Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia.

BACKGROUND: Provision of surgical care continues to receive little attention and funding despite the growing burden of surgical disease worldwide. In 2004, The World Health Organization (WHO) established the Emergency and Essential Surgical Care (EESC) program, which was designed to strengthen surgical services at the first-referral hospital. There are limited data documenting the implementation and scale-up of such services. We describe the nationwide implementation of the EESC program in Mongolia over a 6 year period. METHODS: Surgical services were increased in rural areas of Mongolia using the WHO Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit from 2004 to 2010. Fund of knowledge tests and program evaluation was done to measure uptake, response, and perceived importance of the program. Two years after the pilot sites were launched, programmatic impact on short-term process measures was evaluated using the WHO Monitoring and Evaluation form. RESULTS: The program was implemented in 14 aimags/provinces (66.67 %) and 178 soum hospitals (52.66 %). Fund of knowledge scores increased from 47.72 % (95 % confidence interval (CI) 40.7-54.7) to 77.9 % (95 % CI 70.1-85.7, p = 0.0001) after the training program. 1 year post-training, there was a 57.1 % increase in the availability of emergency rooms, 59.1 % increase in the supply of emergency kits, a 73.64 % increase in the recording of emergency care cases, and a 46.66 % increase in the provision of facility and instrument usage instructions at the pilot sites. CONCLUSIONS: The EESC program was successfully implemented and scaled up at a national level with improvements in short-term process measures.

Quantifying surgical and anesthetic availability at primary health facilities in Mongolia.

BACKGROUND: Significant barriers limit the safe and timely provision of surgical and anaesthetic care in low- and middle-income countries. Nearly one-half of Mongolia's population resides in rural areas where the austere geography makes travel for adequate surgical care very difficult. Our goal was to characterize the availability of surgical and anaesthetic services, in terms of infrastructure capability, physical resources (supplies and equipment), and human resources for health at primary level health facilities in Mongolia. METHODS: A situational analysis of the capacity to deliver emergency and essential surgical care (EESC) was performed in a nonrandom sample of 44 primary health facilities throughout Mongolia. RESULTS: Significant shortfalls were noted in the capacity to deliver surgical and anesthetic services. Deficiencies in infrastructure and supplies were common, and there were no trained surgeons or anaesthesiologists at any of the health facilities sampled. Most procedures were performed by general doctors and paraprofessionals, and occasionally visiting surgeons from higher levels of the health system. While basic interventions such as suturing or abscess drainage were commonly performed, the availability of many essential interventions was absent at a significant number of facilities. CONCLUSIONS: This situational analysis of the availability of essential surgical and anesthetic services identified significant deficiencies in infrastructure, supplies, and equipment, as well as a lack of human resources at the primary referral level facilities in Mongolia. Given the significant travel distances to secondary level facilities for the majority of the rural population, there is an urgent need to strengthen the delivery of essential surgical and anaesthetic services at the primary referral level (soum and intersoum). This will require a multidisciplinary, multi-sectoral effort aimed to improve infrastructure, procure and maintain essential equipment and supplies, and train appropriate health professionals.

Postpericardiotomy syndrome after minimally invasive repair of pectus excavatum.

Minimally invasive repair of pectus excavatum (MIRPE) was first reported in 1998 and has gained wide acceptance since then. A 17-year-old girl who had undergone thoracotomy and cardiac surgery for transposition of great vessels at the age of 18 months presented with a deep, long pectus excavatum with asymmetry. After initial uneventful postoperative clinical course after MIRPE, the patient had bilateral pleural and pericardial effusion on the sixth postoperative day. Suspecting postpericardiotomy syndrome, systemic steroids were administered, and the symptoms resolved without affecting wound healing. Manifestation of a pericardial effusion combined with bilateral pleural effusion after MIRPE, especially in patients after cardiac surgery, may indicate a postpericardiotomy syndrome that can be treated successfully by intravenous steroids.