The delivery and challenges of Pediatric Anesthesia within the humanitarian sector: Médecins Sans Frontières and Mercy Ships.

Access to healthcare is inequitable. Poverty, natural disasters and war disproportionally effect those most vulnerable, including children. Non-governmental organizations (NGO) hold a vital role in providing pediatric care in these contexts.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness.

Background: Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis.

Objectives: To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact.

Background: The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood.

Methods: We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs.

Economic Case for Scale-up of the WHO Surgical Safety Checklist at the National Level in Sub-Saharan Africa.

Objectives: To evaluate the economic case for nationwide scale-up of the World Health Organization (WHO) Surgical Safety Checklist using cost-effectiveness and benefit-cost analyses.

Background: The Checklist improves surgical outcomes but the economic case for widespread use remains uncertain. For perioperative quality improvement interventions to compete successfully against other worthwhile health and nonhealth interventions for limited government resources they must demonstrate cost-effectiveness and positive societal benefit.

Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon.

Background: Surgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings.

A Mixed-Method Design Evaluation of the SAFE Obstetric Anaesthesia Course at 4 and 12-18 Months After Training in the Republic of Congo and Madagascar.

Background: Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice.

Sustainability of using the WHO surgical safety checklist: a mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar.

Background: The WHO Surgical Safety Checklist reduces postoperative complications by up to 50% with the biggest gains in low-income and middle-income countries (LMICs). However in LMICs, checklist use is sporadic and widespread implementation has hitherto been unsuccessful. In 2015/2016, we partnered with the Madagascar Ministry of Health to undertake nationwide implementation of the checklist.

A Prospective Observational Study of Anesthesia-Related Adverse Events and Postoperative Complications Occurring During a Surgical Mission in Madagascar.

Background: Two-thirds of the world's population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined.

Measurement of patient reported disability using WHODAS 2.0 before and after surgical intervention in Madagascar.

Background: Patient reported outcomes (PRO) measure the quality of care from the patient's perspective. PROs are an important measure of surgical outcome and can be used to calculate health gains after surgical treatment. The World Health Organisation Disability Assessment Schedule (WHODAS) 2.

Epidemiology of antibiotic-resistant wound infections from six countries in Africa.

Introduction: Little is known about the antimicrobial susceptibility of common bacteria responsible for wound infections from many countries in sub-Saharan Africa.

Methods: We performed a retrospective review of microbial isolates collected based on clinical suspicion of wound infection between 2004 and 2016 from Mercy Ships, a non-governmental organisation operating a single mobile surgical unit in Benin, Congo, Liberia, Madagascar, Sierra Leone and Togo. Antimicrobial resistant organisms of interest were defined as methicillin-resistant (MRSA) or resistant to third-generation cephalosporins.

Evaluation of a countrywide implementation of the world health organisation surgical safety checklist in Madagascar.

Background: The 2009 World Health Organisation (WHO) surgical safety checklist significantly reduces surgical mortality and morbidity (up to 47%). Yet in 2016, only 25% of East African anesthetists regularly use the checklist. Nationwide implementation of the checklist is reported in high-income countries, but in low- and middle-income countries (LMICs) reports of successful implementations are sparse, limited to single institutions and require intensive support.

Overcoming challenges in implementing the WHO Surgical Safety Checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar.

The WHO Surgical Safety Checklist was launched in 2009, and appropriate use reduces mortality, surgical site infections and complications after surgery by up to 50%. Implementation across low-income and middle-income countries has been slow; published evidence is restricted to reports from a few single institutions, and significant challenges to successful implementation have been identified and presented. The Mercy Ships Medical Capacity Building team developed a multidisciplinary 3-day Surgical Safety Checklist training programme designed for rapid wide-scale implementation in all regional referral hospitals in Madagascar.

Limited sterile processing capabilities for safe surgery in low-income and middle-income countries: experience in the Republic of Congo, Madagascar and Benin.

It is highly difficult to perform safe surgery without sterile instruments, yet the capacity to adequately clean, disinfect and sterilise surgical instruments in low-income and middle-income countries is largely unknown. Sterile Processing Education Charitable Trust developed an assessment tool and, in partnership with Mercy Ships, evaluated the sterile processing capacity in 59 facilities in Madagascar, Benin and the Republic of Congo. This data-driven analysis paper illustrates how lack of sterile processing capacity acts as a barrier to safe surgical care.

Facilitating access to surgical care through a decentralised case-finding strategy: experience in Madagascar.

Over two-thirds of the world's population lack access to surgical care. Non-governmental organisation's providing free surgeries may overcome financial barriers, but other barriers to care still exist. This analysis paper discusses two different case-finding strategies in Madagascar that aimed to increase the proportion of poor patients, women and those for whom multiple barriers to care exist.

Clinical Outcome, Social Impact and Patient Expectation: a Purposive Sampling Pilot Evaluation of Patients in Benin Seven Years After Surgery.

Background: Access to affordable and timely surgery is not equitable around the world. Five billion people lack access, and while non-governmental organizations (NGOs) help to meet this need, long-term surgical outcomes, social impact or patient experience is rarely reported.

Method: In 2016, Mercy Ships, a surgical NGO, undertook an evaluation of patients who had received surgery seven years earlier with Mercy Ships in 2009 in Benin.

Interval follow up of a 4-day pilot program to implement the WHO surgical safety checklist at a Congolese hospital.

Background: The World Health Organisation Surgical Safety Checklist (SSC) improves surgical outcomes and the research question is no longer 'does the SSC work?' but, 'how to make the SSC work?' Evidence for implementation strategies in low-income countries is sparse and existing strategies are heavily based on long-term external support. Short but effective implementation programs are required if widespread scale up is to be achieved. We designed and delivered a four-day pilot SSC training course at a single hospital centre in the Republic of Congo, and evaluated the implementation after one year.

An Observational Assessment of Anesthesia Capacity in Madagascar as a Prerequisite to the Development of a National Surgical Plan.

Background: The global lack of anesthesia capacity is well described, but country-specific data are needed to provide country-specific solutions. We aimed to assess anesthesia capacity in Madagascar as part of the development of a Ministry of Health national surgical plan.

Methods: As part of a nationwide surgical safety quality improvement project, we surveyed 19 of 22 regional hospitals, representing surgical facilities caring for 75% of the total population.

An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan.

Background: The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework.

Effect of Pre-operative Anaemia on Post-operative Complications in Low-Resource Settings.

Background: In high-resource settings, even mild anaemia is associated with an increased risk of post-operative complications. Whether this is true in low-resource settings is unclear. We aimed to evaluate the effect of anaemia on surgical outcomes in the Republic of Congo and Madagascar.

Retrospective Review of the Anaesthetic Management of Maxillectomies and Mandibulectomies for Benign Tumours in Sub-Saharan Africa.

Background: Safe anaesthesia is a crucial component of safe surgical care, yet anaesthetic complications are common in resource-limited settings. We describe differences in anaesthetic needs for Mandibulectomy vs. Maxillectomy in three sub-Saharan African countries.

An update on newer pediatric supraglottic airways with recommendations for clinical use.

Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

Current UK practice of pediatric supraglottic airway devices - a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland.

Objectives: Over half of general anesthetics in the UK involve supraglottic airway devices (SADs). The National Audit Project 4 undertaken by the Royal College of Anaesthetists demonstrated that aspiration was the most frequent complication relating to SAD use. SADs designed to reduce this risk (second-generation devices) are increasingly recommended in both adults and children.

Pain management in 100 episodes of severe mucositis in children.

Objective: We aimed to review the pain management in 100 episodes of severe mucositis in children and determine the incidence of associated side effects.

Background: Mucositis is a painful, debilitating condition affecting the alimentary mucosa and occurs following many anticancer treatments. Severe pain associated with mucositis may necessitate reductions, delays or termination of anticancer therapy and so intravenous morphine, preferably by patient-controlled analgesia (PCA) is the treatment of choice.