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23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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385
bank, preparation of operation theaters, readiness in intensive care units,
resource mobilization, and enhanced patient care). Communication in patient
safety has a very important role in reducing harm. In Australia, 11% of adverse
events leading to permanent disability were found to be due to “communication
issues” [36].
Lack of effective communication is an important factor in the majority of
adverse events and is especially prominent in demanding situations like perioperative care. Patient handover (or handoff) communication starts from the receiving of the patient by healthcare providers, continues during handovers amongst
caregiver teams, and nishes with handing over of patient to the family by a
healthcare provider to maintain continuity of care. Communication strategies during patient handovers like SBAR (situation, background, assessment, recommendation) are designed to improve inter-professional collaboration and transfer of
comprehensive information in an organized manner. It is considered a current best
practice in communication that improves patient safety, especially in critical situations. “Repeat back” and “read back” steps, limiting communication during
handover to that related to patient care, and trainings on effective communication
and handover all help in minimizing errors during patient handover (see
Fig.23.7) [37].
Day care surgeries and ambulatory anesthesia involve early discharge of
patients. Discharging the patient and handing over the patient to their family should
Communication During Patient Hand-Overs
Policy
Provider
Patient
Hand-over
communication
Shift-to shift,
Unit-to-unit
Hand-over
communication
Discharge
Fig. 23.7 Communication during patient hand-overs. Reference Communication during patient
hand-overs. JCI WHO Collaboration Patient Safety Solutions | volume 1, solution 3 | May 2007
Put in place a standardized approach to hand-over communication between staff change of
shift and between different patient care units in the course of a patient transfer.
Ensure that a responsible provider has updated information regarding the patient’s status,
medications, treatment plans, advance directives, and any significant status changes.
Engage patients and family members in decisions about their care at the level of
involvement they choose.
Provide patients with information about their medical condition and treatment care
plan in a way that is understandable to the patient.
Use a standardized approach to minize confusion.
Allocate sufficient time for staff to ask and respond to questions.
Incorporate repeat-back and read-back steps as part of the hand-over process.
Limit the exchange to information that is necessary to providing sage care to the patient.
Provide the patient and the next provider of care with information on discharge diagnoses,
treatment plans, medications, and test results.
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M. N. Cherian et al.
involve detailed communication with the patient and have the patient involved in
their own care. The prescription, medications, and precautions should be explicitly
told to the patient. When to contact and whom to contact in an emergency should
be clearly written in the discharge paper. “Teach back” is a technique in which
patients have to describe what they have understood about the medical advice
given [37].
A 2004 WHO initiative “Patients for Patient Safety” was established to involve
and engage patients in their own care. Patients should be communicated with in
detail about their medical condition and the planned treatment and kept continuously involved in their management and decisions. Informed consent is also an
integral part of patient safety. Patients should be encouraged to take ownership
of their health, give relevant information to the healthcare provider before surgery, ask questions and clear their doubts regarding the perioperative period,
follow medical advice, and try to familiarize themselves with medications and
treatment, especially during home care. They should be actively involved rather
than be a passive recipient of healthcare service. The WHO tool Patient
Information for Surgical Safety engages and empowers the patient to ask key
questions of the surgical care provider before and after any surgical intervention
(Fig.23.8) [38].
Fig. 23.8 WHO Patient information for surgical safety. Patient’s Communication Tool for
Surgical Safety. Who reference number: WHO/HIS/SDS/2015.18. Patient information for
surgical safety: what you need to know before and after surgery (who.int) https://www.who.
int/publications/i/item/WHO-HIS-SDS-2015.18. Reference https://www.who.int/surgery/publications/patients_communication_tool.pdf?ua=1. https://www.who.int/publications/i/item/
integrated-management-for-emergency-and-surgical-care-(-imeesc)-toolkit
Percentage of total
General doctors providing anaesthesia
23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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387
Strengthening Health Systems toDeliver Quality ofSurgical
Services Toward Achieving UHC
Improving quality and safety of surgical care services requires a “systems thinking”
approach with locally adaptable interventions and strategies to reduce harm; data
systems; professional development; and patient empowerment toward a sustainable
environment. A recent study showed that UHC for SDG conditions could avert
8.6million deaths per year, provided that investments are made for expanding health
service coverage together with high-quality health systems [39].
Surgical (including anesthesia) services should not be seen in isolation in the
tertiary level of care, but should be addressed from a perspective of strengthening
health systems. Provision of safe and quality surgical care to a population requires
a robust health system that has competent surgical personnel. In LMICs, a signicant proportion of nonphysicians (clinical ofcers, surgical technicians, nurses)
deliver surgical and anesthetic care with a wide variation of skills at the district and
subdistrict healthcare facilities (Fig.23.9) [40].
SDG3 indicators specically emphasize quality and safety of essential health
services; health workforce density distribution per 100,000 population; decrease in
45
40
35
30
25
20
15
10
5
0
Health Centers Subdistrict/Community
318 223 325
Hospitals
Districst/Rural
Hospitals
General doctors providing surgery
Surgeons
Nurses/CMO providing anaesthesia
Obstetrician/Gynaecolgists
CMO providing surgery
Anaesthesiologist
General Hospitals
Types of HCF
137
Provincial Hospitals
84 236
Private/NGO/Mission
Hospitals
Fig. 23.9 Human resources according to types of healthcare facility. Reprinted from Sheik Ali S,
Jaffry Z, Cherian MN, etal. Surgical human resources according to types of health care facility: an
assessment in low- and middle-income countries. World J Surg. 2017; 41:2667. https://doi.
org/10.1007/s00268- 017- 4078- 4. Licensed under Creative Commons CC BY
388
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Fig. 23.10 Global distribution of surgeons, anaesthesiologists, and obstetricians, per 100,000
population. (NA=countries or territories that are not WHO members and thus excluded from our
data). Reprinted from The Lancet Global Health, Vol. 3, Suppl. 2, Holmer H, Lantz A, Kunjumen
T, Finlayson S, Hoyler M, Siyam A, Montenegro H, Kelley ET, Campbell J, Cherian MN, Hagander
L, Global distribution of surgeons, anaesthesiologists, and obstetricians., Pages S9–11. Copyright
(2015), with permission from Elsevier
M. N. Cherian et al.
perioperative morbidity and mortality including surgical procedures involving injuries and sexual and reproductive health; cancer and other surgical conditions; and
abdominal and humanitarian emergencies (Fig.23.10) [41, 42].
It is important to ensure that countries incorporate quality and safety of anesthesia and surgical care services. In their national health plans aligning with all the
relevant programs such as maternal and child health, noncommunicable disease
(injuries, cancer, aging, cardiovascular), neglected tropical disease, HIV, and
humanitarian emergencies, capacity for essential surgery and anesthesia services is
severely limited in LMICs due to shortfalls in physical infrastructure, human
resources, and basic equipment and supplies, including continuous water, electricity, and oxygen [43–45].
Achieving post-2015 sustainable development goals, including universal
healthcare, will require signicant investment in surgery and anesthesia capacity [46].
Standard Tools Applicable Globally forQuality Surgical
andAnesthesia Services
Several guidance tools, discussed below, have been developed by the WHO and the
WFSA with professional bodies that could assist ministries of health and funders to
make appropriate investments for improving the quality and safety of surgical and
anesthesia services.
1. WHO Situation Analysis Tool (SAT)
WHO SAT helps in assessing the gaps in emergency and essential surgical
care at resource-limited settings and is used in several countries. The WHO
23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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Integrated Management for Emergency and Essential Surgical Care toolkit contains guidance on improving safety and quality of surgical services [47, 48].
2. WFSA Comprehensive Anesthesia Facility Assessment Tool (AFAT)
AFAT enables data collection and assessment of anesthesia practices, medicines, equipment, and workforce at the facility level, regional level, and national
level. This data can help in the assessment of anesthesia capacity at the regional
and national level, and resource management for the implementation of WHA
resolution 68.15 [49].
3. WFSA guidance on anesthesia machines
Because the supply of electricity and compressed gases varies from location
to location, the WFSA has developed guidelines for those seeking to tender for
and purchase anesthesia machines [50].
4. Global standardization of medical gases
Guidelines on anesthetic gases’ color coding and pin index system to ensure
safe patient care globally have been developed by the International Organization
for Standardization (ISO) and can be adopted by all countries [51, 52].
5. WHO equipment donation
Donation of surplus medical equipment from high-resource settings to low-
resource settings could help in bridging some gaps in healthcare service delivery.
Effective donation requires proper execution. It involves understanding of recipients’ context and providing support system and capacity-building programs for
recipients. Guidelines and training modules on equipment donation have also
been developed by the WHO [53].
6. WHO Service Availability and Readiness Assessment (SARA)
WHO SARA is a tool for assessment and monitoring of health sector service
availability and readiness and helps in health system planning and management.
It contains indicators to assess readiness of surgical services and is used in several countries [54].
389
Improving Quality ofPerioperative Care at theGlobal Stage
At the global stage, it requires understanding and commitments from all stakeholders (ministries of health and nance, professional and civil societies, nongovernment organizations, health providers, and managers) to invest in improving the
quality and safety of perioperative care, which contributes to the SDG targets for
maternal and child health, noncommunicable and neglected tropical diseases, and
humanitarian emergencies.
In order to improve the delivery of safe and quality surgical and anesthesia services, it is important for both policy makers and health providers to adopt the following concrete improvement interventions/steps toward a robust health system:
1. Adapt existing global safety standards to develop national safety standards con-
sistent with the local situation.
2. Sustainable investments to strengthen the implementation of safety standards to
deliver quality care at all levels of healthcare facilities: The essential equipment
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and medicines, and measures for infection control required to deliver safe perioperative care, should not be compromised in the district or primary level of
healthcare facilities. It is often seen that anesthesia services in LMICs are compromised in terms of infrastructure and health workforce [43]. Performancebased assessment, implementation of safety protocols/checklists, and minimum
safety standards in the healthcare facility will encourage nancial investments.
3. Skilled surgical and anesthesia health workforce to meet the country’s local needs:
This will require both short-term and long-term training strategies (both midlevel
health cadres and specialists), supervision, and ongoing evaluation of healthcare
providers. These training programs should be licensed/accredited and approved at
the national level by ministries of health, academia, and professional societies.
Major deciencies were found in specialist surgical workforce, especially
surgeons, anesthesiologists, and obstetricians (SAO) in LMICs in a study by the
Lancet Commission on Global Surgery and the WHO.It recommended SAO
workforce of at least 20/100,000 to achieve SDG 3.8.1 by 2030. Globally, many
countries are much below the target (see Fig.23.10) [42].
In LMICs at the district and subdistrict levels, much of the surgical (including
anesthesia) care providers are nonphysicians (nurses, technicians). See Fig.23.9
[40]. Quality of care provided by midlevel health workers has been studied in
some LMICs such as Malawi, Mozambique, Cameroon, and Tanzania [55]. In
some HICs, physician assistant/associate (USA, Ireland), surgical technicians,
and other healthcare providers are trained to provide preoperative and postoperative care. Continuing professional development platforms for perioperative
healthcare providers (doctors, nurses, technicians), e.g., online courses, training
workshops, meetings, and conferences for recent updates, is essential.
4. Platform/forum for evaluation of implementation of quality and safety standards: For a sustainable quality anesthesia services at rst referral level, rural
and remote health facilities’ policies need to be in place for the retention of
trained anesthesia and surgical workforce. An appropriate environment has to be
maintained (such as structured training and professional development, infrastructure, equipment, medicines, consistent nancial remuneration, and established health posts) [56].
5. Using information technology (medical records, robust data system, patients’
feedback) for choosing implementation of evidence-based interventions and
evaluation, which will improve the quality of perioperative care in the
local context
M. N. Cherian et al.
Three Practical Checkpoints Applicable Globally Toward
thePatient’s Safe Perioperative Journey
A prerequisite to quality perioperative care is a safe infrastructure with continuous
water, electricity, oxygen supply, and a qualied trained surgical team. There are
three checkpoints that guide the implementation of standard protocols and tools for
the patient’s safe perioperative journey that should be promoted globally.
23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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First Checkpoint: Preoperative
• WHO Patient Information tool
• Preoperative anesthesia checkup (history, allergy, comorbidity, medications,
labs, examination, consent, anesthesia and surgical plan, WHO Surgical Safety
Checklist)
• Operating room checks prior to taking the patient into the OR:
– Patient identication (correct patient, correct surgery, correct site)
– Infection control (gloves, antibiotics, alcohol swabs, sterile instruments)
– Equipment check (anesthesia, oxygen, suction, airway, operating room table,
resuscitation, vital monitoring, pulse oximetry, end-tidal carbon dioxide
monitoring)
– Medicines (emergency, anesthetics, opioid)
– Supplies (oxygen, intravenous uids, disposable syringes with needles)
– Trained staff (each member of the surgical team is trained/skilled in what they
do: doctors/nurse/technician/assistants)
– Intravenous access and blood requirements
Second Checkpoint: Intraoperative
– WHO Surgical Safety Checklist
– Critical surgical concerns
– Monitoring
– Maintaining record
391
Third Checkpoint: Postoperative/Recovery Room/Intensive Care/Ward
• Pain relief
• Monitoring (sometimes often the best successful surgical intervention performed
in the OR can end up with a morbidity and mortality discovered much later in the
postoperative period during transfer or in the ward)
• WHO Surgical Checklist: Discharge records are signed off before transfer to the
next level of care
• Room check:
– Infection control (surgical site infection, hand hygiene, etc.)
– Equipment (oxygen, suction, monitoring vital signs, etc.)
– Medicines
– Supplies
Conclusion
The Sustainable Development Goals (SDGs) implementation agenda for 2030 calls
for the global surgical community to act urgently in collaboration and partnership
with local stakeholders to invest in improvements made specically to the SDG core
indicator targets relevant to emergency and essential surgical care and anesthesia.
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M. N. Cherian et al.
These core indicators highlight the important areas required for coverage of quality
essential health services that include service-specic availability and readiness; outpatient service utilization including inpatient admissions and surgical volume; perioperative mortality rate reduction in maternal, newborn, and children;
noncommunicable diseases including injuries and cancer; interventions in neglected
tropical diseases; and health system strengthening for quality and safety of care
including access to medicines, health worker density and distribution, access to
emergency surgery, output training institutions, and ofcial development assistance
to the medical research and basic health sectors [16].
Pursuing UHC through expanding coverage for health services alone is not
enough. LMICs must strive to provide better quality of care (and improve surgical
and anesthesia capacity); otherwise, deaths attributable to receiving poor-quality
healthcare will not enable meeting SDG targets [39].
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