Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years.

OBJECTIVE: To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload. DESIGN: Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB). SETTING: Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres. PARTICIPANTS: The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers. PRIMARY OUTCOME MEASURE: Volume and nature of surgical workload of different anaesthesia providers. RESULTS: Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%. CONCLUSION: Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.

Surveys of post-operative pain management in a teaching hospital in Rwanda - 2013 and 2017.

Background: Postoperative pain management (POPM) appeared to be weak in Rwanda. Aims: The aim of this study was to compare POPM measures in a teaching hospital between 2013 and 2017. Methods: A two-phase observational study in 2013 and 2017. was conducted. Participants were recruited prior to major surgery and followed for two postoperative days. A numerical rating scale (0-10) was administered to all participants in both years, and the International Pain Outcomes questionnaire was administered in 2017. Recruitment, consent, and data collection were performed in participants' preferred language. Results: One hundred adult participants undergoing major general, gynecologic, orthopedic, or urologic surgery were recruited in 2013 and 83 were recruited in 2017. Fourteen percent of participants in 2013 and 46% in 2017 scored their worst pain as severe (>6; P < 0.001). This was despite improved preoperative recognition of patients at high risk for severe postoperative pain (those with chronic pain or preoperative pain); 27% and 0% of these patients were not documented in 2013 and 2017, respectively (P = 0.006). Other measures of improved planning included "any preoperative discussion of POPM" (P < 0.001) and "discussion of POPM options" (P = 0.002). Preemptive analgesia use increased (3% of participants in 2013 and 54% in 2017; P < 0.001). Incidence of participants having no postoperative analgesic at all decreased from 25% in 2013 to 5% in 2017 (P < 0.001). Conclusions: Though severe postoperative pain incidence did not improve from 2013 to 2017, POPM improved by a number of measures. These changes may be attributed to pain research conducted there having raised awareness.

Contexte : La prise en charge de la douleur postopératoire (POPM) semblait faible au Rwanda.Objectifs : Comparer les mesures de prise en charge de la douleur postopératoire dans un hôpital d'enseignement entre 2013 et 2017.Méthodes : Étude observationnelle en deux phases réalisée en 2013 et 2017; les participants ont été recrutés avant de subir une chirurgie majeure et ont été suivis pendant deux jours après l'opération. Une échelle de notation numérique (0 à 10) a été administrée à tous les participants les deux années, tandis que le questionnaire International Pain Outcomes a été administré en 2017. Le recrutement, le consentement et toutes les collectes de données se sont déroulés dans la langue préférée par les participants.Résultats : Cent participants adultes ayant subi une chirurgie générale, gynécologique, orthopédique ou urologique majeure ont été recrutés en 2013; 83 en 2017. Quatorze pour cent des participants ont qualifié leur pire douleur de sévère (> 6) en 2013, et 46 % en 2017 (p = 0,001). Cela est survenu malgré l'amélioration de la reconnaissance préopératoire des patients à haut risque de douleur postopératoire sévère (ceux atteints de douleur chronique ou de douleur préopératoire); 27 % de ces patients n'ont pas été documentés en 2013 ; 0 % en 2017, p < 0,006. Parmi les autres mesures de planification améliorée, mentionnons « toute discussion préopératoire de la prise en charge de la douleur postopératoire ¼ (p < 0,001) et « la discussion des options de prise en charge de la douleur postopératoire ¼ (p < 0,002). L'utilisation préventive de l'analgésie a augmenté (3 % des participants en 2013; 54 % en 2017; p < 0,001). L'incidence des participants n'ayant reçu aucun analgésique postopératoire est passée de 25 % en 2013 à 5 % en 2017 (p < 0,001).Conclusions : Bien que l'incidence de la douleur postopératoire sévère ne se soit pas améliorée de 2013 à 2017, la prise en charge de la douleur postopératoire a été améliorée par un certain nombre de mesures. Ces changements peuvent être attribués au fait que la recherche sur la douleur menée là-bas a permis une plus grande sensibilisation.