Bridging the mismatch: observing the introduction of new anesthesia technology for a low-resource environment.

Objective: The objective of this study was to examine the impact of the introduction of the Universal Anaesthesia Machine (UAM), a device designed for use in clinical environments with limited clinical perioperative resources, on the choice of general anesthesia technique and safe anesthesia practice in a tertiary-care hospital in Sierra Leone. Methods: We introduced an anesthesia machine (UAM) into Connaught Hospital, Freetown, Sierra Leone. We conducted a prospective observational study of anesthesia practice and an examination of perioperative clinical parameters among surgical patients at the hospital to determine the usability of the device, its impact on anesthesia capacity, and changes in general anesthesia technique. Findings: We observed a shift from the use of ketamine total intravenous anesthesia to inhalational anesthesia. This shift was most demonstrable in anesthesia care for appendectomies and surgical wound management. In 10 of 17 power outages that occurred during inhalational general anesthesia, anesthesia delivery was uninterrupted because inhalational anesthesia was being delivered with the UAM. Conclusion: Anesthesia technologies tailored to overcome austere environmental conditions can support the delivery of safe anesthesia care while maintaining fidelity to recommended international anesthesia practice standards.

Ventilator Training through International Telesimulation in Sierra Leone.

Background: The coronavirus disease (COVID-19) pandemic resulted in an increased need for medical professionals with expertise in managing patients with acute hypoxemic respiratory failure, overwhelming the existing critical care workforce in many low-resource countries. Objective: To address this need in Sierra Leone, we developed, piloted, and evaluated a synchronous simulation-based tele-education workshop for healthcare providers on the fundamental principles of intensive care unit (ICU) management of the COVID-19 patient in a low-resource setting. Methods: Thirteen 2-day virtual workshops were implemented between April and July 2020 with frontline Sierra Leone physicians and nurses for potential ICU patients in hospitals throughout Sierra Leone. Although all training sessions took place at the 34 Military Hospital (a national COVID-19 center) in Freetown, participants were drawn from hospitals in each of the provinces of Sierra Leone. The workshops included synchronous tele-education-directed medical simulation didactic sessions about COVID-19, hypoxemia management, and hands-on simulation training about mechanical ventilation. Measures included pre and postworkshop knowledge tests, simulation checklists, and a posttest survey. Test results were analyzed with a paired sample t test; Likert-scale survey responses were reported using descriptive statistics; and open-ended responses were analyzed using thematic analysis. Results: Seventy-five participants enrolled in the program. On average, participants showed 20.8% improvement (a score difference of 4.00 out of a maximum total score of 20) in scores between pre and postworkshop knowledge tests (P = 0.004). Participants reported satisfaction with training (96%; n = 73), achieved 100% of simulation checklist objectives, and increased confidence with ventilator skills (96%; n = 73). Themes from the participants' feedback included increased readiness to train colleagues on critical care ventilators at their hospitals, the need for longer and more frequent training, and a need to have access to critical care ventilators at their hospitals. Conclusion: This synchronous tele-education-directed medical simulation workshop implemented through partnerships between U.S. physicians and Sierra Leone healthcare providers was a feasible, acceptable, and effective means of providing training about COVID-19, hypoxemia management, and mechanical ventilation. Future ICU ventilator training opportunities may consider increasing the length of training beyond 2 days to allow more time for the hands-on simulation scenarios using the ICU ventilator and assessing knowledge application in long-term follow-up.

Onlay Patellofemoral Arthroplasty in Patients With Isolated Patellofemoral Arthritis: A Systematic Review.

BACKGROUND: Patellofemoral arthroplasty (PFA) for isolated patellofemoral osteoarthritis (OA) remains controversial due to variable postoperative outcomes and high failure rates. Second-generation (2G) onlay prostheses have been associated with improved postoperative outcomes. This systematic review was performed to assess the current overall survivorship and functional outcomes of 2G PFA. METHODS: A search was performed using PubMed, Cochrane Library, EMBASE, and Google Scholar. Thirty-three studies published in the last 15 years (2005-2020) were included; of these 22 studies reported patient-reported outcome measures. Operative and nonoperative complications were analyzed. Pooled statistical analysis was performed for survivorship and functional scores using Excel 2016 and Stata 13. RESULTS: The mean age of the patients was 59.7. When analyzing all studies, weighted survival at mean follow-up of 5.52 was 87.72%. Subanalysis of studies with minimum 5 years of follow up showed a survival of 94.24%. Fifteen studies reported Oxford Knee Score with a weighted mean postoperative Oxford Knee Score of 33.59. Mean American Knee Society Score pain was 79.7 while mean American Knee Society Score function was 79.3. The most common operative complication was OA progression for all implants. The percentage of revisions and conversions reported after analyzing all studies was 1.37% and 7.82% respectively. CONCLUSION: Safe and acceptable results of functional outcomes and PFA survivorship can result from 2G PFAs at both short and mid-term follow-up for patients with isolated patellofemoral OA. However, long-term follow-up outcomes are still pending for the newer implants. More extensive studies using standardized functional outcomes and long-term cost benefits should be evaluated.

Evaluating Rapid-cycle Deliberate Practice Versus Mastery Learning in Training Nurse Anesthetists on the Universal Anaesthesia Machine Ventilator in Sierra Leone.

BACKGROUND: Underserved sub-Saharan countries have 0.1 to 1.4 anesthesia providers per 100 000 citizens, below the Lancet Commission's target of 20 per 100 000 needed for safe surgery. Most of these anesthesia providers are nurse anesthetists, with anesthesiologists numbering as few as zero in some nations and 2 per 7 million in others, such as Sierra Leone. In this study, we compared 2 simulation-based techniques for training nurse anesthetists on the Universal Anaesthesia Machine Ventilator-rapid-cycle deliberate practice and mastery learning. METHODS: A 2-week Universal Anaesthesia Machine Ventilator course was administered to 17 participants in Sierra Leone. Seven were randomized to the rapid-cycle deliberate practice group and 10 to the mastery learning group. Participants underwent baseline and posttraining evaluations in 3 scenarios: general anesthesia, intraoperative power failure, and postoperative pulmonary edema. Performance was analyzed based on checklist performance scores and the number of times participants were stopped for a mistake. Statistical significance to 0.05 was determined with the Mann-Whitney U Test. RESULTS: Checklist performance scores did not differ significantly between the 2 groups. When the groups were combined, simulation-based training resulted in a statistically significant improvement in performance. The highest-frequency problem areas were preoxygenation, switching from spontaneous to mechanical ventilation, and executing appropriate treatment interventions for a postoperative emergency. CONCLUSION: Both rapid-cycle deliberate practice and mastery learning are effective methods for simulation-based training to improve nurse anesthetist performance with the Universal Anaesthesia Machine Ventilator in 3 separate scenarios. The data did not indicate any difference between these methods; however, a larger sample size may support or refute our findings.

Medical Simulation as a Vital Adjunct to Identifying Clinical Life-Threatening Gaps in Austere Environments.

BACKGROUND: Maternal mortality and morbidity are major causes of death in low-resource countries, especially those in Sub-Saharan Africa. Healthcare workforce scarcities present in these locations result in poor perioperative care access and quality. These scarcities also limit the capacity for progressive development and enhancement of workforce training, and skills through continuing medical education. Newly available low-cost, in-situ simulation systems make it possible for a small cadre of trainers to use simulation to identify areas needing improvement and to rehearse best practice approaches, relevant to the context of target environments. METHODS: Nurse anesthetists were recruited throughout Sierra Leone to participate in simulation-based obstetric anesthesia scenarios at the country's national referral maternity hospital. All subjects participated in a detailed computer assisted training program to familiarize themselves with the Universal Anesthesia Machine (UAM). An expert panel rated the morbidity/mortality risk of pre-identified critical incidents within the scenario via the Delphi process. Participant responses to critical incidents were observed during these scenarios. Participants had an obstetric anesthesia pretest and post-test as well as debrief sessions focused on reviewing the significance of critical incident responses observed during the scenario. RESULTS: 21 nurse anesthetists, (20% of anesthesia providers nationally) participated. Median age was 41 years and median experience practicing anesthesia was 3.5 years. Most participants (57.1%) were female, two-thirds (66.7%) performed obstetrics anesthesia daily but 57.1% had no experience using the UAM. During the simulation, participants were observed and assessed on critical incident responses for case preparation with a median score of 7 out of 13 points, anesthesia management with a median score of 10 out of 20 points and rapid sequence intubation with a median score of 3 out of 10 points. CONCLUSION: This study identified substantial risks to patient care and provides evidence to support the feasibility and value of in-situ simulation-based performance assessment for identifying critical gaps in safe anesthesia care in the low-resource settings. Further investigations may validate the impact and sustainability of simulation based training on skills transfer and retention among anesthesia providers low resource environments.

Hospital Volume and the Costs Associated with Surgery for Pancreatic Cancer.

BACKGROUND: Data evaluating the financial implications of volume-based referral are lacking. This study sought to compare in-hospital costs for pancreatic surgery by annual hospital volume. METHODS: Eleven thousand and eighty-one patients aged ≥18 years undergoing an elective pancreatic resection for cancer were identified using the Nationwide Inpatient Sample 2002-2011. Multivariable regression analysis was performed to compare length-of-stay (LOS), postoperative morbidity and mortality, failure-to-rescue (FTR), and inpatient costs by annual hospital volume group. RESULTS: Patients undergoing surgery at high-volume hospitals (HVH) demonstrated 23% lower odds (odds ratio [OR] = 0.77, 95% confidence interval [95%CI] 0.63-0.95) of developing a postoperative complication, 59% lower odds of experiencing an LOS > 14 days (OR = 0.41, 95%CI 0.34-0.50), 51% lower odds of postoperative mortality (OR = 0.49, 95%CI 0.34-0.71), and 47% lower odds of FTR (OR = 0.53, 95%CI 0.37-0.76; all p<0.05). The overall mean in-hospital cost was $39,012 (SD = $15,214) with minimal differences observed across hospital volume groups. Rather, postoperative complications (no complication vs. complication $26,686 [SD = $5762] vs. $44,633 [SD = $11,637]) and FTR (rescue vs. FTR $42,413 [SD = $8481] vs. $69,546 [SD = $13,131]) were determinant of higher in-hospital costs. While this pattern was observed at all hospital volume groups, costs varied minimally between hospital volume groups after this stratification. CONCLUSIONS: Annual hospital surgical volume was not associated with in-hospital costs among patients undergoing pancreatic surgery.

Factors Associated With Interhospital Variability in Inpatient Costs of Liver and Pancreatic Resections.

IMPORTANCE: In an era of accountable care, understanding variation in health care costs is critical to reducing health care spending. OBJECTIVE: To identify factors associated with increased hospital costs and quantify variations in costs among individual hospitals in patients undergoing liver and pancreatic surgery in the United States. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of total costs among 42 480 patients undergoing hepatopancreaticobiliary surgery from January 1, 2002, through December 31, 2011, using a nationally representative data set (Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project). Analysis was conducted in May 2015. MAIN OUTCOMES AND MEASURES: Total inpatient costs and proportional variation in inpatient costs among individual hospitals. RESULTS: Among the 42 480 patients who underwent liver or pancreatic resection, the median age was 62 years, 52.4% were female, and 72.9% had a Charlson Comorbidity Index of 2 or higher. The median cost for the entire cohort was $21,535 (interquartile range, $15,373-$31,104), varying from $3320 to $279,102 among individual hospitals. On multivariable analysis, increasing patient comorbidity (coefficient, 2000.30; 95% CI, 1363.33-2637.27; P < .001) and operative characteristics (total pancreatectomy: coefficient, 12 742.31; 95% CI, 10 063.66-15 420.94; P < .001; lobectomy: coefficient, 6336.42; 95% CI, 3934.61-8737.24; P < .001) were associated with higher hospital costs. The development of postoperative complications, such as sepsis (coefficient, 30 571.25; 95% CI, 29 308.96-31 833.54; P < .001) or stroke (coefficient, 8925.34; 95% CI, 2801.38-15 049.30; P = .004), and a longer length of stay were most strongly predictive of higher inpatient cost (length of stay >14 days: coefficient, 44 162.24; 95% CI, 43 125.56-45 198.92; P < .001). After adjusting for patient and hospital characteristics, the overall cost of hepatopancreaticobiliary surgery varied by $9000 among individual hospitals. CONCLUSIONS AND RELEVANCE: Significant variability was noted in hospital costs among patients undergoing pancreatic and liver surgery. Future policies should focus on reducing variations in costs by promoting payment paradigms that support a better quality of care and lower costs.

Do trauma center levels matter in older isolated hip fracture patients?

BACKGROUND: Younger, multi-trauma patients have improved survival when treated at a trauma center. Many regions now propose that older patients be triaged to a higher level trauma centers (HLTCs-level I or II) versus lower level trauma centers (LLTCs-level III or nondesignated TC), even for isolated injury, despite the absence of an established benefit in this elderly cohort. We therefore sought to determine if older isolated hip fracture patients have improved survival outcomes based on trauma center level. METHODS: A retrospective cohort of 1.07 million patients in The Nationwide Emergency Department Sample from 2006-2010 was used to identify 239,288 isolated hip fracture patients aged ≥65 y. Multivariable logistic regression was performed controlling for patient- and hospital-level variables. The main outcome measures were inhospital mortality and discharge disposition. RESULTS: Unadjusted logistic regression analyses revealed 8% higher odds of mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.16) and 10% lower odds of being discharged home (OR, 0.90; 95% CI, 0.80-1.00) among patients admitted to an HLTC versus LLTC. After controlling for patient- and hospital-level factors, neither the odds of mortality (OR, 1.06; 95% CI, 0.97-1.15) nor the odds of discharge to home (OR, 0.98; 95% CI, 0.85-1.12) differed significantly between patients treated at an HLTC versus LLTC. CONCLUSIONS: Among patients with isolated hip fractures admitted to HLTCs, mortality and discharge disposition do not differ from similar patients admitted to LLTCs. These findings have important implications for trauma systems and triage protocols.