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Short-term Surgical Missions: How can we make them safe for patients?

Safe Surgery Considerations in the Developing World

Surgery conducted in developed and developing countries presents different challenges. Schneider et al.’s (2011) “Volunteers in plastic surgery guidelines for providing surgical care of children in the less developed world” outlines 10 guidelines that closely parallel the WHO safety guidelines. However, they were developed from the perspective of surgical providers who practice in developing countries.

They address considerations that providers trained in developing countries will automatically consider. These include: the ramifications of operating on malnourished children, the delayed healing process from poor nutrition, need for longer post operative admission because patients will often need to walk home, or be transported long distances across challenging terrain etc. Failure of providers from developed countries to consider such issues has resulted in reported child deaths and postoperative complications  (Garbern, 2010). They also address the need for a facility site visit to ensure adequate healthcare infrastructure to perform surgery safely. Needle stick HIV chemoprophylaxis is also included in this set of guidelines, and this is considered an important consideration for global health surgical volunteers.

Using Facility Site Visits to Assess Surgical Capacity and Infrastructure

Infrastructure assessment is a vital aspect of setting up a safe global surgical initiative. According to the WHO World Alliance for Patient Safety (2009), medical facilities are divided into three levels, with each having defined equipment requirements.

  • Level 1 facilities are small hospitals or health centers, and they should meet at least “highly recommended” anesthesia standards.
  • Level 2 facilities are district or provincial facilities, and they should meet at least “highly recommended” and “recommended” anesthesia standards.
  • Level 3 facilities are referral facilities, and they should meet at least “highly recommended,” “recommended,” and “suggested” anesthesia standards.

The following are the equipment and infrastructure expected for the respective facility levels of care. However, it is important to note that although these are expected standards, many facilities lack even the most basic infrastructure for safe surgery. One cannot assume that just because a facility has a level designation that it is anywhere close to meeting recommended safety and equipment requirements. This makes a site visit for patient safety infrastructure a requirement for surgical initiatives.

Checklists for Evaluation of Sites

There delineation of these levels and what is expected to meet each level designation in the WHO Alliance for Patient Safety Guidelines for Safe Surgery 2009 on pages 22-24.  This and similar resources can be found on the CHSC Clinical Resources page. In my book When Healthcare Hurts I modified here into infrastructure checklists for surgical providers and project leaders to use during their pre-project site assessment. It is recommended that global surgical programs partner with Level 2 or Level 3 facilities to achieve optimal levels of patient safety.

Facility and site assessment should take place months before the planned short-term surgical project. The WHO equipment and medication lists below should be used to assist in the final site approval. If a facility is a Level 1 but infrastructure can be supplemented with equipment and medication by the visiting group, this is acceptable. The present existing infrastructure, team’s ability to improve the infrastructure, consistency of power supply, consistency of oxygen supply, and functionality of anesthesia equipment should all be taken into consideration in the final site approval.

Many facilities have equipment that has not been used for some time or at all, and it is therefore important to check to make sure not only that the equipment is there but also that it is functioning properly. Consequently, it is ideal that an anesthesia provider complete the surgical site assessment whenever possible. Other medications and equipment highly recommended for global health surgical initiatives that are not included in the WHO medication and infrastructure list include (a) a malignant hyperthermia treatment kit with dantrolene and (b) an HIV needle stick chemoprophylaxis for team members.

References:

Garbern, S. C. (2010). Medical relief trips…what’s missing? Exploring the ethical issues and the physician-patient relationship. Einstein Journal of Biology and Medicine, 38-40.
Schneider, W. J., Politis, G. D., Gosain, A. K., Migliori, M. R., Cullington, J. R., & Peterson, E. L. (2011). Volunteers in plastic surgery guidelines for providing surgical care of children in the less developed world. Journal of Plastic and Reconstructive Surgery, 2477-2486.
WHO World Alliance for Patient Safety. (2009). WHO guidelines for safe surgery. Geneva: WHO.

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