Global Surgery & Anesthesia

Congratulations on a very well written article and plan.

Being a practitioner in a similar area, I can certainly attest to the
challenges of rolling out this sort of service, and applaud you in your
efforts to ensure a high quality of service with well measured results. It
will be very interesting to hear of how things evolve. We have similar
aspirations at TEAM Hospital with regards to ramping up our surgical
capacity, as we're in the midst of building a new facility with three ORs,
and seeing this roll out protocol challenges me to go back a few steps and
think through exactly what the implementation process will look like.

If we here at TEAM Hospital can be of assistance, please do let us know. We
look forward to working together with you in your efforts to improve the
health care available in Far Western Nepal! It's great to know that the
communities we serve together are going to have options outside of having to
go all the way to the Terai for their surgical care!

best Regards,
Doug Lindberg
HDCS TEAM Hospital Medical Director
www.teamhospitalnepal.org

What an amazing undertaking! Your group is to be congratulated for this work.

A few comments on the process measures you are following for “safe surgery”. And this actually relates to a general concern I have- that some of what is being emphasized in global health circles may not have a strong correlation with the actual safety of the operating room environment in resource limited areas. Just two examples.

1. A functioning pulse oximeter is certainly a great tool to have in the operating room. However, is it really one of the most positive indicators of “safe surgery”? I think we have all seen very safe surgery performed in operating rooms without access to this technology and at the same time, have witnessed quite a bit of unsafe surgery performed with a functioning pulse oximeter monitoring the patient.

2. appropriate prophylactic antibiotics. What is the definition of appropriate? And will this apply to only purely elective operations or will emergency operations be included in this measure? I’m thinking of a patient presenting with for example, an acute abdomen or a necrotizing soft tissue infection in need of debridement and there is very limited access to antibiotics at the facility ...

What an amazing undertaking! Your group is to be congratulated for this work.

A few comments on the process measures you are following for “safe surgery”. And this actually relates to a general concern I have- that some of what is being emphasized in global health circles may not have a strong correlation with the actual safety of the operating room environment in resource limited areas. Just two examples.

1. A functioning pulse oximeter is certainly a great tool to have in the operating room. However, is it really one of the most positive indicators of “safe surgery”? I think we have all seen very safe surgery performed in operating rooms without access to this technology and at the same time, have witnessed quite a bit of unsafe surgery performed with a functioning pulse oximeter monitoring the patient.

2. appropriate prophylactic antibiotics. What is the definition of appropriate? And will this apply to only purely elective operations or will emergency operations be included in this measure? I’m thinking of a patient presenting with for example, an acute abdomen or a necrotizing soft tissue infection in need of debridement and there is very limited access to antibiotics at the facility. In these situations, emergent surgical intervention is critical to control the underlying process, but it’s possible the metric will make it appear that the operation is deemed unsafe.

Any thoughts?

And again, congratulations on this work.

Nadine

This is a great paper, and I really look forward to the hearing the results that you'll be getting in the next couple of years.

Nadine brings up some excellent points, which can honestly be expanded to the majority of Box 2--what counts as appropriate IV placement? Why is a post-operative sponge count in particular more important than other factors involved in the safety of surgery?

Specifically, with respect to the question of appropriate perioperative antibiotics, is what counts as "appropriate" in the West appropriate everywhere? As example, is it truly safe to avoid perioperative antibiotics on clean cases in the developing world? If it isn't, then is our concept of appropriate perioperative antibiotics actually "safe" surgery in non-westernized settings?

That said, you've got to choose something to measure, because measuring everything is impossible.

I think Box 3 brings up a few other questions for me--a number of the complications you list are standard M&M complications, but is Bayalpati equipped to deal with them? Is there a blood-bank from which the >4 units of blood could come? Is there a ventilator? (I couldn't find these in the article, but could easily have missed them). If ...

This is a great paper, and I really look forward to the hearing the results that you'll be getting in the next couple of years.

Nadine brings up some excellent points, which can honestly be expanded to the majority of Box 2--what counts as appropriate IV placement? Why is a post-operative sponge count in particular more important than other factors involved in the safety of surgery?

Specifically, with respect to the question of appropriate perioperative antibiotics, is what counts as "appropriate" in the West appropriate everywhere? As example, is it truly safe to avoid perioperative antibiotics on clean cases in the developing world? If it isn't, then is our concept of appropriate perioperative antibiotics actually "safe" surgery in non-westernized settings?

That said, you've got to choose something to measure, because measuring everything is impossible.

I think Box 3 brings up a few other questions for me--a number of the complications you list are standard M&M complications, but is Bayalpati equipped to deal with them? Is there a blood-bank from which the >4 units of blood could come? Is there a ventilator? (I couldn't find these in the article, but could easily have missed them). If not, is there some sort of agreement with the closest hospital to take these patients expeditiously?

More importantly (and controversially), is this sort of infrastructure necessary for the practice of safe surgery in the developing world, or is there a cutoff of major complication rates, in the absence of the ability to treat them, that is acceptable in the effort to scale up surgical capacity?

Again, I think this is a spectacular start and appreciate the chance you've given for comments.

Mark

Thank you all for your comments. I do think we need to fully revamp our core process and outcomes measures. over the course of the month, we aim to get those revised and back for public scrutiny. Also, in discussing the project with Gita Mody (PGY5 resident at BWH), she made two very important insights: 1) the importance of conceptualizing clinical teams (e.g., OR or trauma) at the heart of implementation and quality problems; 2) the notion of creating a common methodology or standard that could evaluate across different levels of implementation. That is, different hospitals may be transitioning/expanding from no OR to c-section only, or from that to ortho, or to major intra-abdominal, etc.; whatever the implementation, we should be able to semi-standardize an approach aimed at both making the implementation happen and at evaluating it. Much more to come!

This is a very exciting paper, particularly from the perspective of a surgical junior. I know I'm a bit late in responding!

One of the central parts of the description of the set up in Bayalpata is the CHW network in the collection and reporting of follow up data. Many areas do not have such a network, so it would seem that if this is not available in other areas, then collecting follow up data may be very challenging. I would be interested to see further suggestion of the development of a CHW network alongside the implementation/expansion of surgical services where CHWs may not already exist. "We hypothesise that this program will be able to provide follow-up services to 95% of patients throughout the study period" - this is very impressive.

I find the arguments about not conducting a community based survey of surgical disease interesting. Having spent some time in Nepal I can understand the logisitical difficulties of conducting such a study, however I wonder how many people are suffering under surgically treatable disease within the catchment area of the hospital who are unable to present (due to logistics), and thus are not captured in the presenting complaint ...

This is a very exciting paper, particularly from the perspective of a surgical junior. I know I'm a bit late in responding!

One of the central parts of the description of the set up in Bayalpata is the CHW network in the collection and reporting of follow up data. Many areas do not have such a network, so it would seem that if this is not available in other areas, then collecting follow up data may be very challenging. I would be interested to see further suggestion of the development of a CHW network alongside the implementation/expansion of surgical services where CHWs may not already exist. "We hypothesise that this program will be able to provide follow-up services to 95% of patients throughout the study period" - this is very impressive.

I find the arguments about not conducting a community based survey of surgical disease interesting. Having spent some time in Nepal I can understand the logisitical difficulties of conducting such a study, however I wonder how many people are suffering under surgically treatable disease within the catchment area of the hospital who are unable to present (due to logistics), and thus are not captured in the presenting complaint data.

It would be useful to have some indication of what resources the hospital already has (autoclave, blood bank, labratory services, oxygen supply) in a little more detail, in order to further evaluate it's applicability to other locations in terms of bost cost and fesability.

The addition of the "plus" aspects ot IMEESC are both sensible and important to add. The surgical care registry (table 1) would be easily transferrable to other units. It is encouraging that the projected implementation costs are $0.5 per capita, as this further supports the use of surgery as a cost effective intervention.

I look forward to reading the outcomes!

Tim