Undergraduate Anesthesia Skills for a Global Surgery Agenda: Students' Self-Reported Competence.

BACKGROUND: Safe anesthesia is imperative for the Global Surgery agenda and Sustainable Development Goal 3. Due to a shortage of specialists in South Africa (SA), anesthetic services are often provided by nonspecialist doctors, often newly qualified and frequently without immediate supervision. The burden of disease in the developing world demands fit-for-purpose, day-one medical graduates. Although undergraduate anesthesia training is mandatory for medical students in SA, no outcomes are specified, and these are decided autonomously at each medical school. This study describes the current self-perceived anesthetic competence of medical students in SA as a needs assessment directed at achieving the goals of Global Surgery in SA and other developing countries. METHODS: In this cross-sectional observational study, 1689 students (89% participation rate), representing all medical schools in SA, rated their self-perceived competence at graduation in 54 anesthetic-related Likert scale items in 5 themes: patient evaluation, patient preparation for anesthesia, practical skills performance, administration of anesthesia, and the management of intraoperative complications. Medical schools were divided into clusters A (≥25 days of anesthetic training) and B (<25 days). Descriptive statistics, Fisher exact test, and a mixed-effects regression model were used in the statistical analysis. RESULTS: Students felt more prepared for history-taking and patient examination than for managing emergencies and complications. The self-perceived competence of students at cluster A schools was higher across all 54 items and all 5 themes. The same was observed for general medical skills and skills relating to maternal mortality in SA. CONCLUSIONS: Time-on-task, capacity for repetition, and student maturity might have impacted self-efficacy and should be considered in curriculum development. Students felt less prepared for emergencies. Focused training and assessment aimed at emergency management should be considered. Students did not feel competent in general medical areas, in which anesthetists are experts, including resuscitation, fluid management, and analgesia. Anesthetists should take ownership of this training at the undergraduate level. Cesarean delivery is the most performed surgical procedure in sub-Saharan Africa. The Essential Steps in Managing Obstetric Emergencies (ESMOE) program was designed for internship training but can be introduced at undergraduate level. This study suggests that curriculum reform is required. The achievement of an agreed-upon set of standardized national undergraduate anesthetic competencies may ensure fit-for-purpose practitioners. Undergraduate and internship training should align to form part of a continuum of basic anesthetics training in SA. The findings of this study might benefit curriculum development in other regions with similar contexts.

Adapted full-face snorkel masks as an alternative for COVID-19 personal protection during aerosol generating procedures in South Africa: A multi-centre, non-blinded in-situ simulation study.

INTRODUCTION: SARS-CoV-2 has resulted in increased worldwide demand for personal protective equipment (PPE). With pressure from ongoing epidemic and endemic episodes, we assessed an adapted snorkel mask that provides full-face protection for healthcare workers (HCWs), particularly during aerosol-generating procedures. These masks have a custom-made adaptor which allows the fitment of standard medical respiratory filters. The aim of this study was to evaluate the fit, seal and clinical usability of these masks. METHODS: This multicentre, non-blinded in-situ simulation study recruited fifty-two HCWs to don and doff the adapted snorkel mask. Negative pressure seal checks and a qualitative fit test were performed. The HCWs completed intubation and extubation of a manikin in a university skills training laboratory, followed by a web-based questionnaire on the clinical usability of the masks. RESULTS: Whilst fit and usability data were generally satisfactory, two of the 52 participants (3.8%) felt that the mask did not span the correct distance from the nose to the chin, and 3 of 34 participants (8.8%) who underwent qualitative testing with a Bitrex test failed. The majority of users reported no fogging, humidity or irritation. It was reportedly easy to speak while wearing the mask, although some participants perceived that they were not always understood. Twenty-one participants (40%) experienced a subjective physiological effect from wearing the mask; most commonly a sensation of shortness of breath. DISCUSSION: A fit-tested modified full-face snorkel mask may offer benefit as a substitute for N95 respirators and face shields. It is, however, important to properly select the correct mask based on size, fit testing, quality of the three-dimensional (3D) printed parts and respiratory filter to be used. Additionally, HCWs should be trained in the use of the mask, and each mask should be used by a single HCW and not shared.

Development of a Clinical Prediction Model for In-hospital Mortality from the South African Cohort of the African Surgical Outcomes Study.

BACKGROUND: Data on the factors that influence mortality after surgery in South Africa are scarce, and neither these data nor data on risk-adjusted in-hospital mortality after surgery are routinely collected. Predictors related to the context or setting of surgical care delivery may also provide insight into variation in practice. Variation must be addressed when planning for improvement of risk-adjusted outcomes. Our objective was to identify the factors predicting in-hospital mortality after surgery in South Africa from available data. METHODS: A multivariable logistic regression model was developed to identify predictors of 30-day in-hospital mortality in surgical patients in South Africa. Data from the South African contribution to the African Surgical Outcomes Study were used and included 3800 cases from 51 hospitals. A forward stepwise regression technique was then employed to select for possible predictors prior to model specification. Model performance was evaluated by assessing calibration and discrimination. The South African Surgical Outcomes Study cohort was used to validate the model. RESULTS: Variables found to predict 30-day in-hospital mortality were age, American Society of Anesthesiologists Physical Status category, urgent or emergent surgery, major surgery, and gastrointestinal-, head and neck-, thoracic- and neurosurgery. The area under the receiver operating curve or c-statistic was 0.859 (95% confidence interval: 0.827-0.892) for the full model. Calibration, as assessed using a calibration plot, was acceptable. Performance was similar in the validation cohort as compared to the derivation cohort. CONCLUSION: The prediction model did not include factors that can explain how the context of care influences post-operative mortality in South Africa. It does, however, provide a basis for reporting risk-adjusted perioperative mortality rate in the future, and identifies the types of surgery to be prioritised in quality improvement projects at a local or national level.