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GHF2010 – PS18 – Emergency and Essential Surgery: Where Do We Stand?

Session Outline

Parallel session PS18, Tuesday, April 20 2010, 11:00-12:30, Room 2
Chair(s): Pierre Hoffmeyer, Head, Department of Surgery, Geneva University Hospitals, Switzerland
Charles Mock
, Medical Officer, Department of Violence and Injury Prevention and Disability, World Health Organization, Switzerland
A Surgeon's Experience in Haiti
Mathieu Assal, Associate Professor, Division of Orthopaedic Surgery, Geneva University Hospitals, Switzerland
The Challenge of Developing Surgical Care in Africa
Vincent Djientcheu, Professor, Department of Neurosurgery, Central Hospital Yaoundé, Cameroon
The Global Initiative for Emergency and Essential Surgical Care
Meena Nathan Cherian, Emergency and Essential Surgical Care, Clinical Procedures Unit, Department of Essential Health Technologies, Health Systems and Services, World Health Organization, Switzerland
WHO Trauma Care Checklist
Angela Lashoher, Patient Safety Programme, Information, Evidence and Research Cluster, World Health Organization, Switzerland

Session Documents

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Session Report

Submitted by: Erica Chan Wong (ICVolunteers); Contributors: Matthew O'Brien (ICVolunteers)

Dominican Red Cross volunteer in Cite Soleil, Port-au-Prince, attending 10-year old girl, Photo: American Red Cross/Talia Frenkel

In exciting presentations from Haiti, Cameroon and the World Health Organization, the speakers highlighted the challenges of providing surgical care in low-resource settings as well as the measures currently underway to improve surgical access and outcomes worldwide.

Dr. Mathieu Assal, of the Geneva University Hospitals, began the session with an account of his experience working with the Swiss Humanitarian Unit in Haïti soon after the 12 January earthquake. One component of his presentation was a video showing a typical day in the medical tents where his team worked.  His video successfully captured the emotion and atmosphere at the clinic located near the site of the original Hôpital Universitare de Haïti. The surgical teams from Switzerland provided much of the equipment and worked with local hospital staff utilising surgical techniques that were adapted to the local protocols and resources.  In doing so, they ensured that the hospital care was sustained following their departure. In addition, Dr. Assal discussed the common types of injuries suffered by quake victims and the effective techniques used to treat them.  Specifically, he highlighted crush injuries, skull fractures, de-gloving, compartmental injuries and fractures. Most interestingly, he found that amputations were in fact very rare despite what was portrayed by the media. During the period in question, Dr. Assal noted that the patient load was not overwhelming, but that the complications caused by delayed treatment were a challenge.

Dr. Vincent Djientcheu, from the Department of Neurosurgery in the Central Hospital Yaoundé (Cameroon), presented an optimistic view of the barriers to surgical care in low-resource settings as well as possible solutions to overcome them.  Diversity of culture and traditional concepts of disease found in Africa, as well as limited funding, were cited as barriers. As a result, there is lack of training and compensation for health care professionals, delay in technology transfer and poorly organised health care systems. Even so, Dr. Djientcheu noted that there is much potential for change in Africa. The financial and emotional support of family and friends, increased enthusiasm of health care workers and local production of generic drugs all point to a positive future for surgical care in Africa. Similarly to Dr. Assal, Dr. Djientcheu highlighted the importance of bilateral collaboration with local staff to promote sustainable initiatives and local ownership. In a personal interview following the session, Dr. Djientcheu expressed the need for outside support in Africa, and emphasised international collaboration as necessary for Africa’s survival. He also described an effective programme as one that addresses local needs and maintains strong communication with local contacts. Ultimately, Dr. Djentcheu encourages outside support and bilateral cooperation as a means to improve access to surgical care in Africa.

Dr. Meena Nathan Cherian, of the Emergency and Essential Surgical Care, Clinical Procedures Unit at the WHO, expressed a need to prioritise surgical care as an integral part of public health. She set out the recently developed WHO approach to surgical care, including a global forum of biennial meetings since 2005, to address the barriers to accessing emergency and basic lifesaving care through discussions of progress and future goals. As part of this initiative, the WHO standards entitled “Surgical Care at the District Hospital” as well as the “Integrated Management for Emergency and Essential Surgical Care” have been published to provide basic guidelines and education materials toward developing surgical systems. An exciting change took place in 2008 when surgery was included in the World Health Report as an integral part of the continuum of care between primary care and the district level. Finally, Dr. Cherian described advocacy, research and support of centres of excellence as key ways in which individuals can contribute to this WHO initiative.

Last but not least, Dr. Angela Lashoher, of the Patient Safety Programme at the WHO, gave a presentation about the development and use of checklists to improve the safety and outcomes of surgery.  She described successful use of checklists and mentioned that two checklists, the WHO Trauma Care Checklist and the WHO Safe Childbirth Checklist, are currently being evaluated and show promise for the improvement of outcomes. To conclude her brief presentation, Dr. Lashoher emphasised that checklists do not solve all problems but are able to help hospitals consistently deliver quality care to all patients.

All presenters highlighted the need for improved access and standards for surgical care as an essential component of public health. While recognising the need for continued effort toward this goal, the presenters showed confidence in the potential for further progress.

The Global Initiative for Emergency and Essential Surgical Care

Author(s): M. Cherian1
Affiliation(s): 1Essential Health Technologies, World Health Organization, Geneva, Switzerland
Keywords: Global, surgery, emergency, anesthesia, trauma, obstetrics, first referral level, health personnel, capacity building
Background:

Every year, more than 5 million people worldwide die from injuries and more than one million people lose their lives because of road traffic crashes with up to 50 million more are injured or disabled. Each year more than half a million women die due to pregnancy-related complications. In such situations, the capacity to deliver timely emergency and surgical (including trauma, obstetrics, anesthesia) interventions at first referral level of care is vital. However, in developing countries these life saving interventions is often constrained by lack of adequately trained health personnel and equipment at first referral level of care.

Methods:

WHO established a Global Initiative for Emergency and Essential Surgical Care <www.who.int/surgery> to bring together health professionals, academia, professional and civil societies, NGOs, health authorities towards coordinating efforts in improving emergency and essential anesthesia and surgical care at first referral health facilities. WHO developed an Integrated Management for Emergency and Essential Surgical Care <www.who.int/surgery/imeesc> toolkit which is jointly introduced with Ministries of Health in several low and middle income countries for implementation of WHO standards for capacity building of frontline health providers. The toolkit is used for guidance in development of policies, needs assessment, best practices, quality and safety, monitoring and evaluation towards strengthening capacities of health providers to deliver life -saving and disability preventing surgical services at first referral level health facilities.

Results/Conclusions:

Capacity building in emergency, anesthesia and surgical care at district and sub-district level of health facilities is urgently needed to reduce death and disability as a result of injuries, pregnancy related complications, acute surgical conditions and congenital anomalies.

African Partnerships for Patient Safety: Enhancing Patient Safety Across Continents

Author(s): S. B. Syed1
Affiliation(s): 1African Partnerships for Patient Safety, WHO Patient Safety, World Health Organization, Geneva, Switzerland
Keywords: Hospitals, Patient Safety, Delivery of Health Care, Developing Countries, Africa
Background:

Globalization and the ‘inter-connectedness’ of economic, social and cultural development, necessitates the placement of health in an international context. Patient safety is critical for effective health systems in both developed and developing countries - no country has yet solved all their patient safety issues. Patient safety is receiving increasing attention in Africa. The commitment of African Governments to patient safety, and in particular prevention of health care-associated infection, was a prominent feature of the 58th WHO African Regional Committee (Yaoundé Cameroon September 2008). A technical report outlined the major challenges in patient safety in the African region and proposed twelve patient safety action areas that were endorsed by all 46 countries in the African Region.

Methods:

In 2009, in discussion with partners at WHO AFRO, England and Switzerland, WHO Patient Safety initiated African Partnerships for Patient Safety (APPS) as a pathway for developing safer patient care across continents. The 12 action areas identified by the WHO African Region underpin the entire programme, focusing initially on the prevention of health care-associated infection starting with improved hand hygiene. Other areas of work are being developed simultaneously by each partnership based on the 12 patient safety priority action areas, spanning across safe surgery, health worker protection, heath care waste management and enhancing knowledge and learning on the subject. Key resources have been developed in the first year of the programme by working closely with the six first wave partnerships (from Cameroon, Ethiopia, Malawi, Mali, Senegal and Uganda, as well as their European partners) that can be utilized in various settings in both developed and developing countries. These are reported here.

Results/Conclusions:

The APPS model can inform the global knowledge pool. First, the working definition of partnerships can be learned from. Second, three core APPS objectives form a potential entry point for action: 1.Build and strengthen partnerships between hospitals in Africa and Europe, focusing on patient safety; 2. Implement patient safety improvements in each partnership hospital; 3. Facilitate the spread of patient safety improvements across each country. Third, a range of APPS products can be utilized: 1. Patient safety situational analysis guide; 2. Resource map 3. Evaluation framework. Finally, real patient safety experiences of six first wave partnerships can inform other health systems. APPS provides a channel for the passion of health workers committed to delivering safe effective care, while acknowledging the importance of influencing multiple health system levels The partnerships will foster two-way knowledge transfer and develop patient safety professionals spanning across continents.

GHF2012 – PS26 – Innovators in Practice II

Session Outline

Parallel session PS26, Friday, April 20 2012, 11:00-12:30, Fishbowl Room
Chair(s): Pierre-Jean Wipff, Geneva University Hospitals, Geneva, Switzerland, Jordi Serrano, UniversalDoctor, Barcelona, Spain
Consumers Stopping Pharmaceutical Counterfeiting with Mobile Phones: Nigeria
Hamidu Oluyedun, Oyo State Hospital, Ibadan, Nigeria
Real-time, Continuous, Smartphone Based Ambulatory Assessment of Energy Expenditure: Geneva, Switzerland
Katarzyna Wac, Institute of Services Science, Faculty of Economic and Social Sciences, University of Geneva
Safe Surgery with Structured Teaching Tools
Adam Hager, SEAL, Bromma, Sweden
Innovation in Process - Perspectives from a Young Designer
Andrew Miller, Bespoke Innovations, San Francisco, United States

Safe Surgery with Structured Teaching Tools

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Author(s): Adam Hager1
Affiliation(s): 1SEAL, Bromma, Sweden
1st country of focus: Sudan
Additional countries of focus: Ethipia, Equatorial Guinea, Mali, Sierra Leone, Zambia
Relevant to the conference theme: Research and education
Summary: Basic surgical skills training outside the theatre is often a luxury since it requires mannequins, instruments, sutures and proper guidance. We strive to make it available to everyone everywhere. Our teaching tools are simple, structured and durable and make it possible for anyone, anywhere to set up a complete basic surgical skills course for 16 students in 30 minutes. The Intercollegiate Basic Surgical Skills Course, also adapted and applied in Sweden is the structure behind the practical step-by-step layout of our skills training models.  Today this little practical model is used by surgeons and midwifes at the teaching hospitals of Sweden and at international courses for non-physician clinicians.
What challenges does your project address and why is it of importance?: Due to political instability, heavy workloads and geographic distance, it is often impossible for many health care providers at the rural hospitals in low income settings to leave the clinic for a course in a major city or abroad.
How have you addressed these challenges? Do you see a solution?: Our solution is to equip and train local trainers to bring knowledge, skills and teaching tools to the rural hospitals. Since the equipment we provide also is inexpensive, durable and long lasting it is also very suitable to permanently set up a remote skills lab for web-based courses for surgeons, nurses and midwives.
How do you know whether you have made a difference?: We have made surgical training accessible and inexpensive in a way that no competing companies do. The feedback we get from the hospitals tells us that we are on the right path.
Have you or the project mobilized others and if so, who, why and how?: There is a reference project under formation within the WHO where we will supply a few countries in Africa with the material for web-based courses for nurses and midwives.  We are continuously invited by the Professor of International Health, Staffan Bergström,to set up workshops in surgery for NPCs. We bring one case of equipment and one lecturer and set up the workshops outdoor. We find it very suitable since we get the opportunity to meet Non-Physician Clinicians from many different countries in one spot, we learn a lot, and they appreciate our workshop. We were also invited to the Task Shifting Conference in Addis Ababa in 2009 where we could see immediate positive response from the many delegates who found interest in our work and ideas.
When your donor funding runs out how will your idea continue to live?: We have no donor. If each teaching tool is delivered along with proper training the idea will continue to live and spread naturally.

Rheumatic Heart Disease Revisited: Patterns of Valvular Involvement from a Consecutive Cohort in Eastern Nepal

Author(s): Nikesh Shrestha1, T. Pilgrim2, P. Karki1, R. Bhandari1, S. Basnet1, S. Tiwari1, P. Urban3
Affiliation(s): 1B.P. Koirala Institute of Health Sciences, Dharan, Nepal, 2Swiss Cardiovascular Centre, Bern, Switzerland, 3Hopital de la Tour, Geneva, Switzerland
1st country of focus: Nepal
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Rheumatic heart disease is a major contributor to morbidity and premature death in poor and developing countries. We investigated the patterns of valvular involvement in patients with RHD in a large tertiary care hospital in eastern Nepal. Among 10,860 transthoracic echocardiography studies, 1055 female and 658 male patients were diagnosed with RHD, 25.7% of the patients being <20 years of age. Mitral regurgitation was the most common valvular lesion. Female patients were older and presented with mitral stenosis. Aortic regurgitation was more common in males. Involvement of both mitral and the aortic valve was observed in 49.8% of the patients.
Background (max 200 words): Although there has been a decline in the incidence of rheumatic heart disease (RHD) in industrialized nations, the burden of RHD in poor and developing countries has remained a major contributor to the morbidity and premature death in the working age population. RHD is estimated to affect at least 15.6 million people worldwide and causes 233,000 deaths each year. Several observational studies have reported the prevalence of rheumatic heart disease among various populations in different parts of the world. A particularly high prevalence of acute rheumatic fever (ARF) and RHD has been reported in Southeast Asia, the Western Pacific and Africa. Primary prevention with timely antibiotic treatment of group A β hemolytic streptococci (GABHS) pharyngitis and secondary antibiotic prophylaxis in patients who have undergone ARF is often inappropriate in developing countries due to ineffective health resources and lack of awareness of the disease.
Objectives (max 100 words): The objective of this study was to investigate patterns of left-sided valvular involvement as assessed by echocardiography in a large consecutive cohort from a tertiary care referral hospital in eastern Nepal.
Methodology (max 400 words): We retrospectively reviewed all consecutive transthoracic echocardiography reports from patients diagnosed with rheumatic heart disease collected from the echocardiography laboratory from June 1999 to February 2011. The data collected included age, gender, clinical diagnosis and findings on transthoracic echocardiography (TTE). Echocardiographic studies were performed with Hewlett Packard Sonos 1500 using a 5 MHz  transducer. All patients underwent a standard echocardiographic examination, including M-mode, two-dimensional and Doppler echocardiography.  Mitral stenosis was diagnosed on the presence of valve thickening, diastolic doming, restriction of leaflet motions and was quantified by pressure half time and planimetry. Presence of calcification, fibrosis, and limited leaflet excursion and fusion of commisures and chordate tendinae were also identified. Mitral regurgitation was diagnosed in the presence of thickened valves, dilated mitral valve annuli, and left atrial and left ventricular dilatation and lack of coaptation of the mitral valve leaflets in systole. Doppler echocardiographic analyses identified the presence and severity of regurgitation of the aortic, mitral and tricuspid valves. Thickened and calcified aortic valve leaflets with reduced leaflet motion (aortic cusp separation less than 9 mm) suggested aortic stenosis along with a peak gradient of more than 15mmHg in continuous-wave doppler. Aortic regurgitation was diagnosed when echocardiography with Doppler interrogation of the aortic valve showed the spatial extent of the colour Doppler aliasing in the outflow tract and was used as a rough guide of the severity of aortic insufficiency. Echocardiographic findings associated with pulmonary hypertension included a dilated pulmonary artery and dilation and hypertrophy of the right ventricle (RV), diastolic flattening of the interventricular septum and Doppler evidence of pulmonary hypertension.  SPSS Statistics Version 17.0 was used for all statistical analyses. Countinuous variables are expressed as mean ± standard deviation (SD), whereas categorical data are  presented as frequency (percentages). Two-sided T-tests were used to compare continuous variables, categorical variables were compared by using the chi-square test. A p value <0.05 was considered statistically significant.
Results (max 400 words): Among 10,860 transthoracic echocardiography studies performed between June 1999 and February 2011, a diagnosis of RHD was made in 1713 patients (15.8%), of which 1055 females and 658 males were diagnosed to have RHD (gender ratio 1.6:1). Patients presented for TTE at an average age of 31.1±15.4 years, females being significantly older than males at the time of presentation (32.8±15.2 years versus 28.5±15.4 years, p<0.001). One in four patients presenting with RHD was younger than 20 years of age. Mitral stenosis (MS) was more common in females as compared to males (62.8% versus 51.5%, p<0.001), whereas aortic regurgitation (AR) was more common in males as compared to females (55.6% versus 48.9%, p=0.007). Involvement of both the mitral and the aortic valve was observed in 49.8% of the patients and was more common in males as compared to females (52.7% versus 47.8%, p=0.047); there was no significant difference with regard to age at presentation between patients with single-valve involvement versus patients with involvement of both the mitral and the aortic valve (31.2 ±15.4 years versus 31.1 ±15.4 years, p=0.89). A combination of MR with MS (19.3%) or with AR (17.9%) was the most common finding. MR was the most common valvular pathology across all age groups (n=1321, 77.1%), followed by MS with the exception of patients <20 years of age which presented more frequently with AR than with MS. Aortic stenosis was the least common valvular lesion found in this cohort, but was increasingly observed with advancing age. The prevalence of pulmonary hypertension amounted to 34.9% in our cohort and increased with advancing age from 27.0% in patients <20 years to 43.7% in patients ≥50 years. Echocardiographic evidence of infective endocarditis was documented in 212 (12.4%) patients.
Conclusion (max 400 words): The major findings of our retrospective analysis can be summarized as follows: (1) The prevalence of RHD among patients referred for transthoracic echocardiography in this single-center experience from eastern Nepal was high, (2) one in four patients diagnosed with RHD was younger than 20 years of age, (3) more than 60% of the patients diagnosed with RHD were females, and (4) differential patterns of valvular involvement were observed across gender and age categories. A combination of poverty, lack of awareness, limited access to primary prevention and secondary prophylaxis entertain ARF and make RHD an  unresolved problem in this part of the world. Once significant valvular disease has developed medical options are limited; cardiac surgery for valve replacement is available in the capital city of Kathmandu 500 kilometers west of Dharan and percutanoeous mitral valvotomy has only recently been introduced in our centre.  This was a hospital based study and patients who were symptomatic did come to the hospital to get an echocardiography performed and have the disease diagnosed. However RHD can remain clinically silent and may produce no symptoms in the early course of the disease and if these patients could be diagnosed earlier by means of a community screening program especially in school going children we could probably contribute considerably in reducing the morbidity and mortality due to RHD with simple yet effective secondary prophylaxis with penicillin.

Role of Future Family Physician in Rwandan Health Sector

First: Anaclet
Last: Mugali
1st country of focus: Rwanda
Relevant to the conference theme: New roles and responsibilities of health personnel
Summary: In 1963 the Rwandan government implemented its first University,  National University of Rwanda, which had many faculties including a Faculty of Medicine.  Since that time however, the Faculty of Medicine has produced only undergraduates (6 years for generalist Medical Doctors). In 1997 National University of Rwanda Staff decided to introduce a Master’s in Medicine: Postgraduate specialty training. In 2004 supported by the MInister of Health the first batch commenced with the 4 main disciplines: Surgery, Internal medicine, Ob/Gyn, and pediatrics. Anesthesiology was added in 2005. In 2008 the Family medicine and community (FAMCO) program started with 7 residents for 4 years of training.  The first Rwandan family physicians are expected to graduate in August 2012. According to this four year curriculum family physicians will be able to: coordinate and be involved in clinical activities within institutions, manage clinical programs such as palliative care; non-communicable diseases, communicable diseases, provide integrated clinical care within the scope of training experience and according to Family Medicine principles, coordinate community health care team activities and research, develop the community primary health care capacity at the health center level, collaborate with public health care authorities in the planning and implementation of preventive health care and health promotion activities, train all levels of health professionals i.e. medical students, post-graduate students (family medicine), nurses, Community Health Workers. Within our national health system structure we are looking at how family physicians can improve our communities primary health care.  Key words: Family physician, performance, Rwandan health system. Objectives: To improve our health sector structure by including family physician staff.  Setting: National University of Rwanda / Family Medicine Department / Minister of Health. Subjects: Family physicians in Rwandan health sector structure. .
What challenges does your project address and why is it of importance?: Within our national health sector structure, we are looking for strategies that encourage the family physician to constructively contribute to the the improvement of our health care services in general.
How have you addressed these challenges? Do you see a solution?: In terms of challenges we would like to do more advocacy by faciliating workshops with broad discussions with the Rwanda health program key leaders, districts hospital directors, medical doctors’ representatives, health providers at the district level and in the communities. These workshops, via a detailed explanation of the role of the family physician,  will illustrate how the accumulated knowledge  of the family physician can be delivered to the community.
How do you know whether you have made a difference?: Our future family physicians have not yet graduated and the emergence of this new form of professional staff will be in August 2012 after graduation.  After a certain period the evaluation of these new specialists contribution will be revealed by the evaluation criteria in our health sector policy report.
Have you or the project mobilized others and if so, who, why and how?: No.
When your donor funding runs out how will your idea continue to live?: There is no external funding.