding the standards outlined in this document.

The WFSA Global Anesthesia Workforce Survey.

BACKGROUND: Safe anesthesia and surgical care are not available when needed for 5 billion of the world's 7 billion people. There are major deficiencies in the specialist surgical workforce in many parts of the world, and specific data on the anesthesia workforce are lacking. METHODS: The World Federation of Societies of Anaesthesiologists conducted a workforce survey during 2015 and 2016. The aim of the survey was to collect detailed information on physician anesthesia provider (PAP) and non-physician anesthesia provider (NPAP) numbers, distribution, and training. Data were categorized according to World Health Organization regional groups and World Bank income groups. RESULTS: We obtained information for 153 of 197 countries, representing 97.5% of the world's population. There were marked differences in the density of PAPs between World Health Organization regions and between World Bank income groups, ranging from 0 to over 20 PAP per 100,000 population. Seventy-seven countries reported a PAP density of <5, with particularly low densities in the African and South-East Asia regions. NPAPs make up a large part of the global anesthesia workforce, especially in countries with limited resources. Even when NPAPs are included, 70 countries had a total anesthesia provider density of <5 per 100,000. Using current population data, over 136,000 additional PAPs would be needed immediately to achieve a minimum density of 5 per 100,000 population in all countries. CONCLUSIONS: The World Federation of Societies of Anaesthesiologists Global Anesthesia Workforce Survey is the most comprehensive study of the global anesthesia workforce to date. It is the first step in a process of ongoing data collection and longitudinal follow-up. The authors recommend an interim goal of at least 5 specialist physician anesthesia providers (anesthesiologists) per 100,000 population. A marked increase in training of PAPs and NPAPs will need to occur if we are to have any hope of achieving safe anesthesia for all by 2030.

Perioperative mortality rate (POMR): a global indicator of access to safe surgery and anaesthesia.

INTRODUCTION: The unmet global burden of surgical disease is substantial. Currently, two billion people do not have access to emergency and essential surgical care. This results in unnecessary deaths from injury, infection, complications of pregnancy, and abdominal emergencies. Inadequately treated surgical disease results in disability, and many children suffer deformity without corrective surgery. METHODS: A consensus meeting was held between representatives of Surgical and Anaesthetic Colleges and Societies to obtain agreement about which indicators were the most appropriate and credible. The literature and state of national reporting of perioperative mortality rates was reviewed by the authors. RESULTS: There is a need for a credible national and/or regional indicator that is relevant to emergency and essential surgical care. We recommend introducing the perioperative mortality rate (POMR) as an indicator of access to and safety of surgery and anaesthesia. POMR should be measured at two time periods: death on the day of surgery and death before discharge from hospital or within 30 days of the procedure, whichever is sooner. The rate should be expressed as the number of deaths (numerator) over the number of procedures (denominator). The option of before-discharge or 30 days is practical for those low- to middle-income countries where postdischarge follow-up is likely to be incomplete, but it allows those that currently can report 30-day mortality rates to continue to do so. Clinical interpretation of POMR at a hospital or health service level will be facilitated by risk stratification using age, urgency (elective and emergency), procedure/procedure group, and the American Society of Anesthesiologists grade. CONCLUSIONS: POMR should be reported as a health indicator by all countries and regions of the world. POMR reporting is feasible, credible, achieves a consensus of acceptance for reporting at national level. Hospital and Service level POMR requires interpretation using simple measures of risk adjustment such as urgency, age, the condition being treated or the procedure being performed and ASA status.

The impact of the Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia training course in Ethiopia: A mixed methods longitudinal cohort study.

SummaryReducing maternal mortality remains a global priority, particularly in low- and middle-income countries (LMICs). The Safer Anaesthesia from Education (SAFE) Obstetric Anaesthesia (OB) course is a three-day refresher course for trained anaesthesia providers addressing common causes of maternal mortality in LMICs. This aim of this study was to investigate the impact of SAFE training for a cohort of anaesthesia providers in Ethiopia.We conducted a mixed methods longitudinal cohort study incorporating a behavioural questionnaire, multiple-choice questionnaires (MCQs), structured observational skills tests and structured interviews for anaesthesia providers who attended one of four SAFE-OB courses conducted in two regions of Ethiopia from October 2017 to May 2018.Some 149 participants from 60 facilities attended training. Behavioural questionnaires were completed at baseline (n = 101, 69% response rate). Pre- and post-course MCQs (n = 121, n = 123 respectively) and pre- and post-course skills tests (n = 123, n = 105 respectively) were completed, with repeat MCQ and skills tests, and semi-structured interviews completed at follow-up (n = 88, n = 76, n = 49 respectively). The mean MCQ scores for all participants improved from 80.3% prior to training to 85.4% following training (P < 0.0001) and skills test scores improved from 56.5% to 83.2% (P < 0.0001). Improvements in MCQs and skills were maintained at follow-up 3-11 months post-training compared to baseline (P = 0.0006, < 0.0001 respectively). Participants reported improved confidence, teamwork and communication at follow-up.This study suggests that the SAFE-OB course can have a sustained impact on knowledge and skills and can improve the confidence of anaesthesia providers and communication within surgical teams.

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.