Implementation of the World Health Organisation Surgical Safety Checklist in the Republic of Benin
Funding recipient: Dr Kirsty Wright
The World Health Organisation Surgical Safety Checklist (WHO SSC) was just another piece of paper to fill in. My hospital introduced it as I started my basic anaesthesia training, and to me it was just part of the process of giving an anaesthetic. With everything else you learn in those first few months, I had never really thought about the why. And honestly, at times I complained about it as much as the next person.
Fast forward 3 1/2 years and I am on a plane on my way to the Republic of Benin. When I first heard about the opportunity, I had to look on a map to find this francophone country in West Africa, sandwiched between Nigeria and Togo. Now, I’m on my way to meet the Africa Mercy, a hospital ship with Mercy Ships and the largest non-governmental hospital ship in the world. My plan is to spend 4 months working with their Medical Capacity Building (MCB) team on a project to implement the Checklist across the country. I arrive in Cotonou, Benin’s largest city, after 36 hours of travelling – tired, hot, slightly overwhelmed but mainly excited about the task ahead.
On the first night I meet my cabin mates, the three people I will be spending a lot of time with in a very small space! As I stand in the middle of the cabin, swaying slightly (I discovered in the morning that the boat does still move even though it is in port), I learn that between us, we have 4 nationalities and speak 5 languages, which is representative of many of the 400 crew aboard the Africa Mercy. From 49 nationalities with different language and cultural backgrounds, we make a community striving to bring surgery to those with limited or no access and improve the provision of safe of surgery within the country. As I learn more about my project in particular, I am struck by the enormity of the task we have set ourselves. Over 10 months we aim to contact 37 government run hospitals providing surgical services to many of the 10.87 million people living in Benin. The programme includes information and workshops around the WHO SSC (affectionately referred to as ‘La Checklist’), surgical instrument counting for the surgical teams and Lifebox/hypoxia teaching for the anaesthetic teams.
The project has already been going for 6 months by the time I arrive, so I need to hit the ground running. Within 48 hours of boarding the ship, we are off on our first road trip. Leaving the ship at 0500 with our Landrover packed and our last minute checks done, we head north. In 3 days we will visit 5 hospitals, in each meeting the medical director followed by the theatre team. We go on to have a discussion about the Checklist and then have a simulation or live case to watch them using it. And of course, it is all done in French. I start to leave my sense of strict scheduling behind, and get a little better at falling into local patterns. It is a gruelling and exhausting few days, but the enthusiasm and passion of my team is infectious and helps to keep me motivated. The following trips, lasting anywhere from 3 days to 3 weeks, become a routine of early starts and long dusty hours on the road, contending with potholes, dirt roads, speeding articulated lorries and overladen motorbikes. And of course, the journey wouldn’t be complete without the infamous road closed sign – a tree branch across the road – with no diversion signs and limited GPS to decide on an alternative route. This alone taught me my first important lessons of working in Africa: flexibility and patience, two lessons that would stand me in good stead!
The 4 months is a roller coaster of emotions as we teach and provide ongoing support and follow up to each theatre team. The daily challenges faced by these teams are incredible, and the ‘lack of personnel, equipment, infrastructure and reliable electricity’ statement is echoed through many of the institutions. One hospital in particular was using a series of shipping containers as their operating suite, a temporary solution devised several years ago while construction of a permanent facility took place. When we visited, they were still waiting to break ground! However, the commitment from the teams to providing a surgical service in these adverse conditions is inspiring, as is the enthusiasm with which they embrace the initiatives to improve their patient safety. Particularly where the teams had put in place additional systems to improve patient safety as a result of the Checklist, including patient identification labels, specimen labels, ensuring the midwife is present at the beginning of the caesarean section and specific areas of theatre dedicated to neonatal care and resuscitation.
It turns out our task was possible. Over the 10 months, we taught 877 participants and followed up directly with 32 of the 37 hospitals. The majority were using the Checklist on a regular basis, or at least trying to. There are already stories of where it has reduced morbidity, and potentially mortality. One hospital had two patients with the same name from the same village, for two different procedures, and the Checklist identified this. In another hospital, they identified that a key piece of equipment wasn’t working before the patient received their anaesthetic. Whether it is finding that missing surgical swab, or ensuring the right procedure is being done on the right patient, these stories continue to be told. It was a privilege and humbling experience to work with these incredible, hardworking and passionate teams (both on board the Africa Mercy and within the local hospitals). I would like to thank Mercy Ships for the opportunity to work on this project, and the Scottish Society of Anaesthetists for their generous support.
An Experience Working with Felege Hiwot Referral Hospital, Ethiopia
Funding recipient: Dr Ryan Ellis
I am a post FY 2 doctor trained in Scotland and currently working in Ethiopia within the wider developed partnership between The University of Aberdeen/The Soapbox Collaborative and The University of Bahir Dar/Felege Hiwot Hospital. I have been fortunate to have this experience in Ethiopia, working closely with Dr Jolene Moore (a ST 7 Anaesthetist working in Aberdeen involved in the above mention partnership), to develop a number of projects at Felege Hiwot. I would thus firstly like to thank The Scottish Society of Anaesthetists for the funding provided for this 7 month period.
Ethiopia is a landlocked country of 82.8 million people in Eastern Africa. The economy is largely agricultural based with coffee and flowers being major exports to Europe. It is also a country that is undergoing significant development and expansion, particularly of its healthcare services. However, its Gross National Income per capita was estimated at $410 in 20121 and there also remains only 0.2 physicians per 10,000 people2. This paints a picture of a country moving forward in its health care development but with many ongoing challenges.
Felege Hiwot Referral Hospital (FHRH) is located in the Northern Amhara region of Ethiopia, in the city of Bahir Dar. FHRH is one of the earliest known hospitals in the Amhara region established during the reign of Emperor Silasie in 1962. The hospital was originally designed to serve 25,000 people, however, given its large geographical catchment area, at present is expected to serve approximately 12 million!
Approximately 150 major elective procedures and 200 major emergency surgeries are performed per month. To manage this workload the hospital has four general surgical operating rooms and one obstetrics and gynaecology operating room (which has capacity for two patients at one time). There are no physician trained anaesthesiologists with anaesthetists coming from a nursing background with a BSc or MSc in Anaesthesia. Many procedures are performed under spinal anaesthesia (delivered via use of a basic cannula) and there are modern anaesthetic machines for general anaesthesia with halothane as the primary inhalational agent. However, despite the use of relatively modern machines, the monitoring and airway equipment are often basic and limited.
As recognised by the Lancet Commission on Global Surgery, the global burden of disease is increasingly shifting towards a need for significant development of surgical care3. Despite this recognition, surgical and anaesthetic care worldwide, and work conducted to implement improvement, remains significantly disparate across the globe. Good surgical care is indispensable to a properly functioning health system.
With the above in mind Dr Moore and I have worked closely, within the partnership described, to develop a number of quality improvement projects in FHRH around surgical and critical care services.
Beginning with the ICU, which has been newly developed during my time at FHRH. The care provided here is certainly at a higher level compared to the general wards with one to one nursing being employed. There is use of mechanical ventilation too but the lack of highly trained staff and shortages of monitoring equipment often results in great difficulty managing the exceptionally ill patients that present here. The range of presentations is highly variable from trauma to heart disease to metal phosphide poisoning (a common method of attempted suicide in Ethiopia) to cerebral malaria. Much work here has been led by Dr Jolene Moore to provide the much needed training to the enthusiastic ICU staff. We are also prospectively collecting data on every patient that is admitted to the ICU so a series of the cases that come to the ICU, how they are managed and their outcome can be collated.
The difficulty with providing such high level care to often very ill patients leads us to the basis of the work initiated regarding post-surgical monitoring and resuscitation training for Interns and nurses. Focus here was given to training in the concepts of an ABCDE response to a deteriorating patient. This was coupled with the development of improved monitoring in the post-surgical recovery area. The recovery area at FHRH is not in a separate specialised area but a section of the general surgical ward that is designated for post-surgical patients. In such a busy and crowded hospital patients can leave the operating theatre to be placed in a corridor where it is difficult for staff to deliver the attention the patient requires. The teaching around increased monitoring in this area and development of an ABCDE approach to resuscitation of a deteriorating patient were designed around the concept of the ‘Chain of Prevention’ advocated by the Resuscitation Council UK4.
The final piece of work to mention is the gradual introduction of a modified WHO Safe Surgery Checklist5 to the operating rooms of both General Surgery and Obstetrics & Gynaecology. Many clinicians will now be familiar with this checklist that was developed in 2008 from WHO published guidelines that aimed to improve surgical safety worldwide.
Thus my experience in FHRH has taken me to improving care in the operating theatre, to promoting early recognition and prompt intervention of deteriorating post-surgical patients and into the ICU when the patient becomes critical. This has been a broad experience working with exceptional staff in an often very challenging environment. It has also reinforced my belief in the vast benefits patients globally can gain from the very real, achievable and sustainable improvements in surgical and critical care that can be implemented.
Dr Ryan Ellis
- UNICEF (2013) Ethiopia Statistics. (Online; accessed 9th September 2016). Available from: http://www.unicef.org/infobycountry/ethiopia_statistics.html
- WHO (2011) Ethiopia; health profile [Online; accessed 6th September 2016]. Available from: http://www.who.int/gho/countries/eth.pdf
- The Lancet (2015). The Lancet Commission on Global Surgery. Online; accessed 9th September 2016). Available from: http://www.thelancet.com/commissions/global-surgery
- Resuscitation Council UK (2016) Prevention of cardiac arrests and decisions about CPR. Online; accessed 9th September 2016). Available from: https://www.resus.org.uk/resuscitation-guidelines/prevention-of-cardiac-arrest-and-decisions-about-cpr/
- WHO (2016) WHO Surgical Safety Checklist. (Online; accessed 9th September 2016). Available from: http://www.who.int/patientsafety/safesurgery/checklist/en/
Project: Does Procollagen Peptide III (PCP-III) predict susceptibility to lung injury after cardiac surgery?
Funding recipient: Dr Philip McColl
Some patients become unwell with breathing problems following heart-surgery. This can be as a result of the surgery or the supportive techniques used during the operation. Breathing problems range from mild to severe with some patients requiring extra support from a ventilator.
It is difficult to predict which patients will develop difficulties. Measurements performed in blood samples may help predict which patients are at risk. This study will analyse samples already collected from heart-surgery patients to see if we can predict which patients will develop breathing problems. In the future this may allow care to be tailored for individual patients.