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Powell WF, Echeto-Cerrato MA, Gathuya Z, Gray RM, Hodges S, Nabukenya MT, Newton MW, Rai E, Evans FM. Delivery of Safe Pediatric Anesthesia Care in the First 8000 days: Realities, Challenges, and Solutions in Low- and Middle-Income Countries. World J Surg 2023; 47:3429-3435. [PMID: 37891383 DOI: 10.1007/s00268-023-07229-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Worldwide, perioperative mortality has declined over the past 50 years, but the reduction is skewed toward high-income countries (HICs). Currently, pediatric perioperative mortality is much higher in low- and middle-income countries (LMICs) compared to HICs, despite studied cohorts being predominantly low-risk. These disparities must be studied and addressed. METHODS A narrative review of the literature was undertaken to identify contributing factors and potential knowledge gaps. Interventions aimed at alleviating the outcomes disparities are discussed, and recommendations are made for future directions. RESULTS AND CONCLUSIONS There is a lack of adequately trained pediatric anesthesia providers in LMICs, and the number must be bolstered by making such training available. Essential anesthesia medications and equipment, in pediatric-appropriate sizes, are often not available; neither are essential infrastructure items. Perioperative staff are underprepared for emergent situations that may arise and simulation training may help to ameliorate this. The global anesthesia community has implemented several solutions to address these issues. The World Federation of Societies of Anaesthesiologists (WFSA) and Global Initiative for Children's Surgery have published standards that outline essential items for the provision of safe perioperative pediatric care. Several short educational courses have been developed and introduced in LMICs that either specifically address pediatric patients, or contain a pediatric component. The WFSA also maintains a collection of discrete tutorials for educational purposes. Finally, in Africa, large-scale, prospective data collection is underway to examine pediatric perioperative outcomes. More work needs to be done, though, to improve perioperative outcomes for pediatric patients in LMICs.
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Affiliation(s)
- William Francis Powell
- Department of Anesthesiology, Harvard Medical School, Mass Eye and Ear243 Charles Street, Boston, MA, 02114, USA.
| | - Maria Alejandra Echeto-Cerrato
- Department of Anesthesiology and Pediatrics, Hospital del Valle North Blvd, 8Th Street NE, San Pedro Sula, Honduras, 21101
| | | | - Rebecca Mary Gray
- Division of Paediatric Anaesthesia, Division of Global Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, 27 St Michaels Rd, Tamboerskloof, Cape Town, 8001, Republic of South Africa
| | | | - Mary T Nabukenya
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Upper Mulago Hill Rd, Kampala, Uganda
| | - Mark W Newton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ekta Rai
- Department of Anaesthesiology, Christian Medical College, Vellore, India, 632004
| | - Faye M Evans
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
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Clinical Practices Following Train-The-Trainer Trauma Course Completion in Uganda: A Parallel-Convergent Mixed-Methods Study. World J Surg 2023; 47:1399-1408. [PMID: 36872370 PMCID: PMC10156777 DOI: 10.1007/s00268-023-06935-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Despite the growth of trauma training courses worldwide, evidence for their impact on clinical practice in low- and middle-income countries (LMICs) is sparse. We investigated trauma practices by trained providers in Uganda using clinical observation, surveys, and interviews. METHODS Ugandan providers participated in the Kampala Advanced Trauma Course (KATC) from 2018 to 2019. Between July and September of 2019, we directly evaluated guideline-concordant behaviors in KATC-exposed facilities using a structured real-time observation tool. We conducted 27 semi-structured interviews with course-trained providers to elucidate experiences of trauma care and factors that impact adoption of guideline-concordant behaviors. We assessed perceptions of trauma resource availability through a validated survey. RESULTS Of 23 resuscitations, 83% were managed without course-trained providers. Frontline providers inconsistently performed universally applicable assessments: pulse checks (61%), pulse oximetry (39%), lung auscultation (52%), blood pressure (65%), pupil examination (52%). We did not observe skill transference between trained and untrained providers. In interviews, respondents found KATC personally transformative but not sufficient for facility-wide improvement due to issues with retention, lack of trained peers, and resource shortages. Resource perception surveys similarly demonstrated profound resource shortages and variation across facilities. CONCLUSIONS Trained providers view short-term trauma training interventions positively, but these courses may lack long-term impact due to barriers to adopting best practices. Trauma courses should include more frontline providers, target skill transference and retention, and increase the proportion of trained providers at each facility to promote communities of practice. Essential supplies and infrastructure in facilities must be consistent for providers to practice what they have learned.
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French DM, DuBose-Morris RA, Lee FW, Sulkowski SJ, Samuelson GA, Jauch EC. Telesimulation to Improve Critical Decision-Making in Prehospital Airway Management: A Feasibility Study. South Med J 2022; 115:639-644. [PMID: 35922053 DOI: 10.14423/smj.0000000000001429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Telesimulation, in which learners and evaluators use technology to connect remotely to simulation-based learning activities, is effective for skills and decision-making review. Historical models in which learners are colocated with the simulation equipment have inherent issues, especially for emergency medical services (EMS) providers. This feasibility study placed the evaluators in the simulation center, whereas the learners were at a distance steering the scenario evolution through telehealth technologies. METHODS Volunteer EMS providers across South Carolina with varying levels of training and experience completed difficult airway management scenarios focused on clinical decision making. The program consisted of pre- and postexperience examinations, a lecture, and increasingly complicated simulations using high-fidelity mannequins that were facilitated by local trainers under the direction of remote trainees. Audio and video content, including vital signs and cardiac monitoring, were live streamed. Participants worked in two-person teams with lead providers on each scenario clinically assessing and managing cases of anaphylaxis. Data were collected from the simulations using Laerdal software, as well as examination and survey results. RESULTS A total of 24 participants completed all of the elements of the training. Trends toward improvement in times to bag-mask ventilation and initial epinephrine administration were noted. Average cognitive test scores increased by 9.6%, and learners reported improved comfort with simulation (75%, P ≥ 0.0001) and videoconferencing (83%, P ≥ 0.0001). They also reported high degrees of comfort with intubation (73.3%) following the training. CONCLUSIONS This method of telesimulation appears to be a viable addition to continuing EMS education and may address access issues for some providers.
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Affiliation(s)
- David M French
- From Charleston County EMS, Charleston, the Center for Telehealth, Medical University of South Carolina, Charleston, Healthcare Simulation Center, Medical University of South Carolina, Charleston, and the Mission Research Institute, Mission Health System, Asheville, North Carolina
| | - Ragan A DuBose-Morris
- From Charleston County EMS, Charleston, the Center for Telehealth, Medical University of South Carolina, Charleston, Healthcare Simulation Center, Medical University of South Carolina, Charleston, and the Mission Research Institute, Mission Health System, Asheville, North Carolina
| | - Frances W Lee
- From Charleston County EMS, Charleston, the Center for Telehealth, Medical University of South Carolina, Charleston, Healthcare Simulation Center, Medical University of South Carolina, Charleston, and the Mission Research Institute, Mission Health System, Asheville, North Carolina
| | - Stanley J Sulkowski
- From Charleston County EMS, Charleston, the Center for Telehealth, Medical University of South Carolina, Charleston, Healthcare Simulation Center, Medical University of South Carolina, Charleston, and the Mission Research Institute, Mission Health System, Asheville, North Carolina
| | - Greig A Samuelson
- From Charleston County EMS, Charleston, the Center for Telehealth, Medical University of South Carolina, Charleston, Healthcare Simulation Center, Medical University of South Carolina, Charleston, and the Mission Research Institute, Mission Health System, Asheville, North Carolina
| | - Edward C Jauch
- From Charleston County EMS, Charleston, the Center for Telehealth, Medical University of South Carolina, Charleston, Healthcare Simulation Center, Medical University of South Carolina, Charleston, and the Mission Research Institute, Mission Health System, Asheville, North Carolina
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