'The recent SARANF conference was held in Kinshasa, DRC. 75 delegates attended the workshop entitled ‘Safe Surgery knows no religion, nationality or race’. Lifebox partnered with Mercy Ships to explain, demonstrate and facilitate a discussion on the WHO Surgical Safety checklist and pulse oximetry.
There were approximately 300 delegates from all over Africa. The conference was widely supported by hospital directors in Kinshasa and elsewhere as they encouraged their anesthetists (both medical and nursing) to attend. I had been in DRC for the two weeks prior to the conference working with Mercy Ships, visiting multiple hospitals in Kinshasa and Bas Congo and they all knew about the conference. That was a good sign because in order to initiate changes, such as introduce the checklist or to buy a pulse oximeter requires support from those in authority in the hospital.
In my experience in West and Central Africa, people love role play and they always enjoy discussions. It all adds to the experience. This workshop was no different. And, as always the discussion also facilitates my learning. In every country I learn something new and it increases my cultural understanding and the challenges faced by people who literally battle every day to perform safe surgery.
In the discussion session at SARANF, the participants thought that the biggest barriers to safe surgery were primarily lack of teamwork and communication, followed by lack of resources. In developed countries, anaesthetists often have a voice that is heard, but this is not always the case elsewhere. The ‘lack of voice’ makes it difficult for anesthetists alone to implement the checklist or persuade hospital directors to buy a much needed pulse oximeter. At the end of the workshop there were many requests from anesthetists in the DRC and elsewhere for pulse oximetry. They also requested training in the checklist for their surgeons and hospital directors! Closing the pulse oximetry gap is vital and so is training the whole surgical team in the WHO checklist.
My last few years here in Africa have taught me three things and SARANF typified them all. Be as prepared as possible, be as flexible as possible, and enjoy the experience. The afternoon before I was expecting to deliver a short talk (20-30 mins), but then discovered I was hosting a session for 90 mins beginning at 8am the next day. Always be prepared. Thankfully I had plenty more resources and previous talks on my laptop. On the day, I arrived at 7.40 in the morning, only to find the conference venue deserted. Be flexible. The program had been changed, I was now starting at 10.30. But at 10.30 there were only 3 people in the room, by 10.40 there were 8. Enjoy the experience, be flexible and be prepared to realize that here in Africa there will always be enough time for the important things…..and right now, at that moment, it was coffee and croissants. 10.30 was break time. So I went and joined in!
45 minutes later at 11.30 the workshop was full, and extra chairs were being found. 75 participants and standing room only for the next hour and a half ! All the important material was covered, we all enjoyed the experience. I don’t know what happened in the afternoon, I left to catch a flight. But it was one of my nicest croissants ever in Africa and one of my favorite teaching experiences.
Today is our final day of teaching in Nicaragua and we traveled up to Leon this morning to Hospital Heodra. The first thing we noted was a sign reading ‘Silencio Hospital’ out in front of the auditorium where we were to teach that day.
The entryway into the auditorium was also the area for medical students and medical faculty to take their breaks throughout the day. It was very warm and quite humid and these areas do not have any air conditioning.
The hospital sign was covered a bit by foliage but still visible from the street.
The auditorium began to fill with enthusiastic participants and the program was introduced by a few of our host Anesthesiologists from Leon and surrounding areas.
My group today in Leon was a great group of student nurses with their instructor. They were enthusiastic about learning the basics of pulse oximetry and how to use it to help manage patients in both the PACU and ICU settings.
Dra. Maria Espizona is quite a powerful speaker and was able to get everyone enthusiastic both during and after the workshop for implementing and using both pulse oximetry and surgical safety checklists. Checklists are currently used in the private hospitals in Nicaragua, however, they have not been implemented into the public hospitals as of yet. The goal of Dra. Espinoza and groups in Nicaragua are to implement them into the public hospitals within the next six months. She emphasized to everyone to start talking about the importance of the checklist now and not in six months so that when it is introduced people are already on board with using the list!
That concludes our wonderful trip to Central America and our supported programs by the ASA and CSA with training of over 400 people and distribution of 250 Lifeboxes.
Christina Menor MD
Part of ASA GHO team
What a whirl wind day of teaching for the first day in Managua—two classes throughout the day with almost 50 participants per class!!!
The day was very successful with everyone being receptive to the information and interested in the safety aspects that were being emphasized throughout the day with the presentations, videos, and small hands-on groups.
After a bit of respite with our hosts at a local restaurant, El Churrasco, we were ready to go for another day of teaching in Managua. The morning started very well with large and small group work and each of us now very accustomed to the teaching materials and able to flow through the class like old pros.
Small groups in the final day in Managua were well received by the participants, whom we broke into groups based on their level of education—nurses, anesthesiology technicians, anesthesiology residents, and practicing anesthesiologists. This separation by education level seemed to work well to be able to tailor clinical discussions to the appropriate level and not impress on others in the group at a level they were either bored or confused by the material discussed.
The host physicians and our team gathered for some great group photos.
One of our host physicians, Dr. Amador, discussed the importance of the WHO Surgical Safety Checklist with everyone after our presentations and encouraged group discussion and sharing of events that participants have experienced at their respective hospitals.
The day came to an end with a final presentation of Lifebox certificates to the participants by Drs. Espinoza and our team. What a wonderful two days of instruction and discussion with anesthesiology providers of Managua and surrounding hospitals about Lifebox pulse oximeters, the science behind pulse oximetry, practical applications and ability to improve the safety of patients during the perioperative period with utilization of pulse oximetry as an early warning sign of hypoxia and how to work through an algorithm to care for the patient in such situations and the WHO Surgical Safety Checklist and studies showing why the checklist is so important to improve patient safety.
We were whisked away by our hosts to Granada for a nice dinner after two successful days of teaching, with over 250 people trained!!! Off to Leon in the morning for teaching two sessions there.
Arrival into Managua met us with much warmer and more humid weather than we had in Guatemala City.
We flew from Guatemala City to Managua with a plane change in El Salvador and while walking onto the tarmac we felt the heat and humidity hit us and it was a far reaching difference from the weather back in Pennsylvania, Massachusetts, and even California.
During our approach into Managua you could see the Lake Nicaragua that is traditionally called the ’sweet sea’ by locals because it was initially thought it was a fresh water sea because of its size.
We were met at the airport by members and leaders of the Asociacion Nucaraguense de Anestesiologia y Reanimacion (ANARE), including Dra. Maria Espinoza, the president of the association.
After checking into our hotel our hosts gave us a small tour around Managua, visiting a new Monument to Hugo Chavez that was erected after his death earlier this year.
We also drove by the Monument to the Heroes of Alba, a series of panels representing significant times in the history of Latin America.
Dinner by the lake at El Puerto Salvador Allende with mosquitos above our head but hopefully no bites with our DEET working as Dengue is both endemic and currently in an epidemic here in Managua.
Morning of training was a little rocky to start as the reserved auditorium in the Hospital Monte Espana was also being used for another group. After that was settled, we had attendees arrive slowly but surely and began the program with Dra Maria Espinoza introducing Lifebox ASA & CSA teaching team and program.
As day went on ac stopped working in the hospital auditorium, yet we all kept working away in large and small groups.
The workshops ended with presentation of Lifebox certificates to the participants.
Here are a few pictures of the city from the hospital.
We were off to dinner again and resting for tomorrow’s teachings!
Christina Menor MD
Part of ASA GHO team in Guatemala
Spending time at the main University Teaching Hospital in Kigali was the primary purpose for this trip to Rwanda, in addition to the refresher teaching being given elsewhere. One of the flagship hospitals, CHUK was originally built in 1918 and first worked as a health centre before becoming a full hospital in 1965. Now serving as both a central teaching hospital and tertiary referral centre, it is also one of the main sites for the Human Resources for Health (HRH) program. This high-profile initiative seeks to build healthcare education infrastructure through a partnership between the Ministry of Health in Rwanda and a consortium of leading US healthcare centres.
Against this backdrop, the surgical safety checklist had already been the topic of some previous ground work from a visiting US team.
Affiliates of the University of Virginia had taken some time to publicise the checklist and large copies of this were prominently stuck up on the operating room walls. However, uptake was reported to be inconsistent at best.
This all presented a golden opportunity for Lifebox to provide a protracted period of implementation training to really embed patient safety practice within the local healthcare teams. Support from both the HRH staff (who were delighted we were visiting to help with this) and from existing Paul Farmer Scholars we had coordinated this with should provide the on-going infrastructure and encouragement to make this sustainable.
Enough of the theory, time for the action. Our training sessions were situated in the excellent hospital skills centre, set amongst the immaculate gardens. Split between two rooms, one with a projector and the other with an unused operating room table, this provided the perfect venue. Armed with ample supplies of Rwandan tea and biscuits, we initially welcomed the theatre staff in to join us. An interactive introductory talk helped set the background and the importance of patient safety. But the staff schedule prevented us taking important time to role-play checklist use and walk them through all the steps.
Later sessions saw smaller numbers attending than we’d hoped for and while the staff themselves were keen to learn from us it became clear that publicity, encouragement and availability were proving to be a barrier despite strenuous efforts to arrange this prior to our arrival.
We realised we needed to build awareness of this training opportunity, but it wasn’t clear how we could easily do this or who the best local person to coordinate it amongst the wider multidisciplinary team would be. Furthermore, we realised we were going to have to be more creative at working around the hospital’s schedule in order that staff would be free to attend.
By the end of the first whole-day of training at CHUK we could see this would be no push-over. It was clear that this work could make a big difference. It was clear that the healthcare staff could easily be won over to the merits and need for checklist implementation. But how could we get around the current hospital systems in order to reach out to staff and make this stick?
Dr Ed Fitzgerald
The morning started with a warm welcome and introduction from our
host Dra. Navas, President of AGARTD, to the audience of about 40
participants for our first Lifebox training session in Guatemala City. AGARTD is the Asociacion Guatemalteca de Anestesiology, Reanimacion y Tratamiento del Dolor.
Before going further I want to introduce the rest of the Lifebox team for Guatemala training: Dr Berend Mets, Dr Alex Hannenberg, Dr Adrian Gelb and Dr Pablo Guzman.
Dr Mets was our leader for the Guatemalan site and Pablo introduced the program and overview of the day.
The morning session broke into five enthusiastic groups of participants. It was fascinating to learn of the current utilization of pulse oximeters in some anesthetizing locations, yet this only accounts for about 50% of operating rooms in Guatemala that have this basic monitor available for patient care. Many of our teachings became instruction on how to teach others as many students were residents that oversee anesthesia technicians in more rural areas of the country. The morning concluded the Lifebox portion of the training.
After a nice lunch we had the pleasure of having Dr Marco Vinicio Arevalo, the Vice Minister of Hospitals in the Ministry of Health for Guatemala, join us to speak and support Lifebox and the WHO Surgical Safety Checklist. He even tried out one of our Lifebox oximeters.
The program continued with the WHO Surgical Safety Checklist training and discussion. One of our colleagues from Honduras, Dra. Carolina Haylock Loor – president of the Sociedad Hondurea de Anestesiologia, Reanimacion y Dolor (SHARD), introduced the checklist to the entire group before splitting into five groups again for more training and discussion. Utilization of surgical safety checklists seemed to be pretty consistent within the city and academic training locations, however, the rural ministry hospitals do not use checklists currently. Additionally, there seems to be a lot of apprehension about implementing such programs due to barriers including the culture of the nursing and surgical staff. Emphasis was placed on the instruction others in the importance of the checklist through examples of wrong site surgeries and daily use of checklists for other things in life, such as a grocery list.
The day came to a close with the presentation of certificates of completion to the participants in the program. We had met many new friends and helped spread information and training in the use of Lifebox pulse oximeters and the WHO Surgical Safety Checklist throughout the day…very successful day I do believe. We look forward to the logs and follow-up visits in the future to see how things are going with everyone here in Guatemala.
We finished the night by sharing dinner with our leadership colleagues from Guatemala.
Goodbye Guatemala and here we come Nicaragua!
Christina Menor MDPart of ASA GHO team in Guatemala
Follow-up refresher teaching was scheduled at two different hospital sites today. Both had previously launched the surgical safety checklist, one at the start of the year and the other more recently over the summer months.
Rwanda Military Hospital (RMH) is a large complex providing secondary and tertiary level health care services. Despite its name, the hospital provides the majority of its services to the general population.
An early start saw us arrive in time to speak with the surgical residents at their morning meeting before starting rounds and theatres. A good number had come to hear our presentation and the feedback on their use of their adapted checklist to date was both informative and pleasingly positive. All felt it was clearly making a benefit and were seeing it used regularly, with supportive nursing staff and theatre teams. So much so, I felt like my presentation was redundant! What’s more, the residents were able to provide some insight from other hospitals they had recently worked at in the region – they knew the checklist was a success story at Kibagabaga and they knew work was still be done at CHUK. It was interesting to hear their thoughts about both, and their insight was impressive.
Generally speaking, it was great to engage with fellow surgical trainees directly and they clearly appreciated us making the effort to visit and talk to them about their experiences and patient safety in general. As we left we reflected on the reasons for this and wondered whether some military discipline was giving them an edge. Whatever the reason, it was a cheering visit. As outcome evaluation now begins the proof will be in their results.
The afternoon saw a trip to Kibagabaga Hospital on the outskirts of Kigale. A smaller district general hospital, this is where the checklist was first formally launched in Rwanda.My predecessor, Sophie Reshamwalla, had invested considerable time here overseeing the implementation of the checklist and having heard so much of their successes I was delighted to visit. The hospital itself is a relatively new complex that contrasted markedly with our morning visit. Set in open space and built around a number of wide open courtyards with beautifully tended gardens, the hospital had a relaxing and friendly feel to it.
Our teaching venue seemed to be a sometime children’s play area – come – meeting room, with brightly coloured cartoons across the walls to brighten everyone up. Around these were a host of bar charts plotting the progress of checklist compliance and patient outcomes over the summer. It was clear for all to see that, month by month, the results were getting better. The latest complication results had just been calculated and were clearly outstanding.
Our afternoon group was broadly multidisciplinary with theatre staff, nurses and the new interns coming along to chat. The latter group had recently started at Kibagabaga and were also relatively new to the checklist, so it was important to get them up to speed fast. Following introductions, the afternoon began with a walk through aspects of patient safety in general followed by the checklist in detail. The fun then started as we put this into action. Lying down on a makeshift bed of chairs, the assembled team took it in turns to run the checklist as I repeatedly acted out having my leg chopped off. The engagement and interest from the local staff grew as individual checks and questions were ironed out, and it was clear for all to see how much faster they became with just a few repetitions. Everyone enjoyed getting the opportunity to act out each other’s roles and there were plenty of laughs.
When the day drew to a close, it was very pleasing to see that two very different hospitals, with completely different systems and set-ups, had both clearly ‘got it’. Everyone’s hard work over the preceding months had been well worth it. The next challenge is how to make this stick in both centres, with sustainability the next target following the successful implementations at both sites.
Dr Ed Fitzgerald