Safe Surgery in Countries of Sub Saharan Africa

Editorial

Confronted with worldwide evidence of substantial public health harm due to inadequate patient safety, the World Health Assembly (WHA) in 2002 adopted a resolution (WHA55.18) urging countries to strengthen the safety of health care and monitoring systems. The resolution also requested that WHO take a lead in setting global norms and standards and supporting country efforts in preparing patient safety policies and practices. In May 2004, the WHA approved the creation of an international alliance to improve patient safety globally; WHO Patient Safety was launched the following October. For the first time, heads of agencies, policy-makers and patient groups from around the world came together to advance attainment of the goal of “First, do no harm” and to reduce the adverse consequences of unsafe health care. The purpose of WHO Patient Safety is to facilitate patient safety policy and practice. It focuses on safety campaigns called Global Patient Safety Challenges, coordinating Patients for Patient Safety, developing a standard taxonomy, designing tools for research policy and assessment, identifying solutions for patient safety, and developing reporting and learning initiatives aimed at producing ‘best practice’ guidelines. The Global Patient Safety Challenge brings together the expertise of specialists to improve the safety of care. The area chosen for the first Challenge in 2005-2006, was infection associated with health care. This campaign established simple, clear standards for hand hygiene, an educational campaign and WHO’s first Guidelines on Hand Hygiene in Health Care [1]. The problem area selected for the second Global Patient Safety Challenge, in 2007–2008, was the safety of surgical care. A review of the annual volume of major surgeries performed globally from 56 selected countries in 2004 revealed that there were as many as 187-281 million operations done during that period, significantly higher than the 136 million childbirths reported in 2006 [2, 3]. This highlighted the importance of surgery in health care delivery and the role complications associated with surgery may play in patient safety matters. Although the rates of hospital deaths and complications after surgery are difficult to standardize due to a diverse case mix, in developed countries the rate of major complications is between 3 and 22 percent and death rate 0.4-0.8% [4, 5]. The situation is very different in developing countries where death rates following major surgery have been reported to be as high as 5-10% [6, 7]. Surgical safety is therefore an important component of surgical care. In the developing world many factors such as poor state of infrastructure and equipment, lack of proper supplies and medications, poor infection control strategies, lack of properly trained personnel and lack of adequate finance contribute towards unsafe surgery. Most of these factors are avoidable. Other factors that may contribute towards unsafe surgery in the developing countries include lack of awareness by theatre users on avoidable risk factors, lack of baseline data to assist with preventive measures, lack of standardized protocols for use before, during and after surgery and lack of a well- coordinated implementation strategy. The World Health Organization established the Safe Surgery Saves Lives program to reduce the number of surgical deaths. Safety issues that are addressed include inadequate anesthetic safety practices, avoidable surgical infection and proper communication by team members. The Safe Surgery Saves Lives program developed the WHO Surgical Safety Checklist to address ten areas associated with patient safety namely, proper patient identification, proper identification of site for surgery, proper function of anesthetic machine and medication, placement of a functioning pulse ox meter on the patient, medical history of the patient with emphasis on history of drug allergy, airway intubation challenges and risks of intraoperative blood loss, administration of prophylactic antibiotics, proper display of the images, introduction of the theatre team and the anticipated procedure [8]. A cross-sectional study by Epiu et al. [9] reviewed the impact of the WHO Surgical Safety Checklist in the major referral hospitals of the 5 member countries of the East African Community, an economic block of East African states, Kenya, Uganda, Tanzania, Rwanda and Burundi. The referral hospitals involved were Kenyatta National Hospital (Kenya), Mulago (Uganda), Muhimbili (Tanzania), Centre Hospitalier Universities de Kigali (Rwanda) and Centre Hospitalo-Universitaire de Kamenge (Burundi). Using a pre-set questionnaire the authors interviewed anaesthetists on their knowledge and attitudes towards use of the WHO surgical checklist. Of the 85 anaesthetists interviewed, only 25 % regularly used the WHO surgical checklist. None of the anaesthetists in Mulago (Uganda) or Centre Hospitalo- Universitaire de Kamenge (Burundi) used the checklist, mainly because it was not available, in contrast with Muhimbili (Tanzania), Kenyatta (Kenya), and Centre Hospitalier Universities de Kigali (Rwanda), where 65 %, 19 % and 36 %, respectively, used the checklist. The authors concluded that there is a need to make the checklist available in these East African Community member states and to train the surgical/anesthesia team on its importance. Efforts should also be taken to involve the relevant Ministries of Health in the distribution of the check list to all hospitals performing surgeries in those countries. This paper illustrates an important point on health care delivery in sub Saharan Africa; the need to follow up on important life saving policy decisions/protocols with education and supply of the relevant tools/materials to the health workers. A follow up study should be done to assess, among other things, the effect of use of the WHO Surgical Safety Checklist on death rates.