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Ensuring Safe Short-term Surgical Initiatives

In my previous blog post I began to discuss the WHO safe surgery initiatives, at least from the perspective of assessing the infrastructure through which care is provided. In this blog post I wanted to expand on that theme and discuss in more detail specific guidelines and objectives for the WHO Safe Surgery program. You can find much more detail on this subject in my book: When Healthcare Hurts: An evidence based guide for best practices in global health initiatives, and on the CHSC Clinical Resources Page.

Preventing Tragedies

Ensuring adherence to clinical practice guidelines, clinical pathways, and other evidence-based recommendations could not have more value than it does in short-term surgical initiatives. Few if any global health initiatives have as much to offer as surgical initiatives, however they also represent the highest potential for adverse outcomes. The potential for tragic outcomes can be decreased significantly by simply following the WHO safe surgery protocols, checklists, and current evidence-based recommendations for surgical safety in developing countries. The WHO World Alliance for Patient Safety (2009) “guidelines for safe surgery” outline the critical aspects of surgical safety in all countries. This document can be downloaded from the WHO website along with the safe surgery checklist and infrastructure requirements for safe surgery. There are 10 essential objectives for the WHO safe surgery guidelines, which are:

Ten Essential Objectives for Safe Surgery

Objective 1: Operate on the correct patient at the correct site.

Objective 2: Use methods known to prevent harm from administration of anesthetics while protecting the patient from pain.

Objective 3: Recognize and effectively prepare for life-threatening loss of airway or respiratory function.

Objective 4: Recognize and effectively prepare for risk of high blood loss.

Objective 5: Avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.

Objective 6: Consistently use methods known to minimize the risk for surgical site infection.

Objective 7: Prevent inadvertent retention of instruments and sponges in surgical wounds.

Objective 8: Secure and accurately identify all surgical specimens.

Objective 9: Communicate and exchange critical information for surgical safety.

Objective 10: Hospitals and public health systems will establish routine surveillance of surgical capacity, volume, and results.

(WHO World Alliance for Patient Safety, 2009, p. 10)

Levels of Recommendation

The WHO safe surgery guidelines are designed to meet these 10 objectives and are organized in three sections. They have been developed based on clinical evidence and expert opinion and are categorized based on their ability to reduce the likelihood of serious, avoidable surgical complications or adverse events. The three categories are as follows:

  • Highly Recommended: a practice that should be in place for each and every surgery.
  • Recommended: a practice that is encouraged for each and every surgery.
  • Suggested: a practice that should be considered for any surgery.

(WHO World Alliance for Patient Safety, 2009, p. 7)

Highly Recommended Practices

The following are considered highly recommended for peri-operative and peri-anesthesia care by the WHO.

  • Continuous presence of a vigilant, professionally trained anesthesia provider. If an emergency requires the brief, temporary absence of the primary anesthetist, judgment must be exercised in comparing the threat of an emergency to the risk of the anaesthetized patient’s condition and in selecting the clinician left responsible for anesthesia during the temporary absence.
  • Supplemental oxygen should be supplied for all patients undergoing general anesthesia. Tissue oxygenation and perfusion should be monitored continuously using a pulse oximeter with a variable-pitch pulse tone loud enough to be heard throughout the operating room.
  • The adequacy of the airways and of ventilation should be monitored continuously by observation and auscultation. Whenever mechanical ventilation is employed, a disconnect alarm should be used.
  • Circulation should be monitored continuously by auscultation or palpation of the heartbeat or by a display of the heart rate on a cardiac monitor or pulse oximeter.
  • Arterial blood pressure should be determined at least every 5 minutes and more frequently if indicated by clinical circumstances.
  • A means of measuring body temperature should be available and used at frequent intervals where clinically indicated (e.g., prolonged or complex anesthesia, children).
  • The depth of anesthesia (degree of unconsciousness) should be assessed regularly by clinical observation. (WHO World Alliance for Patient Safety, 2009, p. 25)

Recommended Practices

The following are considered recommended for peri-operative and peri-anesthesia care by the WHO.

  • Inspired oxygen concentration should be monitored throughout anesthesia with an instrument fitted with a low oxygen-concentration alarm. In addition, a device to protect against the delivery of a hypoxic gas mixture and an oxygen supply-failure alarm should be used.
  • Continuous measurement and display of the expired carbon dioxide waveform and concentration (capnography) should be used to confirm the correct placement of an endotracheal tube and the adequacy of ventilation.
  • The concentrations of volatile agents should be measured continuously, as should inspiratory or expired gas volumes.
  • An electrocardiograph should be used to monitor heart rate and rhythm.
  • A cardiac defibrillator should be available.
  • Body temperature should be measured continuously in patients in whom a change is anticipated, intended, or suspected. This can be done by continuous electronic temperature measurement, if available.
  • A peripheral nerve stimulator should be used to assess the state of paralysis when neuromuscular-blocking drugs are given. (WHO World Alliance for Patient Safety, 2009, p. 25)
WHO World Alliance for Patient Safety. (2009). WHO guidelines for safe surgery. Geneva: WHO.

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