John Sampson

Engaging staff to improve quality and safety in an austere medical environment: a case-control study in two Sierra Leonean hospitals.

QUALITY PROBLEM OR ISSUE Inadequate observance of basic processes in patient care such as patient monitoring and documentation practices are potential impediments to the timely diagnoses and management of patients. These gaps exist in low resource settings such as Sierra Leone and can be attributed to a myriad of factors such as workforce and technology deficiencies. INITIAL ASSESSMENT In the study site, only 12.4% of four critical vital signs were documented in the pre-intervention period. CHOICE OF SOLUTION Implement a failure mode and effects analysis (FMEA) to improve documentation of four patient vital signs: temperature, blood pressure, pulse rate and respiratory rate. IMPLEMENTATION FMEA was implemented among a subpopulation of health workers who are involved in monitoring and documenting patient vital signs. Pre- and post-FMEA monitoring and documentation practice were compared with a control site. EVALUATION Participants identified a four-step process to monitoring and documenting vital signs, three categories of failure modes and four potential solutions. Based on 2100 patient days of documentation compliance data from 147 patients between July and November 2012, staff members at the study site were 1.79 times more likely to document all four patient vital signs in the post-implementation period (95% CI [1.35, 2.38]). LESSONS LEARNED FMEA is a feasible and effective strategy for improving quality and safety in an austere medical environment. Documentation compliance improved at the intervention facility. To evaluate the scalability and sustainability of this approach, programs targeting the development of these types of process improvement skills in local staff should be evaluated.

Anesthesia Practice and Perioperative Outcomes at Two Tertiary Care Hospitals in Freetown, Sierra Leone.

BACKGROUND:Anesthesia in West Africa is associated with high mortality rates. Critical shortages of adequately trained personnel, unreliable electrical supply, and lack of basic monitoring equipment are a few of the unique challenges to surgical care in this region. This study aims to describe the anesthesia practice at 2 tertiary care hospitals in Sierra Leone. METHODS:We conducted an observational study of anesthesia care at Connaught Hospital and Princess Christian Maternity Hospital in Freetown, Sierra Leone. Twenty-five percent of the anesthesia workforce in Sierra Leone, resident at both hospitals, was observed from June 2012 to February 2013. Perioperative assessments, anesthetic techniques, and intraoperative clinical and environmental irregularities were noted and analyzed. The postoperative status of observed cases was ascertained for morbidity and mortality. RESULTS:Between the 2 hospitals, 754 anesthesia cases and 373 general anesthetics were observed. Ketamine was the predominant IV anesthetic used. Both hospitals experienced infrastructural and environmental constraints to the delivery of anesthesia care during the observation period. Vital sign monitoring was irregular and dependent on age and availability of monitors. Perioperative mortality during the course of the study was 11.9 deaths/1000 anesthetics. CONCLUSIONS:We identified gaps in the application of internationally recommended anesthesia practices at both hospitals, likely caused by lack of available resources. Mortality rates were similar to those in other resource-limited countries.

Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone

Background Anaesthesia care in developed countries involves sophisticated technology and experienced providers. However, advanced machines may be inoperable or fail frequently when placed into the austere medical environment of a developing country. Failure mode and effects analysis (FMEA) is a method for engaging local staff in identifying real or potential breakdowns in processes or work systems and to develop strategies to mitigate risks. Methods Nurse anaesthetists from the two tertiary care hospitals in Freetown, Sierra Leone, participated in three sessions moderated by a human factors specialist and an anaesthesiologist. Sessions were audio recorded, and group discussion graphically mapped by the session facilitator for analysis and commentary. These sessions sought to identify potential barriers to implementing an anaesthesia machine designed for austere medical environments—the universal anaesthesia machine (UAM)—and also engaging local nurse anaesthetists in identifying potential solutions to these barriers. Results Participating Sierra Leonean clinicians identified five main categories of failure modes (resource availability, environmental issues, staff knowledge and attitudes, and workload and staffing issues) and four categories of mitigation strategies (resource management plans, engaging and educating stakeholders, peer support for new machine use, and collectively advocating for needed resources). Conclusions We identified factors that may limit the impact of a UAM and devised likely effective strategies for mitigating those risks.

Assessing the surgical and obstetrics-gynecology workload of medical officers: findings from 10 district hospitals in Ghana.

HYPOTHESIS Surgical and obstetrics-gynecology (Ob-Gyn) workload of medical officers (MOs) is substantial and may inform policies for training investment and surveillance to strengthen surgical care at district hospitals in Ghana. DESIGN Observational study. SETTING Academic research. PARTICIPANTS Using standardized criteria, 12 trained on-site observers assessed the surgical and Ob-Gyn workload of MOs at 10 district hospitals in each of 10 administrative regions in Ghana, West Africa. The number of patients seen by MOs and the time spent managing each patient were recorded. According to each patients diagnosis, the encounters were categorized as medical/nonsurgical, Ob-Gyn, or surgical. MAIN OUTCOME MEASURES The proportions of patients having Ob-Gyn and surgical conditions and the time expended providing care to Ob-Gyn and surgical patients. RESULTS Of the observed patient encounters, 1600 (64.5%) were classified as medical or nonsurgical, 514 (20.7%) as Ob-Gyn, and 368 (14.8%) as surgical (9.0% nontrauma and 5.8% trauma). The most common diagnosis among Ob-Gyn patients was obstetric complication requiring cesarean section. The most common diagnosis among surgical patients was inguinal hernia. Medical officers devoted 24.8% of their time to managing Ob-Gyn patients and 18.9% to managing surgical patients (which included 5.4% for the management of traumatic injuries). CONCLUSIONS Surgical and Ob-Gyn patients represent a substantial proportion of the workload among MOs at district hospitals in Ghana. Strategies to increase surgical capacity at these facilities must include equipping MOs with the appropriate training and resources to address the significant surgical and Ob-Gyn workload they face.

Evaluation of a cardiopulmonary resuscitation curriculum in a low resource environment

Objectives To evaluate whether a 2-day International Liaison Committee on Resuscitation (ILCOR) Universal Algorithm-based curriculum taught in a tertiary care hospital in Liberia increases local health care provider knowledge and skill comfort level. Methods A combined basic and advanced cardiopulmonary resuscitation (CPR) curriculum was developed for low-resource settings that included lectures and low-fidelity manikin-based simulations. In March 2014, the curriculum was taught to healthcare providers in a tertiary care hospital in Liberia. In a quality assurance review, participants were evaluated for knowledge and comfort levels with resuscitation before and after the workshop. They were also videotaped during simulation sessions and evaluated on standardized performance metrics. Results Fifty-two hospital staff completed both pre- and post-curriculum surveys. The median score was 45% pre-curriculum and 82% post-curriculum (p<0.00001). The median provider comfort level score was 4 of 5 pre-curriculum and 5 of 5 post-curriculum (p<0.00001). During simulations, 93.2% of participants performed the pulse check within 10 seconds, and 97.7% performed defibrillation within 180 seconds. Conclusion Clinician knowledge of and comfort level with CPR increased significantly after participating in our curriculum. A CPR curriculum based on lectures and low-fidelity manikin simulations may be an effective way to teach resuscitation in this low-resource setting.

Medical Simulation as a Vital Adjunct to Identifying Clinical Life-Threatening Gaps in Austere Environments

BACKGROUND Maternal mortality and morbidity are major causes of death in low-resource countries, especially those in Sub-Saharan Africa. Healthcare workforce scarcities present in these locations result in poor perioperative care access and quality. These scarcities also limit the capacity for progressive development and enhancement of workforce training, and skills through continuing medical education. Newly available low-cost, in-situ simulation systems make it possible for a small cadre of trainers to use simulation to identify areas needing improvement and to rehearse best practice approaches, relevant to the context of target environments. METHODS Nurse anesthetists were recruited throughout Sierra Leone to participate in simulation-based obstetric anesthesia scenarios at the countrys national referral maternity hospital. All subjects participated in a detailed computer assisted training program to familiarize themselves with the Universal Anesthesia Machine (UAM). An expert panel rated the morbidity/mortality risk of pre-identified critical incidents within the scenario via the Delphi process. Participant responses to critical incidents were observed during these scenarios. Participants had an obstetric anesthesia pretest and post-test as well as debrief sessions focused on reviewing the significance of critical incident responses observed during the scenario. RESULTS 21 nurse anesthetists, (20% of anesthesia providers nationally) participated. Median age was 41 years and median experience practicing anesthesia was 3.5 years. Most participants (57.1%) were female, two-thirds (66.7%) performed obstetrics anesthesia daily but 57.1% had no experience using the UAM. During the simulation, participants were observed and assessed on critical incident responses for case preparation with a median score of 7 out of 13 points, anesthesia management with a median score of 10 out of 20 points and rapid sequence intubation with a median score of 3 out of 10 points. CONCLUSION This study identified substantial risks to patient care and provides evidence to support the feasibility and value of in-situ simulation-based performance assessment for identifying critical gaps in safe anesthesia care in the low-resource settings. Further investigations may validate the impact and sustainability of simulation based training on skills transfer and retention among anesthesia providers low resource environments.

Post‐Ebola situational assessment of opportunities for capacity building at the national obstetrics and gynecology referral hospital in Sierra Leone

To describe a site assessment of the Princess Christian Maternity Hospital (PCMH; Freetown, Sierra Leone), the national referral center for reproductive, maternal, newborn, child and adolescent health (RMNCAH) services and logical site for focused efforts to train and expand the RMNCAH workforce in Sierra Leone.

Cardiopulmonary Resuscitation Capacity in Referral Hospitals in Nigeria: Understanding the Global Health Disparity in Resuscitation Medicine

INTRODUCTION Little is known about the state of resuscitation services in low- and middle-income countries (LMICs), including Nigeria, Africas most populous country. We sought to assess the cardiopulmonary resuscitation (CPR) care in referral hospitals across Nigeria to better inform capacity-building initiatives. METHODS We designed a survey to evaluate infrastructure, equipment, personnel, training, and clinical management, as no standardized instrument for assessing resuscitation in LMICs was available. We included referral teaching hospitals with a functioning intensive care unit (ICU) and a department of anaesthesiology. We pilot-tested our tool at four hospitals in Nigeria and recruited participants electronically via the Nigerian Society of Anaesthetists directory. RESULTS Our survey included 17 hospitals (82% public, 12% private, 6% public-private partnership), although some questions include only a subset of these. We found that 20% (3 out of 15) of hospitals had a cardiac arrest response team system, 21% (3/14) documented CPR events, and 21% (3/14) reviewed such events for education and quality improvement. Most basic supplies were sufficient in the ICU (100% [15/15] availability of defibrillators, 94% [16/17] of adrenaline) but were less available in other departments. While 67% [10/15] of hospitals had a resuscitation training program, only 27% [4/15] had at least half their physicians trained in basic life support. CONCLUSION In this first large-scale assessment of resuscitation care in Nigeria, we found progress in training centre development and supply availability, but a paucity of cardiac arrest response team systems. Our data indicate a need for improved capacity development, especially in documentation and continuous quality improvement, both of which are low-cost solutions.

Board 355 - Research Abstract Training Non-Physician Anesthetists Using Medical Simulation In Freetown, Sierra Leone (Submission #1140)

Introduction/Background Medical simulation is a proven, powerful tool that is increasingly being used for training healthcare workers worldwide. Unfortunately, high-fidelity simulation has predominately remained an instrument found in high resource countries and experience with simulation for medical training in austere environments remains primarily anecdotal,1 and has not been extensively documented in the scientific literature.2,3 Anesthesia delivery in Sierra Leone, as with many other countries in Sub-Saharan Africa and worldwide, is performed primarily by non-physicians with two years of anesthesia training in a traditional apprenticeship model consisting of primarily didactic sessions, observation and direct patient care. We present our experience with introducing high fidelity, mobile simulation as a method for teaching anesthesia delivery using a new anesthesia machine at two tertiary-care hospitals in Freetown, Sierra Leone. Methods After obtaining IRB approval from the Johns Hopkins School of Medicine and the Ministry of Health and Sanitation, we conducted 100 high-fidelity medical simulations with non-physician anesthetists from seven different hospitals in and near Freetown, Sierra Leone. Educational goals of the training sessions were established based upon a targeted needs assessment from direct observation of over 700 anesthetics performed between April 2012 to January 2013 and upon informal discussions with nurse anesthetists at Connaught Hospital and Princess Christian Maternity Hospital (PCMH). A formal online presentation was developed and utilized for training. After participants viewed the online educational modules, using a mobile simulation system consisting of the IngMar Medical QuickLung® in combination with a RespiTrainer® and the Universal Anaesthesia Machine (UAM), we tested the ability of each participant to perform twelve cognitive/ psychomotor skills (Appendix A) with four scenarios: 1) Light anesthesia/ bronchospasm, 2) Management of anesthesia during a power outage with the UAM, 3) Routine airway management during a failed spinal and 4) A pre-use anesthesia machine check. The scenarios were conducted within the operating theaters at PCMH and Connaught Hospitals. We rated the participant’s ability to perform the twelve tasks on an ordinal scale from 1–5, as well as rating their need for more development/proficiency on a 1–5 scale. Immediate verbal feedback was given on their performance and an opportunity to train to greater proficiency was provided using the simulation platform. The perceived effect of medical simulation in this environment was surveyed before and after each session. Results We observed a total of 25 participants recruited from seven hospitals in and around Freetown. All were non-physician anesthetists, with years of experience performing anesthesia ranging from 0.25 to 6 years (2.5 +/− 1.68) and number of hours per week performing anesthesia ranging from 4 to 64 hours (44.8 +/− 17.2). We observed that more training was needed in almost all of the areas tested, but particularly with preparing the anesthesia machine and identifying hypoxia and bronchospasm (Table 1). Participants surveyed also sensed other areas were needed improvement, namely managing difficult airways and assessing hypoventilation. Conclusion Mobile medical simulation offers a versatile and effective tool for medical training but remains largely underutilized in the developing world. By tailoring our training to situations commonly found in these low resource hospitals (power outages, failed spinal, bronchospasm, etc.), our simulations carried a greater significance and as a result, participant feedback was strongly positive. Average level of comfort for each participant increased significantly with managing an airway, as did the average level of comfort during crisis situations such as bronchospasm and power failure. A common difficulty encountered during our mobile training simulations was power failure during the sessions due to an unreliable power grid to the hospital. We used the QuickLung® ventilator because simulated spontaneous ventilation can be hand-powered and thus used without electricity, allowing for simulation training to continue unimpeded by power outages. References 1. Bibliography: Unknown. 2013. The Inaugural SAFE Obstetrical Anesthesia Course in Rwanda: We Did It!!!. SAFE in Rwanda, [blog] January 19th, Available at: http://pattyalexrwanda.blogspot.com/2013/01/the-inaugural-safe-obstetrical.html [Accessed: July 30th, 2013]. 2. A low cost simulator for learning to manage postpartum hemorrhage in rural Africa. Perosky, J., Richter, R., Rybak, O., Gans-Larty, F., Mensah, M. A., Danquah, A., & Andreatta, P. (2011).A low-cost simulator for learning to manage postpartum hemorrhage in rural Africa. Simulation in Healthcare, 6(1), 42-47. 3. Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania S. Taché, N. Mbembati, N. Marshall, F. Tendick, C. Mkony and P. O’Sullivan, Human Resources for Health 2009, 7:64. Disclosures Gradian Health Systems Gradian Health Systems LLC Gradian Health Systems, LLC Gradian Health Systems.