Anaesthesia Manpower Research Articles

Obstetric Anesthesia Manpower and Service Provision Issues: Introduction and European Perspective

Obstetric Anesthesia Manpower and Service Provision Issues: Introduction and European Perspective

Obstetric anaesthesia manpower and service provision issues (introduction and European perspective)

Global health is an important and far-reaching concept in which health and access to surgical and anaesthetic care is crucial. Universal access to anaesthesia is a challenge in many countries. Manpower shortages are an important cause of difficulties and each European country has found different ways of facing a lack of healthcare professionals. In obstetric anaesthesia, the availability of competent anaesthesiologists has been related to the morbidity and mortality outcomes of patients.In this narrative review, authors from different European countries explain how manpower is managed in obstetric anaesthesia in delivery suites and obstetric operating rooms in different settings. To address manpower difficulties and issues, the goals are to achieve a minimum standard of care and at the same time, to promote clinical excellence through training, delegation to younger or less experienced colleagues, direct or at-a-distance supervision, or other means.The experience of sharing knowledge about the way in which manpower and service provision are organised in other healthcare settings is a significant opportunity to develop strategies for advancing tomorrow’s obstetric anaesthesia in the world. While taking into account the level of socio-economic development in different countries, the aim is to standardise practice and workload organisation. Co-operative international projects in training and education in obstetric anaesthesia are ways in which better obstetric patient care can be achieved in the future.

History of Anaesthesia in Ghana - (1): Human Resource Development in Anaesthesia

The history of medicine in Ghana has been documented but there has not been any documentation of the history of anaesthesia in the country. Anaesthesia in Ghana has seen a number of changes in the last fifty to sixty years. These changes have been seen in the areas of anaesthetic drugs, anaesthetic techniques, the training of anaesthetic manpower and introduction of intensive care facilities.There has been the introduction of new and modern anaesthetic machines and monitors which were completely absent some decades ago. This article seeks to highlight some of the major changes that have taken place in the specialty. The challenges facing the specialty in terms of the supply of consumables, the lack of maintenance of equipment and the low numbers of enrolment into the specialty by physicians are discussed. International collaborations, the setting up of new specialised units like the National Cardio-thoracic Centre are also mentioned in this article.

History of Anaesthesia in Ghana (2): Development of Equipment, Consumables and Anaesthetic Drugs

This is the second instalment in the series on HISTORY OF ANAESTHESIA IN GHANA. The history of medicine in Ghana has been documented but there has not been any documentation of the history of anaesthesia in the country. Anaesthesia in Ghana hasseen a number of changes in the last fifty to sixty years. These changes have been seen especially in the areas of anaesthetic drugs, anaesthetic techniques, the training of anaesthetic manpower and introduction of intensive care facilities. There has been an introduction of new and modern anaesthetic machines and monitors which were completely absent some decades ago. This articleseeks to highlight some of the major changes that have taken place in the specialty. The challenges facing the specialty in terms of the supply of consumables, the lack of maintenance of equipment and the low numbers of enrolment into the specialty by physicians arediscussed. The role of international collaborations and the setting up of new specialised units like the National Cardio-thoracic Centre are also mentioned in this article.

History of Anaesthesia in Ghana (3): Anaesthetic Techniques, Care of the Critically Ill, Extension of Anaesthetic Services and International Collaboration

This is the third instalment in the series on HISTORY OF ANAESTHESIA IN GHANA. The first instalment was on Human ResourceDevelopment in Anaesthesia.The second was on Developmentof Equipment, Consumables and Anaesthetic Drugs. The history of medicine in Ghana has been documented but there has not been any documentation of the history of anaesthesia in the country.Anaesthesia in Ghana has seen a number of changes in the last fifty to sixty years. These changes have been seen especially in the areas of anaesthetic drugs, anaesthetic techniques, the training of anaesthetic manpower and introduction of intensive care facilities.There has been an introduction of new and modern anaesthetic machines and monitors which were completely absent some decades ago. This article seeks to highlight some of the major changes that have taken place in the specialty. The challenges facing the specialty in terms of the supply of consumables, the lack of maintenance of equipment and the low numbers of enrolment into the specialty by physicians are discussed. The role of international collaborations and the setting up of new specialised units like the National Cardio-thoracic Centre are also mentioned in this article.

Why is the labor epidural rate low and cesarean delivery rate high? A survey of Chinese perinatal care providers.

China has a high cesarean delivery (CD) and low labor epidural analgesia (LEA) rate. This online survey was conducted to explore the reasons behind this phenomenon and potential solutions. A voluntary, anonymous survey was distributed via both WeChat and professional websites for 4 months amongst groups of Chinese perinatal professionals. Data was collected and analyzed using a Chi-square test and presented as percentages of respondents. 1412 respondents were recorded (43% anesthesiologists, 35% obstetricians, 15.5% midwives or labor and delivery nurses, and 6.5% others), and 1320 respondents were care providers. It was found that 82.7% (1092/1320) of the provider respondents used CD per patient request in fear of lawsuits or yinao/yibao and 63.4% (837/1320) used CD for respecting superstitious culture. The number one reason (noted by 60.2% (795/1320) of all the three specialties) for low LEA use was lack of anesthesia manpower without statistical difference among specialties. The most recommended solution was increasing the anesthesia workforce, proposed by 79.8% (1053/1320) of the three specialties. However, the top solution provided by the two non-anesthesia specialties is different from the one proposed by anesthesiologists. The later (83%, 504/606) suggested increasing the incentive to provide the service is more effective. The answers to questions related to medical knowledge about CD and LEA, and unwillingness of anesthesiologists, parturients and their family members to LEA were similar for the most part, while the opinions regarding low LEA use related to poor experiences and unwillingness of obstetricians and hospital administrators were significantly divided among the three specialties. In the providers' point of view, the unwillingness to LEA from parturient's family members was the most salient (26.1%, 345/1320), which is more than all care providers, hospital administrators, and parturients themselves (16.8%, 222/1320). The reasons for high CD rate and low LEA use are multifactorial. The sociological issues (fear of yinao/yibao and superstitious culture) were the top two contributing factors for the high CD rate in China, while lack of anesthesia manpower was the top response for the low LEA use, which contributes to its being the most recommended solution overall from the three specialties. An incentive approach to providers is a short-term solution while training more perinatal care providers (especially among anesthesiologists and midwives), improving billing systems, and reforming legal systems are 3 systemic approaches to tackling this problem in the long-term.

Pediatric Perioperative Mortality in Kenya: A Prospective Cohort Study from 24 Hospitals.

The global surgery access imbalance will have a dramatic impact on the growing population of the world's children. In regions of the world with pediatric surgery and anesthesia manpower deficits and pediatric surgery-specific infrastructure and supply chain gaps, this expanding population will present new challenges. Perioperative mortality rate is an established indicator of the quality and safety of surgical care. To establish a baseline pediatric perioperative mortality rate and factors associated with mortality in Kenya, the authors designed a prospective cohort study and measured 24-h, 48-h, and 7-day perioperative mortality. The authors trained anesthesia providers to electronically collect 132 data elements for pediatric surgical cases in 24 government and nongovernment facilities at primary, secondary, and tertiary hospitals from January 2014 to December 2016. Data assistants tracked all patients to 7 days postoperative, even if they had been discharged. Adjusted analyses were performed to compare mortality among different hospital levels after adjusting for prespecified risk factors. Of 6,005 cases analyzed, there were 46 (0.8%) 24-h, 62 (1.1%) 48-h, and 77 (1.7%) 7-day cumulative mortalities reported. In the adjusted analysis, factors associated with a statistically significant increase in 7-day mortality were American Society of Anesthesiologists Physical Status of III or more, night or weekend surgery, and not having the Safe Surgery Checklist performed. The 7-day perioperative mortality rate is less in the secondary (1.4%) and tertiary (2.4%) hospitals when compared with the primary (3.7%) hospitals. The authors have established a baseline pediatric perioperative mortality rate that is greater than 100 times higher than in high-income countries. The authors have identified factors associated with an increased mortality, such as not using the Safe Surgery Checklist. This analysis may be helpful in establishing pediatric surgical care systems in low-middle income countries and develop research pathways addressing interventions that will assist in decreasing mortality rate.

Parotidectomy with local anesthetics: a viable option in medical outreach in a resource poor setting

Background: Parotidectomy has been traditionally done with general endotracheal anaesthesia mostly in tertiary institutions where there is adequate anaesthetic manpower. A lot of patients with parotid masses presents to other cheaper healthcare providers including medical outreaches where there is paucity of both anaesthetic manpower and gadgets. Aim: To share our experience in parotidectomy using local anaesthetics in medical outreaches where there is inadequate support of anaesthetic personnel and gadgets. Method: Patients counseled for parotidectomy had local anesthetic infiltration and nerve block with 1% ligdocaine in 1:100,000 adrenaline. Lazy-S incision was used starting pre-tragally down to the angle of the mandible. Branches of the facial nerve were gently separated from the mass which is delivered to the wound and shelled out. Wounds were closed in layers without drain. Conclusion: Parotidectomy with local anaesthetic agents is a safe option especially in settings of medical outreaches in resource poor countries with limited anaesthetic manpower and gadgets. The safety of surgery on day case basis and avoidance of use of hardly available nerve stimulator all the more make it an appealing alternative.

Has the Middle-Level Anaesthesia Manpower Training Program of the West African College of Surgeons Fulfilled its Objectives?

An audit of the West African College of Surgeons' middle-level Diploma in Anaesthesia program was carried out to determine the current status of the diplomates. Using the West African College of Surgeons' database, social media and personal communications, the current status of Diploma in Anaesthesia graduates spanning 20 years was determined. A total of 303 (97%) out of 311 of graduates were traced. Eighty percent were still practising anaesthesia, while 5% were now in other disciplines. Two hundred and four (67.3%) still resided in West Africa (183 in Nigeria, 50 in Ghana, one in Sierra Leone), while 69 (22.7%) were abroad: 35 (11.5%) in the United Kingdom, 21 (6.9%) in the United States of America and four (1.3%) in Canada. More Ghanaian than Nigerian graduates had emigrated (41 vs 14%, respectively). Only 9% of diplomates remained in rural communities (as originally envisaged), while 31% were now consultants (as fellows) and 30% were registrars in fellowship training. These findings indicate that most diplomates moved on to acquire further qualifications and a significant proportion migrated. The program did not appear to have achieved the objectives of meeting rural middle-level manpower needs in anaesthesia as envisaged. It has, however, boosted the recruitment drive for residency training in anaesthesia. Perhaps a less migrant cadre such as nurses may better serve this function if recruited into a suitably designed training program in countries desiring to use middle-level manpower in anaesthesia.

A first step in determining appropriate amounts of obstetric anesthesia work

Ginosar, et al. describe a new performance indicator, the Obstetric Anesthesia Activity Index, to represent the current amount of obstetric anesthesia work done daily at each of 25 Israeli hospitals. The authors claim, correctly, that this index is a closer reflection of the anesthetic workload than simply looking at the number of deliveries at each hospital. However, the Obstetric Anesthesia Activity Index could easily be refined to reflect more closely the actual obstetric anesthesia workload by using the average cesarean delivery time for each hospital rather than one value for all hospitals. Although the authors state that they developed the Obstetric Anesthesia Activity Index out of concern for inadequate obstetric anesthesia manpower in Israel, they have not compared the Obstetric Anesthesia Activity Index with the size of the patient population or any measure of patient satisfaction or patient safety. In its current form, the Obstetric Anesthesia Activity Index describes the current work situation but does not evaluate the extent of the unmet need for additional anesthesia providers. Despite these shortcomings, the Obstetric Anesthesia Activity Index is an important first step in developing a tool to assess unmet obstetric anesthesia needs.

A Measure of Gold

Since its founding in 1954, the Society of Anaesthetists of Hong Kong has set fundamental aims to assure professionalism of the specialty, uphold the honor and status of anesthetists, provide appropriate anesthetic training, establish close liaison with professional partners worldwide and educate the lay public about anesthesia.

Impact of a nurse practitioner‐assisted preoperative assessment program on quality

The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient-centered care by instituting a nurse practitioner-assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program. One thousand five hundred and nine children aged 1 month-18 years, 463 parents, 25 anesthesiologists and 20 preoperative clinic nurses were studied. Indicators of quality were incidence of respiratory complications (apnea/hypopnea, laryngospasm, bronchospasm, and supplemental oxygen use in postanesthesia care unit), patient preoperative preparation time and parent and staff (anesthesiologists and preoperative clinic nurse) satisfaction. These indicators were recorded for 1 week every 3 months for 1 year. The first week (baseline) was an anesthesiologist-only preoperative assessment (three anesthesiologists performing approximately 120 evaluations per day). The subsequent four data collection weeks at 3, 6, 9, and 12 months were nurse practitioner (NP)-aided preoperative assessments (one anesthesiologist with six NPs performing approximately 120 evaluations per day). The incidence of respiratory complications, patient preoperative preparation time, and levels of parental satisfaction did not differ significantly between anesthesiologist-only and NP-aided assessments. However, anesthesiologist and preoperative clinic nurse satisfaction increased significantly postimplementation of the program. Our study revealed that within a year of its implementation, the NPAPE program maintained patient safety, timeliness, and a high level of parent satisfaction as well as increased staff satisfaction, while shifting two anesthesiologists to the OR. A NP-assisted preoperative evaluation program can offer operational advantages without compromising care.

Demography of French anaesthesiologists. Results of a national survey by the French College of Anaesthesiologists (CFAR) and the French National Society of Anaesthesia and Intensive Care (SFAR), supported by the National Institute for Demographic Studies (INED).

The perception of a looming manpower shortage led the French College of Anaesthesiologists (CFAR) and the French Society of Anaesthesia and Intensive Care (SFAR), with assistance from the National Institute for Demographic Studies (INED), to conduct a national survey of French anaesthesiologists in order to determine precise physician characteristics data, analyse professional practices and project future service provision. The survey was based on self-administered individual questionnaires, approved by the National Committee on Informatics and Freedom (CNIL). The survey was carried out at the end of 1998 among 1484 hospitals (590 public and 894 private), under the supervision of local referees and regional co-ordinators. Of 9741 anaesthesiologists' posts, 5694 (58%) are in public hospitals, 3569 (37%) in private practice and 478 (5%) in private hospitals within the National Health Service, i.e. the participant au service public hospitalier (PSPH). Complex validation of the results was necessary to account for the missing responses and multiple sites of activity. The survey identified 8876 specialists practising anaesthesia and intensive care in France at the beginning of 1999, including 216 in French overseas territories. This figure is consistent with that published by the Medical Council (Ordre des Médecins) on 1 January 1999, identifying 8950 anaesthesiologists in France, including 234 in the overseas territories. Annual growth in the anaesthesiologist population has fallen from 9% pre-1989 to 0% in 1999. Male anaesthesiologists outnumber females (35.7%). The average age has risen from 42.8 yr in 1989 to 45.9yr in 1999. The age distribution of anaesthesiologists has become bell shaped, reflecting reduced numbers of younger practitioners. There are currently 14.75 anaesthesiologists per 100 000 people (compared to 12.9 in 1989), a figure slightly above the European average, but there is considerable geographical inequality between the north and south of France, with increased concentrations in large cities that contain university hospitals. Future service provision must take account of falling numbers of new anaesthesiologists and an increase in retirements, but must also include changes in working practices, such as the European Working Time Directive. If anaesthesia manpower shortages are to be avoided, there must be a restructuring of the work-place, a redefinition of tasks and improved management of working time.

From Anaesthetic Nurse to Nurse Anaesthetist: Is This Possible in the UK?

Current practice in the United Kingdom (UK) dictates that the administration of a general anaesthetic is undertaken by a physician. However, for several years now the controversial question has been raised as to whether other practitioners, primarily nurse anaesthetists, should also be allowed administer general anaesthetics. The ensuing debate has been refueled in recent times resulting from the trend towards providing cost-effective health care delivery combined with concerns over current and anticipated further shortages in anaesthetic manpower. This paper discusses some of the arguments both for and against the introduction non-physician anaesthetists in the UK, also drawing on the debate in other parts of the world, concluding with a call for more research to address the controversy. First though, because there appears to be some confusion over the difference between the meaning of the titles ‘Anaesthetic Nurse’ and ‘Nurse Anaesthetist’, it will be helpful to provide brief definitions of these terms.

Les médecins anesthésistes-réanimateurs en France en 1999 Premiers résultats de l’enquête démographique nationale Cfar-Sfar-Ined

Objectives: Fears related to the future of anaesthesia manpower in France have led the French College of Anaesthesiologists (Cfar) and the French Society of Anaesthesia and Intensive Care (Sfar), in scientific partnership with the National Institute for Demographic Studies (Ined), to set-up a national survey among French anaesthetists (MAR) practicing in France, to describe their demographic evolution and to analyse their professional activities. Methods: The survey was based on a personal questionnaire, filled by each individual, approved by the National Commission on Informatics and Freedoms (CNIL). The survey was conducted in November 1998, in the 1484 hospitals, public (590) and private (894) where anaesthetics are performed, under the control of local and regional referents. Results: The anaesthesiologists positions count gave a total of 9741 positions shared between 5694 in public practice (58%), 3569 in private practice (37%) and 478 in private hospitals taking part to the national health service-PSPH (5%). The evaluation of the number of anaesthesiologists from the number of positions has made necessary a methodology of rectification of the survey to take in account the lack of response and the multiple sites of activity. The survey allows an evaluation of around 8876 physicians practising anaesthesia and intensive care in France at the beginning of 1999, among them 216 overseas. This census is in concordance with the count made by the Medical Council— Ordre des médecins—which published a number of 8716 anaesthesiologists in France, and 234 overseas, at the 1st January 1999, corresponding to a total of 8950. The annual demographic growth has felt from 9% per year, before 1989, to reach the level zero, in 1999. The masculinisation of the speciality is growing with a proportion of 35.7% of females, as well as ageing, the overage of age increasing from 42.8 in 1989 to 45.9 years in 1999. The pyramid of ages does not correspond to a growing population but to ageing people due to a decrease of the youngest classes. The medical density of 14.75 anaesthesiologists for 100 000 inhabitants in 1999, compared to 12.9 in 1989, is slightly above the European average, but the geographic distribution is very unequal between north and south, the large cities, centre of a university hospital, and the smaller one even if a reduction of differences is observed. The study and the analysis of professional activities bring important data to take in account side of demographic evolution. Conclusion: The demographic evolution must integrate non-only the reduction of the entries in the speciality, of the retirements, but also the sociological evolutions linked to the working time reduction. The solutions face to the promised shortcut of manpower consist of a reorganisation of the structures, a new definition of tasks and managements, without the possibility to avoid and adjustment of the anaesthesiologists population.

Anaesthesia manpower in Belgium until 2020: nurse anaesthetists - a possible solution?

Background and objective: The study evaluated the manpower requirements in anaesthesia in Belgium until 2020. The basic intent was to estimate the need for anaesthesiologists in different hospitals because the number of medical students will be reduced to 700 in 2004 and to 600 in 2007 (numerus clausus), and the number of trainees in anaesthesia from 110 to 42 (best scenario) or to 21 (worst scenario). Simultaneous anaesthesia (more than one patient at the same time) is not allowed by our professional safety rules or by the Belgian Ministry of Public Health. The questions are: will we have enough anaesthesiologists in the next 20 years, and is there a need for nurses to administer anaesthesia? This professional title of nurse anaesthetist does not presently exist in Belgium. Methods: Every registered anaesthesiologist in Belgium received a questionnaire about the manpower requirements in his or her institution expected over the next 20 years. The workload in the specialty was also considered. Results: We received 154 replies from 186 different hospitals. The workload is definitely high: 10 h per day was devoted to clinical work and 4.6 h per week to administration. Belgium will need 51 anaesthesiologists each year after 2004, and 58 each year from 2010 to 2020. Conclusions: Will anaesthesiologists accept their present high workload for the next 20 years? If not, the consequences will be serious. Three-quarters (75.4%) of the replies identified a need for more anaesthesiologists and considered that an anaesthesiologist supervising anaesthesia nurses for a number of patients simultaneously was a possible solution.

Anaesthesia manpower in Belgium until 2020: nurse anaesthetists--a possible solution?

The study evaluated the manpower requirements in anaesthesia in Belgium until 2020. The basic intent was to estimate the need for anaesthesiologists in different hospitals because the number of medical students will be reduced to 700 in 2004 and to 600 in 2007 (numerus clausus), and the number of trainees in anaesthesia from 110 to 42 (best scenario) or to 21 (worst scenario). Simultaneous anaesthesia (more than one patient at the same time) is not allowed by our professional safety rules or by the Belgian Ministry of Public Health. The questions are: will we have enough anaesthesiologists in the next 20 years, and is there a need for nurses to administer anaesthesia? This professional title of nurse anaesthetist does not presently exist in Belgium. Every registered anaesthesiologist in Belgium received a questionnaire about the manpower requirements in his or her institution expected over the next 20 years. The workload in the specialty was also considered. We received 154 replies from 186 different hospitals. The workload is definitely high: 10 h per day was devoted to clinical work and 4.6 h per week to administration. Belgium will need 51 anaesthesiologists each year after 2004, and 58 each year from 2010 to 2020. Will anaesthesiologists accept their present high workload for the next 20 years? If not, the consequences will be serious. Three-quarters (75.4%) of the replies identified a need for more anaesthesiologists and considered that an anaesthesiologist supervising anaesthesia nurses for a number of patients simultaneously was a possible solution.

Evolution of the demography of anesthesia practitioners in French speaking Sub-Saharan Africa

To assess the course of the demography of anaesthesia providers in French-speaking subsaharian countries. Retrospective survey. Doctors trained in anaesthesia and nurse anaesthetists registered in West African medical societies. Countries, hospitals, anaesthesia manpower, seniority and place of training were analysed. In the 13 French-speaking subsaharian countries including 97.5-M inhabitants, 122 doctors and 868 nurses were registered as anaesthetists in 1998. Mean ratios were one doctor trained in anaesthesia for 799,180 inhabitants and one nurse anaesthetist for 112,327 inhabitants. From 1980 to 1998, these figures increased by a factor 11 for doctors (+1100%) and by a factor two for nurses (+100%). Most doctors were working in the chief town, in both public and private health care institutions. In all French-speaking subsaharian countries, a major shortage of doctors trained in anaesthesia is existing.

A survey of anaesthetic manpower and training in the south-west Pacific region.

A survey of anaesthetic manpower and training in the south-west Pacific region.

Anaesthesia services and the education of anaesthetists in Nepal: a model for sustainable development?

In 1985 the University of Calgary in Canada and Tribhuvan University in Kathmandu, Nepal Jointly established the Diploma in Anaesthesiology (DA) programme in Nepal. To evaluate the impact of the DA Programme and provide a data base for long-term planning we conducted a national survey in 1992. We sought to describe anaesthesia manpower and workloads, and to make an inventory of facilities, equipment, and supplies in different sized hospitals. Twenty-seven hospitals providing surgical services were included, nine inside and 18 outside the Kathmandu valley. Seventeen of the 21 respondent hospitals had at least one specialist anaesthetist. The results identify both strengths and weaknesses in Nepal's anaesthesia services and provide important guidelines for planning. When the DA course was launched there were only seven specialist anaesthetists in Nepal. The shortage of anaesthetists was an important factor limiting surgical services, and after DA graduates were posted to zonal (50 bed) and regional (150-200 bed) hospitals the surgical case loads doubled. There are now about 40 specialist anaesthetists in the country, of which half are DA graduates, but many hospitals have only one anaesthetist. That isolation, plus lack of continuing education (CME), are important factors threatening quality of care. Recognizing the singular role of the DA programme in alleviating Nepal's shortage of anaesthetists, we conclude that it should be renewed and strengthened to meet the needs of the next decade. Techniques commonly used at the zonal level: regional, draw-over, and total IV anaesthesia, should be stressed. At the same time fresh initiatives are required in CME and higher education for the renewal of teaching staff.(ABSTRACT TRUNCATED AT 250 WORDS)