Non-physician Anaesthetists Research Articles

Evaluation of practice change following SAFE obstetric courses in Tanzania: a prospective cohort study.

Anaesthesia has been shown to contribute disproportionately to maternal mortality in low-resource settings. This figure exceeds 500 per 100,000 live births in Tanzania, where anaesthesia is mainly provided by non-physician anaesthetists, many of whom are working as independent practitioners in rural areas without any support or opportunity for continuous medical education. The three-day Safer Anaesthesia from Education (SAFE) course was developed to address this gap by providing in-service training in obstetric anaesthesia to improve patient safety. Two obstetric SAFE courses with refresher training were delivered to 75 non-physician anaesthetists in the Mbeya region of Tanzania between August 2019 and July 2020. To evaluate translation of knowledge into practice, we conducted direct observation of the SAFE obstetric participants at their workplace in five facilities using a binary checklist of expected behaviours, to assess the peri-operative management of patients undergoing caesarean deliveries. The observations were conducted over a 2-week period at pre, immediately post, 6-month and 12-month post-SAFE obstetric training. A total of 320 cases completed by 35 participants were observed. Significant improvements in behaviours, sustained at 12 months after training included: pre-operative assessment of patients (32% (pre-training) to 88% (12 months after training), p < 0.001); checking for functioning suction (73% to 85%, p = 0.003); using aseptic spinal technique (67% to 100%, p < 0.001); timely administration of prophylactic antibiotics (66% to 95%, p < 0.001); and checking spinal block adequacy (32% to 71%, p < 0.001). Our study has demonstrated positive sustained changes in the clinical practice amongst non-physician anaesthetists as a result of SAFE obstetric training. The findings can be used to guide development of a checklist specific for anaesthesia for caesarean section to improve the quality of care for patients in low-resource settings.

Global obstetric anaesthesia: bridging the gap in maternal health care inequities through partnership in education

Maternal mortality rates are unacceptably high globally. Low- and middle-income countries (LMICs) face challenges of an inadequate anaesthesia workforce, under-resourced healthcare systems and sub-optimal access to labour and delivery care, all of which negatively impact maternal and neonatal outcomes. In order to effect the changes in surgical-obstetric-anaesthesia workforce numbers advocated by the Lancet Commission on Global Surgery to support the UN sustainable development goals, mass training and upskilling of both physician and non-physician anaesthetists is imperative. The implementation of outreach programmes and partnerships across organisations and countries has already been shown to improve the provision of safe care to mothers and their babies, and these efforts should be continued. Short subspecialty courses and simulation training are two cornerstones of modern obstetric anaesthesia training in poorly resourced environments. This review discusses the challenges to accessing quality maternal healthcare in LMICs and the use of education, outreach, partnership and research to protect the most vulnerable women from coming to harm in the peripartum period.

Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal.

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

Using behavioural science to explore impact and implementation of obstetric anaesthesia training in Tanzania, Nepal and Bangladesh: a qualitative evaluation study with obstetric anaesthesia providers

Objective: High quality obstetric anaesthetic care is integral to reducing preventable maternal deaths in Low-and-Middle-Income-Countries (LMICs). We applied behavioural science to evaluate SAFE Obstetrics, a 3-day Continuing Professional Development (CPD) course, on physician and non-physician anaesthetists’ practice behaviours across 3 LMICs.Methods: Seven anaesthetist Fellows from Bangladesh, Nepal and Tanzania were trained in qualitative methods and behavioural science. Structured interviews were undertaken by Fellows and two UK behavioural scientists with course participants. Interviews were based on the Theoretical Domains Framework: a comprehensive framework of influences on behaviour change. Interviews were recorded, transcribed and analysed using content and thematic analysis.Results: 78 physician and non-physician anaesthetists participated (n = 26 Bangladesh, n = 24 Nepal and n = 28 Tanzania). Participants reported positive improvements in patient-centered working, safety, teamwork and confidence. Across countries, we found similar barriers and facilitators: environmental resources, a strong professional identity and positive social influences were key facilitators of change.Conclusion: This multi-country theory-based evaluation highlighted the impact of SAFE Obstetrics on participants’ clinical practice. A supportive work environment was crucial for implementing learning following training; CPD courses in LMICs must furnish participants with skills and equipment to address training implementation challenges. Building local behavioural science capacity can strengthen LMIC health intervention evaluations.

Defining complexity in anaesthesia: description and validation of the Oxford Anaesthetic Complexity (OxAnCo) score.

Increasing demand for surgery and anaesthesia has created an imperative to manage anaesthetic workforce and caseload. This may include changes to distribution of cases amongst anaesthetists of different grades, including non-physician anaesthetists. To achieve this safely, an assessment of case complexity is essential. We present a novel system for scoring complexity of cases in anaesthesia, the Oxford Anaesthetic Complexity score. This integrates patient, anaesthetic, surgical and systems factors, and is different from assessments of risk. We adopted an end-user development approach to the design of the score, and validated it using a dataset of anaesthetic cases. Across 688 cases, the median (IQR [range]) complexity score was 19 (17-22 [15-33]). Cases requiring a consultant anaesthetist had a significantly higher median (IQR [range]) score than those requiring a senior trainee at 22 (20-25 [15-33]) vs. 19(17-21 [15-28]), p < 0.001. Cases undertaken in a tertiary acute hospital had a significantly higher score than those in a district general hospital, the median (IQR [range]) scores being 20 (17-22 [15-33]) vs. 17 (16-19 [17-28]), p < 0.001. Receiver-operating characteristic analysis showed good prediction of complexity sufficient to require a consultant anaesthetist, with area under the curve of 0.84. Any rise in complexity above baseline (score > 15) was strongly predictive of a case too complex for a junior trainee (positive predictive value 0.93). The Oxford Anaesthetic Complexity score can be used to match cases to different grades of anaesthetist, and can help in defining cases appropriate for the expanding non-physician anaesthetist workforce.

Surgical procedures for children in the public healthcare sector: a nationwide, facility-based study in Uganda

ObjectiveThis study investigated the surgical services for children at the highest levels of the public healthcare sector in Uganda. The aim was to determine volumes and types of procedure performed...

Anaesthesia practices for Caesarean section amongst non-physician anaesthesia providers at an Ethiopian referral hospital.

Sub-Saharan Africa faces high rates of maternal mortality and there is an urgent need to reduce this. Shortfalls in access to safe surgery and anaesthetic care result in avoidable maternal death. Providing quality training to anaesthesia providers is of key importance to reduce mortality. This mixed-methods prospective study incorporated workplace observations of anaesthesia for Caesarean section, a paper-based questionnaire and semi-structured, face-to-face interviews in Felege Hiwot Referral Hospital in Ethiopia.A total of 67 Caesarean section cases under spinal anaesthesia provided by 12 non-physician anaesthetists were observed and a 92% (n = 11) response rate to questionnaires obtained. Deficiencies were observed in communication, pre-operative assessment, spinal height evaluation and application of lateral tilt, while interviews revealed anaesthesia provider perceptions of hierarchy within the surgical team and deficiency in anticipation of potential complications. This study suggests that focusing on communication and anticipation of complications could aid providers in preventing and preparing for complications.

Training non-physician anaesthetists in sub-Saharan Africa: a qualitative investigation of providers’ perspectives

ObjectivesTo explore the views of non-physician anaesthesia providers (NPAPs) and their colleagues regarding the effectiveness of NPAP training programmes in three contrasting sub-Saharan African countries.DesignThis was a qualitative exploratory descriptive...

Lifebox pulse oximeter implementation in Malawi: evaluation of educational outcomes and impact on oxygen desaturation episodes during anaesthesia.

Pulse oximetry is an essential monitor for safe anaesthesia but is often not available in low-income countries. The aim of this study was to determine whether the introduction of pulse oximetry with training was feasible and could reduce the incidence of oxygen desaturation during anaesthesia in a low-income country. Pulse oximeters were donated, with training, to 83 non-physician anaesthetists in Malawi. Knowledge was tested immediately before and after training and at follow-up. Providers were asked to record the lowest peripheral oxygen saturation (SpO2 ) for the first 100 cases anaesthetised after training. The primary clinical outcome was the proportion of cases with an oxygen desaturation event (SpO2 < 90%). Seventy-seven of 83 (93%) participants completed all pre- and post-training tests. Pulse oximetry knowledge improved after training from a median (IQR [range]) score of 39 (37-42 [28-48]) to 44 (42-46 [35-50]) and this knowledge was maintained for 8 months (p < 0.001). Oxygen saturation data and provider responses were recorded for 4772 cases. The proportion of oxygen desaturation episodes decreased from 17.2% to 6.5%, representing a 36% reduction in the odds of an oxygen desaturation event in the second 50 cases compared with the first 50 (OR 0.64, 95%CI 0.50-0.82, p < 0.001). We conclude that donation of pulse oximeters, with training, in Malawi was feasible, improved knowledge and reduced the incidence of oxygen desaturation events.

Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.

The risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem have not been comprehensively studied up to now. We aimed to obtain precise estimates of anaesthesia-attributed deaths in pregnant women exposed to anaesthesia and to identify the factors linked to adverse outcomes in pregnant women exposed to anaesthesia in low-income and middle-income countries. In this systematic review and meta-analysis, we searched major electronic databases from inception until Oct 1, 2015, for studies reporting risks of maternal death from anaesthesia in low-income and middle-income countries. Studies were included if they assessed maternal and perinatal outcomes in pregnant women exposed to anaesthesia for an obstetric procedure in countries categorised as low-income or middle-income by the World Bank. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990 to ensure that the estimates reflect the current burden of the condition. Two independent reviewers undertook quality assessment and data extraction. We computed odds ratios for risk factors and anaesthesia-related complications, and pooled them using a random effects model. This study is registered with PROSPERO, number CRD42015015805. 44 studies (632,556 pregnancies) reported risks of death from anaesthesia in women who had an obstetric surgical procedure; 95 (32,149,636 pregnancies and 36,144 deaths) provided rates of anaesthesia-attributed deaths as a proportion of maternal deaths. The risk of death from anaesthesia in women undergoing obstetric procedures was 1·2 per 1000 women undergoing obstetric procedures (95% CI 0·8-1·7, I(2)=83%). Anaesthesia accounted for 2·8% (2·4-3·4, I(2)=75%) of all maternal deaths, 3·5% (2·9-4·3, I(2)=79%) of direct maternal deaths (ie, those that resulted from obstetric complications), and 13·8% (9·0-20·7, I(2)=84%) of deaths after caesarean section. Exposure to general anaesthesia increased the odds of maternal (odds ratio [OR] 3·3, 95% CI 1·2-9·0, I(2)=58%), and perinatal deaths (2·3, 1·2-4·1, I(2)=73%) compared with neuraxial anaesthesia. The rate of any maternal death was 9·8 per 1000 anaesthetics (5·2-15·7, I(2)=92%) when managed by non-physician anaesthetists compared with 5·2 per 1000 (0·9-12·6, I(2)=95%) when managed by physician anaesthetists. The current international priority on strengthening health systems should address the risk factors such as general anaesthesia and rural setting for improving anaesthetic care in pregnant women. Ammalife Charity and ELLY Appeal, Bart's Charity.

Surgical and anaesthetic capacity of hospitals in Malawi: key insights.

Background Surgery is increasingly recognized as an important driver for health systems strengthening, especially in developing countries. To facilitate quality improvement initiatives, baseline knowledge of capacity for surgical, anaesthetic, emergency and obstetric care is critical. In partnership with the Malawi Ministry of Health, we quantified government hospitals’ surgical capacity through workforce, infrastructure and health service delivery components.Methods From November 2012 to January 2013, we surveyed district and mission hospital administrators and clinical staff onsite using a modified version of the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool from Surgeons OverSeas. We calculated percentage of facilities demonstrating adequacy of the assessed components, surgical case rates, operating theatre density and surgical workforce density.Results Twenty-seven government hospitals were surveyed (90% of the district hospitals, all central hospitals). Of the surgical workforce surveyed (n = 370), 92.7% were non-surgeons and 77% were clinical officers (COs). Of the 109 anaesthesia providers, 95.4% were non-physician anaesthetists (anaesthesia COs or ACOs). Non-surgeons and ACOs were the only providers of surgical services and anaesthetic services in 85% and 88.9% of hospitals, respectively. No specialists served the district hospitals. All of the hospitals experienced periods without external electricity. Most did not always have a functioning generator (78.3% district, 25% central) or running water (82.6%, 50%). None of the district hospitals had an Intensive Care Unit (ICU). Cricothyroidotomy, bowel resection and cholecystectomy were not done in over two-thirds of hospitals. Every hospital provided general anaesthesia but some did not always have a functioning anaesthesia machine (52.2%, 50%). Surgical rate, operating theatre density and surgical workforce density per 100 000 population was 289.48–747.38 procedures, 0.98 and 5.41 and 3.68 surgical providers, respectively.Conclusion COs form the backbone of Malawi’s surgical and anaesthetic workforce and should be supported with improvements in infrastructure as well as training and mentorship by specialist surgeons and anaesthetists.

Evaluation of a large-scale donation of Lifebox pulse oximeters to non-physician anaesthetists in Uganda.

SummaryPulse oximetry is widely accepted as essential monitoring for safe anaesthesia, yet is frequently unavailable in resource-limited settings. The Lifebox pulse oximeter, and associated management training programme, was delivered to 79 non-physician anaesthetists attending the 2011 Uganda Society of Anaesthesia Annual Conference. Using a standardised assessment, recipients were tested for their knowledge of oximetry use and hypoxia management before, immediately following and 3–5 months after the training. Before the course, the median (IQR [range]) test score for the anaesthetists was 36 (34–39 [26–44]) out of a maximum of 50 points. Immediately following the course, the test score increased to 41 (38–43 [25–47]); p < 0.0001 and at the follow-up visit at 3–5 months it was 41 (39–44 [33–49]); p = 0.001 compared with immediate post-training test scores, and 75/79 (95%) oximeters were in routine clinical use. This method of introduction resulted in a high rate of uptake of oximeters into clinical practice and a demonstrable retention of knowledge in a resource-limited setting.

Building and retaining the neglected anaesthesia health workforce: is it crucial for health systems strengthening through primary health care?

Background The world health report 2008 emphasizes putting people at the centre of service is not only about service delivery models from a short-term perspective, but rather about long-term commitment to health care. (1) Given the critical shortage of the health workforce, investments in training, retaining and sustaining them are necessary. Sub-Saharan Africa is a prime example of uneven distribution of health-care personnel. The subcontinent carries 24% of the global burden of disease in 11% of the world's population, but has as little as 3% of the world's health workers. (2) The concern for countries in sub-Saharan Africa and other nations was recognized by the World Health Assembly resolution WHA59.23 that urged for rapid scaling up of health workforce production. (3) Addressing the situation should take into account the four reforms (universal coverage, people-centred service delivery, leadership and public policies) towards refocusing health systems through primary health care. Importance of anaesthesia workforce The contribution of surgical conditions to the global burden of disease and the potential impact of the provision of basic surgical services at the first referral level facility is widely under appreciated. It is estimated that 11% of the world's disability-adjusted life years (or years lost from healthy lives) are from conditions that are very likely to require surgery. (2) Adequate surgical care as a primary care strategy can address and greatly alleviate this burden. (4) Increasing evidence is beginning to emerge that maternal and infant survival is proportionately correlated to the number of health workers providing obstetric care that includes anaesthesia. (5,6) The delivery of surgical (including obstetrics and trauma) care is highly dependent on the availability and retention of a trained anaesthesia healh workforce. The United Kingdom Confidential Enquiry for Perioperative Death in 1987 reported one death per 185 000 anaesthetic procedures; whereas in Zambia (University teaching hospital), it was one death per 1925. The avoidable anaesthesia-mortality rate in Malawi (central hospital) was one death per 504; in Nigeria (teaching hospital) for Caesarean sections, one death per 387 anaesthetic procedures; in Togo (teaching hospital), one death per 133; and in Zimbabwe (district hospital), one death per 482. (7) Many of these unnecessary deaths were a result of airway problems and hypovolaemia in healthy young patients. (7) Though the common perception is that anaesthesia services are only required at the level of secondary and tertiary health-care facilities, the availability of basic services at the first referral level facility can contribute significantly to a reduction in death and disability. At the district and sub-district level, health personnel are expected to provide a range of anaesthesia services (local, intravenous ketamine, spinal and general anaesthesia) for the management of pregnancy-related complications, unsafe abortion, injuries (road traffic accidents, domestic violence, burns, falls, rape), complications of female genital mutilation, congenital anomalies as well as other surgical conditions. To safely deliver anaesthesia in emergency and surgical procedures, investments for appropriate training are required. The role of anaesthesia extends beyond the operating room, and is necessary in postoperative monitoring, intensive care units, for co-existing medical conditions, as well as providing pain relief (particularly in children and women in labour). A workforce trained in basic anaesthetic techniques at the primary health care level can also resuscitate critically ill patients or those with severe trauma and stabilize their condition, before transfer to a more specialized facility. The anaesthesia services required at the first referral level facilities can mostly be delivered by trained nonphysician anaesthetists. Current situation Physician anaesthetists are scarce in many developing countries and not available at first referral level health facilities. …

Non‐physician anaesthetists: should we still continue with the provision?

Acta Anaesthesiologica ScandinavicaVolume 53, Issue 2 p. 273-274 Letters to the Editor Non-physician anaesthetists: should we still continue with the provision? L. D. Mishra, L. D. MishraSearch for more papers by this author L. D. Mishra, L. D. MishraSearch for more papers by this author First published: 19 January 2009 https://doi.org/10.1111/j.1399-6576.2008.01792.xCitations: 1 Address:Dr Lal D. Mishra, MBBS, MD, PhDProfessor in Anaesthesiology & Head Division of NeuroanaesthesiaInstitute of Medical SciencesBanaras Hindu UniversityVaranasi 221 005Indiae-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume53, Issue2February 2009Pages 273-274 RelatedInformation

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.

Non-physician anaesthetists and who should provide anaesthesia?

Non-physician anaesthetists and who should provide anaesthesia?

Non-physician anaesthetists: can we agree on their role in Europe?

Non-physician anaesthetists: can we agree on their role in Europe?

Anaesthesia and non-physician anaesthetists: what are the real needs for which kind of health policy?

Anaesthesia and non-physician anaesthetists: what are the real needs for which kind of health policy?

Non-physician anaesthetists: can we agree on their role in Europe?

An abstract is not available for this content so a preview has been provided. Please use the Get access link above for information on how to access this content.

Non-physician anaesthetists: can we agree on their role in Europe?

Non-physician anaesthetists: can we agree on their role in Europe?