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23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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Fig. 23.2 Top ten global causes of death, 2016. Percentages are the proportion of total global
deaths attributable to each cause. Data, except those on postoperative deaths, are from the Global
Burden of Disease Study 2016. COPD- chronic obstructive pulmonary disease. LRTI- lower respiratory tract infections. Reprinted from The Lancet, Vol. 393, Issue 10170, Nepogodiev D, Martin
J, Biccard B, Makupe A, Bhangu A; National Institute for Health Research Global Health Research
Unit on Global Surgery, Global burden of postoperative death, Page 401, Copyright (2019), with
permission from Elsevier
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of these are caused by congenital malformations, violence and injury, and childhood
neoplasms. Each year, 15million people between the ages of 30 and 69years die
from a noncommunicable disease; about 85% of these deaths occur in LMICs and
are a result of cardiovascular diseases (heart disease, stroke), cancer, and diabetes.
Each year, 1.35million die as a result of road trafc crashes, 93% of which occur in
LMICs, and these are the leading cause of death for children and young adults aged
5–29years. The majority of these conditions are most appropriately treated with
surgical care [6]. There is a correlation between surgical access, anesthesia capacity,
and patient safety on the one hand and mortality on the other hand [9].
Delivering Quality Perioperative Care
The World Health Assembly resolution 68.15 created an interest and better understanding in some players in the surgical global community, but more advocacy is
needed in the global public health domain to improve surgical services on par with
anesthesia services. Providing quality perioperative care requires a multi-sectoral
approach, exploring nancing mechanisms and appropriate resource allocation to
improve training to meet local needs, in addition to monitoring and evaluation, and
strengthening surgical care systems.
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M. N. Cherian et al.
Safe and quality perioperative care takes into account the basic principles that the
correct patient receives the correct procedure, performed on the correct site, at the
correct time, while avoiding any harm.
Surgically correctable diseases constitute up to one-third of global burden of
diseases, which implies universal and on-demand access to anesthesia and surgical
care in all parts of the world, including remote areas. Maintenance of quality in
these services is imperative, without which the core intent of improving patients’
health will be defeated [12].
Surgical intervention should ensure patients’ and healthcare providers’ safety
equally, at all levels of care (from tertiary to primary, elective and urgent, minor and
major procedures, including in humanitarian crises) [13].
The rst-level hospitals (rural, community hospital) receive referrals from health
clinics and community centers that mostly require emergency surgical care. Often,
these rst-level hospitals lack trained anesthesia providers, which becomes a major
barrier to providing essential emergency surgeries [7]. Therefore, priority should be
given to improve the quality of perioperative care in these facilities through evaluation of minimum standards for infrastructure, equipment, medicines, supplies, data
records, and skills of the surgical health workforce.
For a surgical intervention to be successful, strict measures are required during
the entire perioperative period. Building an operating room is not enough for delivering safe and quality surgical services. It requires strengthening the entire surgical
care system and investments in the implementation of a robust system, which, if
ignored, has serious implication for the delivery of safe and quality perioperative care.
Perioperative care starts with a detailed preoperative check and continues with
precise intraoperative and postoperative management until the discharge of the
patient. Therefore, improvement in its safety and quality requires a multifactorial
approach with safe infrastructure and maintenance of equipment, access to medicines, and a surgical workforce (anesthesia, nursing, technicians) trained and
motivated to participate in quality measurement and improvement standards
[14, 15].
“No single improvement in the care of surgical patients has had as profound an
impact as the advancement of safe practices in anesthesia” [15].
With advancements in anesthesia and perioperative care, the ARM has reduced
drastically from 2 per 10,000 to 1in 200,000in healthy patients. But it is not uniform globally. LMICs still have higher ARM rates, which can be as high as 1in
300 [12].
This is due to absent or weak policies, lack of adherence to global standards, lack
of development or consensus on national standards, and sometimes differing standards in hospitals within the same region. Even though anesthesia has advanced on
par with surgical interventions, investments are not equally distributed in LMICs to
enable high-quality anesthesia services to upgrade the equipment, medicines, skills
of the anesthesia workforce, and continuing professional development.
Safe anesthesia for essential surgery is a basic human right [12]. Every
patient must receive the highest standard of safe care possible, regardless of
23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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types of anesthesia and surgical procedure performed, or the patient’s nancial
status. The recommended safety standards should not be ignored or compromised by the location, hierarchy, or resource availability of the healthcare delivery system [12].
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Improving Safety andQuality of Perioperative Care
Anesthesia Safety
International Standards for a Safe Practice of Anesthesia were developed by the
WFSA and the WHO, applicable globally both in HICs and in LMICs. This has
been adapted by some countries in agreement with their national professional societies; however, these standards have not been implemented equally at all levels of
care, resulting in “near misses” and perioperative morbidity and mortality. In addition, when these are reported (within the healthcare system or by media), it emphasizes the “blame factor” rather than investigating the implementation and adherence
to national standards. The WFSA has set up recommendations in three categories:
(i) highly recommended (minimum mandatory) standards, (ii) recommended standards, and (iii) suggested standards.
If the highly recommended minimum standards are implemented from the primary to the tertiary levels of health care that perform minor or major surgical interventions, it will assist countries toward meeting the 2018 Global Reference List of
100 Core Health Indicators (plus health-related SDGs), particularly the perioperative mortality rate (POMR) [16].
The Highly Recommended Standards are mandatory requirements that must be
present in any setup providing general anesthesia, regional anesthesia, or moderate
to deep sedation. Recommended and suggested standards should be followed as per
resource availability.
Highly Recommended Standards include continuous presence of trained and
vigilant anesthesia provider throughout anesthesia care, use of the surgical safety
checklist, conrmation of endotracheal tube positioning by auscultation and endtidal carbon dioxide, continuous monitoring of oxygenation and perfusion through
clinical observation, noninvasive blood pressure (NIBP), and pulse oximetry.
Pre-anesthesia checkup includes formulation and documentation of anesthesia
plan, written explained anesthesia consent, checking anesthesia equipment and
medications prior to induction, clean labeling and date on medications, provision of
supplemental oxygen to all patients undergoing general anesthesia or deep sedation,
loud audible alarms for vital monitoring, and maintenance of detailed perioperative
anesthesia records.
Postanesthesia care should be provided in recovery rooms with facilities of oxygen, suction, ventilation, and resuscitation capabilities. Continuous postoperative
monitoring by a trained healthcare worker for airway, breathing, circulation, oxygenation, NIBP, and pulse oximetry, along with management of postoperative pain
with adequate analgesics, is critical for safe postanesthesia care [12].
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M. N. Cherian et al.
The WFSA recommends that anesthesiologists should have formal, documented
training from the national accredited program and should be trained in proper and
safe use of equipment [12].
Surgical Checklist
The WHO surgical checklist is a simple tool designed to improve the safety of surgical procedures by bringing together the entire operating team (surgeons, anesthesia
providers, and nurses) to perform key safety checks during vital phases of perioperative care (Fig.23.3) [15]:
(i) Prior to the induction of anesthesia
(ii) Prior to skin incision
(iii) Before the patient and team leave the operating room
A study in hospitals with a diverse clinical and economic environment in HICs
and LMICs showed that the implementation of the WHO checklist decreased the
rates of mortality and postoperative complications, thus improving the safety of
surgical patients worldwide [17].
Fig. 23.3 WHO Surgical Safety Checklist. Reference WHO guidelines for safe surgery: 2009:
safe surgery saves lives
23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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Trauma Checklist
Trauma mortality rates have been reduced in many HICs, resulting from good planning and organization of trauma care services; more than 90% of injury deaths
occur in LMICs [18]. The WHO trauma checklist emphasizes immediate steps
(resuscitation and stabilization procedures) following the primary and secondary
survey. It ensures recording the treatment given and next plans prior to handing over
to the next team. The perioperative period in acute traumatic injury generally does
not give enough time to arrange lifesaving items (chest tubes, resuscitation equipment, medicines, debrillator, airway devices). These should be readily available, in
adequate numbers, functioning with proper maintenance (like sterility, cold chain,
charged battery, and expiry of unused items). Perioperative trauma care quality is
inuenced by overall patient care starting from the prehospital setting extending
until rehabilitation (Fig.23.4a, b).
Quality in trauma care aims at better monitoring of trauma care services, identication of problem areas, formulation and implementation of corrective strategies
(such as protocols, education, communication, resource enhancement), monitoring
their effectiveness, and ensuring achievement of intended results [18].
Strengthening of trauma quality improvement (QI) in LMICs aims at preventing
deaths due to low-severity injuries. Trauma registry records all information such as
the injury event, demographics, prehospital care, diagnosis, management, outcome
of the patient, and cost of treatment. Quality in any service, including perioperative
Fig. 23.4 WHO Trauma Care checklist WHO 2016. WHO Trauma Care Checklist. WHO 2016;
reference https://www.who.int/publications/i/item/trauma-care-checklist
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Fig. 23.4 (continued)
M. N. Cherian et al.
trauma care, is a combined result of “human factors” and “system factors.” System
improvements make a large and long-lasting impact on quality improvement.
Corrective strategies for individual provider performance include counseling and
training. Some measures such as multidisciplinary morbidity and mortality conferences, recordkeeping, and computerized registries have consistently shown to
improve trauma quality [18].
Safety andQuality Perioperative Care
inHumanitarian Emergencies
Providing adequate perioperative safety should address workplace and health workers’ safety, along with patient safety. Although any humanitarian crisis is challenging, it is still feasible to ensure safety and healthcare quality in an austere environment
[19]. It is a common misconception that in an endeavor to provide medical care to a
large number of patients, quality is inevitably compromised. However, it only
requires adherence to context-adapted policies. Médecins Sans Frontières (MSF)
recommendations for eld anesthesia provide excellent guidelines to ensure perioperative safety, even in austere environments [20].
23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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Specialty training of the entire team, along with exibility and situational adaptability, is essential. Scarcity of workforce demands multitasking. An anesthesiologist may be required to double up as a pediatrician for newborn resuscitation, or as
a circulatory nurse or a technical assistant. Preparedness for alternative plans (having plans A, B, and C) is useful. Patient privacy, dignity, and consent, in accordance
with the local culture, should be respected. Basic principles of “rst do no harm”
and “best practice for most” are used. Simple and safe practices that are effective for
the majority of patients allow maximum output with minimum dependence on
sophisticated technology. Use of common, locally available, and affordable medicines and equipment enables a functional, sustainable medical unit, even after shortterm projects conclude. Adherence to patient safety protocols in the perioperative
period by the visiting surgical team, even if it is for short periods, can impact a
behavioral change in the host health facility to continue following such practices.
Recordkeeping and regular reviews are as important as any other surgical area to
improve outcomes and maintain accountability, including in short surgical missions
[21, 22].
The WHO Health Resources Availability Monitoring System (HERAM) allows
the assessment and monitoring of the status of health facilities and the availability
of health services and resources in areas affected by emergencies [23]. The WHO
developed a global verication system for quality-assured emergency medical
teams (EMTs) that meet the WHO EMT minimum standards for deployment in
health emergencies [24].
381
Safe andQuality Perioperative Care inChildbirth
Fourteen million women globally suffer from postpartum hemorrhage, which is the
largest direct cause of maternal mortality. The WHO Safe Childbirth Checklist
targets major causes of maternal mortality, intrapartum-related stillbirths, and neonatal deaths. This checklist was developed with the goal to improve the quality of
care during four points of childbirth in any level of healthcare facility (Fig.23.5a,
b) [25]:
1. At admission
2. Just before pushing or before C-section
3. Soon after birth
4. Before discharge
The WHO “global core indicators for assessing the quality of health care provided to mothers, newborns, and children in health facilities” include prenatal optimization, facilities for infection control, neonatal resuscitation, and availability of
uninterrupted oxygen supply and essential lifesaving medicines, all of which
enhance perioperative mother and child safety [26].
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THE RIGHT
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MOMENTS TO
PAUSE AND
CHECK
The WHO
Safe Childbirth
Checklist is
intended for
use at four pause
points during
facility-based
births:
PAUSE POINT 1: ON ADMISSION
Checking the mother at the of admission
is important to detect and treat complications
that she may already have, to confirm
whether she needs to be referred to another
facility, to prepare her (and her companion)
for labour and delivery, and to educate her
(and her companion) about danger sings for
which she should call for help.
1
M. N. Cherian et al.
PAUSE POINT 2: JUST BEFORE PUSHING
(or before Caesarean)
Checking the mother just before pushing
(or before Caesarean) is important to
detect and treat complications that can
occur during labour and to prepare for
routine events and possible crisis situations
that may occur after birth.
2
DELIVERY PROCESS
PAUSE POINT 3: SOON AFTER BIRTH
(within one hour)
Checking the mother and newborn soon after birth
(within 1 hour) is important to detect and treat
complications that can occur after delivery, and to
educate the mother (and her companion) about
danger signs for which she should call
for help.
3
ADMISSION DELIVE
PAUSE POINT 4: BEFORE DISCHARGE
Checking the mother and newborn before discharge is important
to be sure that the mother and newborn are healthy before discharge,
that follow-up has been arranged, that family planning options have been
discussed and offered to the mother (and her companion), and that
education on danger signs to look out for, both in the mother and
her baby, has been given in case immediate skilled care is needed.
4
DISCHARGE ONGOING CARE
RY
Fig. 23.5 The right moments to pause and check. WHO safe childbirth checklist is intended to use
at four pause points during facility-based births. Reference WHO safe childbirth checklist implementation guide: Improving the quality of facility-based delivery for mothers and newborns.
Geneva, WHO, 2015. https://apps.who.int/iris/bitstream/handle/10665/199177/9789241549455_
eng.pdf ISBN 978 92 4 154945 5 (NLM classication: WQ 300)
Infection Control inPerioperative Care
Postoperative infections lead to prolonged hospital stays, more intensive care, and
increased cost of care. Improving the quality of perioperative care infection control
and antimicrobial resistance (AMR) plays a very important role globally at all levels
of healthcare facilities, resulting in decreased health costs due to shorter hospital
23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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383
stay and less intensive care. The WHO standards and guidelines for perioperative
infection control are:
(i) WHO standards on hand hygiene [27, 28]
(ii) WHO recommendations for prevention of surgical site infections and to combat
AMR [29]
Pain Relief Is Essential forQuality Perioperative Care
Pain management is not just a “humanitarian” act; it is basic to the right to health
[30–32].
It limits chronic pain, enables rehabilitation, and improves overall outcome.
Inadequately treated pain can contribute to long-term disability, morbidity, and,
rarely, mortality.
The “Reversed WHO Pain Management Ladder” is useful in the management of
acute pain during a humanitarian crisis. It involves immediate pain relief with the
use of strong opioids that are tapered gradually (Fig.23.6) [33].
Often in LMICs at the district and subdistrict levels of care, optimum postoperative pain relief (particularly for children and women in labor) is not provided due to
lack of medicines and a skilled health workforce.
Fig. 23.6 Reversed WHO Pain Management Ladder. Reference Mahoney PF, Jeyanathan J, Wood
P, Craven R. The ICRC Anaesthesia Handbook. Geneva: International Committee of the Red
Cross, 2017: Annexure 3, Reversed WHO Pain Management Ladder; p 175
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The WHO list of essential medicine includes effective and inexpensive analgesics, nonsteroidal anti-inammatory medicines, and opioids, but they are frequently
insufcient in supply. The postoperative surgical team is not allowed to administer
these essential medicines or trained to administer safely, which may contribute to
POMR [9]. The World Health Assembly resolution in 2015 (WHA 68.15) highlighted the limited access to opioids for perioperative pain relief in a large proportion of the global population and requested that member states take suitable
action [5].
Effective regional anesthesia causes good analgesia, is opioid sparing, attenuates
sympathetic stress response, and can sometimes avoid general anesthesia. Use of
ultrasound has shown to improve efcacy and safety of regional anesthetic
procedures.
M. N. Cherian et al.
Patient Safety inPerioperative Care
If investments are made into high-quality frontline health services, it will improve
the quality and safety of patient care and resource utilization. This will generate a
trust in health services in the community and therefore enhance local health security, which is a key to global health security [2].
Various WHO Global Patient Safety initiatives focus on improving perioperative
safety. The rst Global Patient Safety Challenge in 2005, “Clean care is safer care,”
aimed at reducing hospital-acquired infections (HAIs) with May fth designated as
Global Hand Hygiene Day [34].
The second Global Patient Safety challenge in 2009, “Safe surgery saves lives,”
focused directly on perioperative safety standards and led to the implementation of
the evidence-based WHO Surgical Safety Checklist. The checklist aims at preventing errors from the preoperative until postoperative period and at improving communication amongst the team. Its use has been shown to reduce patient mortality by
one-third (see Fig.23.3) [15].
The third patient safety challenge in 2014, “Medication without harm,” aimed at
reducing avoidable medication-related harm and involves system improvements,
role of healthcare professionals, and patient participation in ensuring medication
safety [35].
Communication at an individual level and mass communication are both very
important tools in ensuring the quality of trauma care and patient safety such as:
– Detailed patient monitoring charts and careful handing over at staff shift changes
(Fig.23.7)
– Clear and audible announcements by the team leader during surgery or
resuscitation.
Announcement of codes like initiation of “massive transfusion protocol” or
“disaster management” can activate all relevant departments simultaneously
and reduce their response times (like early availability of blood from blood
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