Iain H. Wilson

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anesthesia care in low- and middleincome countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labor, congenital anomalies, and breast and cervical cancer. Although the term, low- and middleincome countries (LMICs), has been used throughout the report for brevity, the Commission realizes that tremendous income diversity exists between and within this group of countries. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, noncommunicable diseases, and injuries. Surgical and anesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anesthesiacare,whichshouldbeavailable, affordable,timely,andsafetoensuregood coverage, uptake, and outcomes. Despite a growing need, the develop

Global operating theatre distribution and pulse oximetry supply: an estimation from reported data

BACKGROUND Surgery is an essential part of health care, but resources to ensure the availability of surgical services are often inadequate. We estimated the global distribution of operating theatres and quantified the availability of pulse oximetry, which is an essential monitoring device during surgery and a potential measure of operating theatre resources. METHODS We calculated ratios of the number of operating theatres to hospital beds in seven geographical regions worldwide on the basis of profiles from 769 hospitals in 92 countries that participated in WHOs safe surgery saves lives initiative. We used hospital bed figures from 190 WHO member states to estimate the number of operating theatres per 100,000 people in 21 subregions throughout the world. To estimate availability of pulse oximetry, we sent surveys to anaesthesia providers in 72 countries selected to ensure a geographically and demographically diverse sample. A predictive regression model was used to estimate the pulse oximetry need for countries that did not provide data. FINDINGS The estimated number of operating theatres ranged from 1·0 (95% CI 0·9-1·2) per 100,000 people in west sub-Saharan Africa to 25·1 (20·9-30·1) per 100,000 in eastern Europe. High-income subregions all averaged more than 14 per 100,000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100,000. Pulse oximetry data from 54 countries suggested that around 77,700 (63,195-95,533) theatres worldwide (19·2% [15·2-23·9]) were not equipped with pulse oximeters. INTERPRETATION Improvements in public-health strategies and monitoring are needed to reduce disparities for more than 2 billion people without adequate access to surgical care. FUNDING WHO.

Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development

John G Meara*, Andrew J M Leather*, Lars Hagander*, Blake C Alkire, Nivaldo Alonso, Emmanuel A Ameh, Stephen W Bickler, Lesong Conteh, Anna J Dare, Justine Davies, Eunice Dérivois Mérisier, Shenaaz El-Halabi, Paul E Farmer, Atul Gawande, Rowan Gillies, Sarah L M Greenberg, Caris E Grimes, Russell L Gruen, Edna Adan Ismail, Thaim Buya Kamara, Chris Lavy, Ganbold Lundeg, Nyengo C Mkandawire, Nakul P Raykar, Johanna N Riesel, Edgar Rodas‡, John Rose, Nobhojit Roy, Mark G Shrime, Richard Sullivan, Stéphane Verguet, David Watters, Thomas G Weiser, Iain H Wilson, Gavin Yamey, Winnie Yip

Global oximetry: an international anaesthesia quality improvement project

Pulse oximetry is mandatory during anaesthesia in many countries, a standard endorsed by the World Health Organization ‘Safe Surgery Saves Lives’ initiative. The Association of Anaesthetists of Great Britain and Ireland, the World Federation of Societies of Anaesthesiologists and GE Healthcare collaborated in a quality improvement project over a 15‐month period to investigate pulse oximetry in four pilot sites in Uganda, Vietnam, India and the Philippines, using 84 donated pulse oximeters. A substantial gap in oximeter provision was demonstrated at the start of the project. Formal training was essential for oximeter‐naïve practitioners. After introduction of oximeters, logbook data were collected from over 8000 anaesthetics, and responses to desaturation were judged appropriate. Anaesthesia providers believed pulse oximeters were essential for patient safety and defined characteristics of the ideal oximeter for their setting. Robust systems for supply and maintenance of low‐cost oximeters are required for sustained uptake of pulse oximetry in low‐ and middle‐income countries.

Extending the WHO ‘Safe Surgery Saves Lives’ project through Global Oximetry

Pulse oximetry is widely accepted as essential during anaesthesia and its use is considered mandatory in the UK, Canada and the USA, Australia and New Zealand, much of Europe and South America, and many other countries around the world. At present, however, there are still places where oximeters are simply not available [1, 2]. At the World Congress of Anaesthesiologists in Paris in 2004, the Quality and Safety of Practice Committee of the World Federation of Societies of Anaesthesiologists (WFSA) identified the provision of pulse oximeters for use on every patient undergoing anaesthesia in the world as a priority for patient safety. From this grew the Global Oximetry (GO) initiative [3, 4]. Pilot projects have been underway in regions of Uganda, Vietnam, the Philippines and India. The World Health Organization (WHO) has now adopted this mission as a significant component of its Second Global Patient Safety Challenge. This challenge, Safe Surgery Saves Lives (SSSL) [5], launched in 2007, recognised the rising importance of surgery to public health. With increasing urbanisation and longevity, diseases characteristic of industrialised nations are becoming more prevalent even in resource-challenged low income nations and access to safe and effective surgery is increasingly essential for the health of populations worldwide. In 2008, Weiser et al. estimated the number of operations performed annually around the world as in the order of 230 million – double the number of births [6]. Global distribution is uneven: only 3.5% of surgery is undertaken in the poorest third of the world’s population, and this inadequacy of surgical services in many countries leads to the loss of 164 million disability-adjusted life years annually [7]. Even in industrialised countries, where there is generally good access to surgical services, major complication rates (estimated between 3% and 17%) are unacceptably high. Some of these complications are attributable to anaesthesia; many of them are avoidable. Safe surgery depends on (amongst other things) safe anaesthesia. The WHO SSSL initiative intends to improve safety in surgery and anaesthesia on a global scale. Anaesthesia today is typically very safe in high-income countries, where mortality solely attributable to anaesthetic complications has fallen to rates between 1 in 50 000 and 1 in 200 000 [8]. Unfortunately, there are still places where the anaesthesia mortality rate is probably 1000 times higher than this [9]; in such areas most anaesthesia providers tend to have little training and appallingly inadequate resources [10]. Furthermore, these colleagues are often very disempowered, and poorly placed to address the serious deficiencies in the services they are asked to provide for the large numbers of patients in need of surgery. If adequate access to surgery is important for a nation’s health, then so is adequate access to anaesthesia. However, surgery (and particularly elective surgery) is only worthwhile at acceptable limits of safety. No surgeon would attempt to provide an elective surgical service without a basic set of sterile instruments and sutures; safe anaesthesia is just as important and, in the same way, safety requires trained anaesthesia providers in adequate numbers with access to essential equipment and drugs. In the Safe Surgery Saves Lives project [5], the WHO brought together experts in surgery, anaesthesia, perioperative nursing and related disciplines. The task was to develop a strategy for safer surgery globally. The participants met face to face on several occasions during 2007 and 2008, corresponded between meetings, reviewed the relevant evidence, and iteratively developed consensus guidelines, captured in a substantial technical document. A key output was the WHO Surgical Safety Checklist [11]. As part of the development of this work, the International Standards for a Safe Practice of Anaesthesia, developed in the early 1990s, were revised to reflect advances in anaesthesia over the intervening years [12]. A key revision was the recommendation that pulse oximetry should be used in all anaesthetics worldwide. On the basis of this recommendation, oximetry was included as an essential item on the ‘Sign-In’ of the WHO surgical safety checklist. For some, this endorsement of oximetry by the WHO may seem controversial. In this era of evidence-based medicine (EBM), the fact is that hard evidence to support the routine use of pulse oximetry is limited. In fact, a 2002 Cochrane review concluded: ‘... we have found no evidence that pulse oximetry affects the outcome of anaesthesia. The conflicting subjective and objective results of the studies, despite an intense, methodical collection of data from a relatively large population, indicate that the value of peri-operative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency.’ [13] It is tempting to ignore this review or, as with the value of parachute use [14], simply to discount it as flying in the face of the obvious. However, a close analysis of this Cochrane review is quite illuminating. The starting point of such an analysis must be an appreciation that ‘evidence’ does not only come from randomised controlled trials. Sackett has defined EBM as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research’ [15]. We think the 2002 Cochrane review of Pedersen et al. fails Anaesthesia, 2009, 64, pages 1045–1050 .....................................................................................................................................................................................................................

Nationwide survey on resource availability for implementing current sepsis guidelines in Mongolia

OBJECTIVE To assess if secondary and tertiary hospitals in Mongolia have the resources needed to implement the 2008 Surviving Sepsis Campaign (SSC) guidelines. METHODS To obtain key informant responses, we conducted a nationwide survey by sending a 74-item questionnaire to head physicians of the intensive care unit or department for emergency and critically ill patients of 44 secondary and tertiary hospitals in Mongolia. The questionnaire inquired about the availability of the hospital facilities, equipment, drugs and disposable materials required to implement the SSC guidelines. Descriptive methods were used for statistical analysis. Comparisons between central and peripheral hospitals were performed using non-parametric tests. FINDINGS The response rate was 86.4% (38/44). No Mongolian hospital had the resources required to consistently implement the SSC guidelines. The median percentage of implementable recommendations and suggestions combined was 52.8% (interquartile range, IQR: 45.8-67.4%); of implementable recommendations only, 68% (IQR: 58.0-80.5%) and of implementable suggestions only, 43.5% (IQR: 34.8-57.6%). These percentages did not differ between hospitals located in the capital city and those located in rural areas. CONCLUSION The results of this study strongly suggest that the most recent SSC guidelines cannot be implemented in Mongolia due to a dramatic shortage of the required hospital facilities, equipment, drugs and disposable materials. Further studies are needed on current awareness of the problem, development of national reporting systems and guidelines for sepsis care in Mongolia, as well as on the quality of diagnosis and treatment and of the training of health-care professionals.

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.

The World Health Organization and anaesthesia

The World Health Organization has been involved in a wide range of global healthcare initiatives for many years. Recently an initiative ‘Safe Surgery Saves Lives’ has been launched to improve the safety of surgery throughout the world. Safe anaesthesia is a key component to achieving this aim.

Evaluation of a large-scale donation of Lifebox pulse oximeters to non-physician anaesthetists in Uganda

Pulse oximetry is widely accepted as essential monitoring for safe anaesthesia, yet is frequently unavailable in resource‐limited settings. The Lifebox pulse oximeter, and associated management training programme, was delivered to 79 non‐physician anaesthetists attending the 2011 Uganda Society of Anaesthesia Annual Conference. Using a standardised assessment, recipients were tested for their knowledge of oximetry use and hypoxia management before, immediately following and 3–5 months after the training. Before the course, the median (IQR [range]) test score for the anaesthetists was 36 (34–39 [26–44]) out of a maximum of 50 points. Immediately following the course, the test score increased to 41 (38–43 [25–47]); p < 0.0001 and at the follow‐up visit at 3–5 months it was 41 (39–44 [33–49]); p = 0.001 compared with immediate post‐training test scores, and 75/79 (95%) oximeters were in routine clinical use. This method of introduction resulted in a high rate of uptake of oximeters into clinical practice and a demonstrable retention of knowledge in a resource‐limited setting.

Lifebox: A Global Patient Safety Initiative.

The safety of anesthesia was dramatically improved by the introduction of pulse oximetry. This technology was rapidly adopted by anesthesiologists and made a standard of practice in many countries. In 2007, during development of the Surgical Safety Checklist, the World Health Organization recommended a pulse oximeter as a monitor for all patients undergoing anesthesia. However, clinicians in low- and middle-income countries lack access to basic anesthesia equipment, including pulse oximeters. The Lifebox Foundation was formed to determine how a suitable oximeter could be made available to anesthesia providers in these countries. Almost 11,000 oximeters have been delivered in 90 countries, with education courses completed in over 50 countries.