Improving Anesthetic Safety in Low/Middle Income Countries: A Different Challenge

Patricia Livingston, MD; Marcel Durieux, MD, PhD

The mission of APSF is “to improve continually the safety of patients during anesthesia care by encouraging and conducting: (1) safety research and education, (2) patient safety programs and campaigns, and (3) national and international exchange of information and ideas.” Whereas we focus mostly on improving anesthetic safety in the U.S., work being done in other settings fits the APSF mission statement perfectly. This article describes 2 papers published recently about anesthetic safety improvement in Rwanda.

ANTS in Africa

Rwanda, a small and densely populated country in East Africa, has about 15 anesthesiologists for 12 million people. All physician anesthesiologists work at a few university-associated teaching hospitals. In about 40 district hospitals throughout the country, technicians, who have no more than 3 years training after high school, provide all anesthesia services. They work in geographic isolation and have virtually no opportunity for continuing education. Cesarean deliveries form the majority of procedures in district hospitals, and maternal mortality is estimated at 340 deaths per 100,000 live births in Rwanda (the U.S.number is about 19*).1 Suboptimal anesthetic management plays an important role in this: an observational study in a Rwandan district hospital found that pre-anesthetic assessment was omitted in 95% of patients and general anesthesia with an unprotected airway was given in 84% of patients.2 Overall, in sub-Saharan Africa one-third of perioperative mortality for cesarean section is considered attributable to anesthesia factors.3

* This number has been increasing from 12.4 in 1990, as published recently in the Lancet by Dr. Kassebaum, a pediatric anesthesiologist.11

A group of Rwandan, Canadian, and U.S. anesthesiologists set out to provide safety training. This was not an easy proposition, for both logistical and cultural reasons. Approaches to safety education must be culturally informed, or they will likely fail. The group therefore performed an assessment of Anesthetists’ Non-Technical Skills (ANTS)4—something not previously done in low/middle income countries.5 Through observation and interviews, they identified recurring themes that prevented providers from practicing safely. Communication, a key concept in ANTS, was found to be influenced in Rwanda by lack of resources and a formal hierarchical structure. The former led to persistent frustration, but also induced resignation to being without adequate supplies; the latter led to a fear of speaking up for safety. It is obviously difficult to maintain safety standards when critical equipment or drugs are routinely missing, and cultural barriers prevent one from voicing concern about unsafe situations.

These findings indicated that educational efforts to improve safety in the country should include training in leadership and communication skills, encouraging both role definition and speaking up for patient safety.

The SAFE Course

These concepts were subsequently applied to an educational safety initiative for anesthesia technicians to improve obstetric anesthesia practice in Rwanda.6 The model used was the Safer Anaesthesia From Education (SAFE) course, a 3-day refresher course developed by the Association of Anaesthetists of Great Britain and Ireland.7 Topics include essential obstetric anesthesia knowledge and skills, management of critical events (such as airway difficulties, hemorrhage and preeclampsia), and non-technical skills. Training-of-trainers (TOT) is embedded in the course, in order to allow subsequent courses to be given without outside support. Given the constraints identified in the ANTS study, it was clear that simply delivering educational material would not likely change habits. To ensure new knowledge would be incorporated into practice, a framework known as the Knowledge-to-Action cycle8 was used. Its basic premise is that learners are more likely to implement new knowledge if they perceive it relevant to their needs and appropriate to their context. Thus, the SAFE course, adapted to Rwanda circumstances, featured active hands-on learning, dialogue between participants and mentors, as well as discussions around enablers and barriers to practice change.

Ninety technicians, representing about half of the Rwanda district hospitals, participated in the course and 26 trainers were invited for TOT. Needs assessments were conducted with participants to ensure their priority topics would be well covered. Immediately before the course, a full-day workshop was held to reflect on current practice: experiences, positive and negative, were explored to identify areas of strength and weakness. During the course itself, mentors assigned to geographic regions met with small groups of participants from that area to start a program known as the Anesthesia Practice Network (APN). The purpose of APN is to support participants in practice change after the course and to reduce their sense of isolation.

At the end of the course, the participants were asked to identify concrete changes they wanted to make in their practice, obstacles to those changes, and factors that would help them to make the changes. They were also provided with logbooks to record their progress. In addition, 90 Lifebox pulse oximeters9 were distributed to the participants as a start to country-wide distribution of 250 units. This includes training on use of the pulse oximeter, as well as an introduction to the WHO Surgical Safety Checklist.10

Going Forward

In order to assess impact, 6 months following the course, a purposive (i.e., chosen to best enable the researchers to understand the subject being studied) sample of participants was visited and interviewed. These interviews and review of logbooks showed that real change had taken place: participants routinely performed preoperative assessment, prepared better for anesthesia, employed left lateral tilt, and managed emergencies more systematically. In addition, they felt more confident in speaking up for safety. However, resistance to change by colleagues who had not attended the course remained a problem, as were supply shortages.

To build on this momentum, a second course was held a year later for a smaller group, which (in response to feedback) also included surgeons, midwives, and nurses. Some of the TOT graduates taught in this second course. The hope is that the future will see more smaller, regional courses, run by prior SAFE course graduates.

Lessons Learned

What can we learn from this remarkable program? First, it exemplifies how patient safety educational interventions need to be matched closely to the learners. This would not have worked without all the careful preparation, assessment and adaptation. This lesson is as applicable to the U.S. as it is to Rwanda; indeed, it would be good for us to consider if our safety initiatives are always optimally prepared in this respect. Second, it is possible to achieve real improvements in patient safety with modest expenditures in low/middle income countries. In fact, when considered as a value proposition (impact per expenditure), an intervention such as the SAFE course ranks very high, and as such this project is a model for other countries. Finally, it is good to realize that work fulfilling the 3 aspects of the APSF mission does not need to be restricted to the western world.

Patricia Livingston, MD, is Associate Professor of Anesthesiology, Dalhousie University, Canada.

Marcel Durieux, MD, PhD, is Professor of Anesthesiology, University of Virginia, USA.


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