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• The surgical safety checklist-mainly a challenge for anaesthesia mortality in low-income countries?
  Gregor Pollach
  Published on: 23 October 2013

• Published on: 23 October 2013

  The surgical safety checklist-mainly a challenge for anaesthesia mortality in low-income countries?

  • Gregor Pollach, Head of Department

  Working on a daily basis in the theatres of the largest hospital in a low-income country (Malawi) we were pleased to read the study of Aveling and colleagues [1]. They demonstrated in a clear, quite comprehensive and critical manner challenges involved with the surgical safety checklist in resource poor situations.

  Continuously experiencing the real life situation in Africa we do think that there is an important...

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  Working on a daily basis in the theatres of the largest hospital in a low-income country (Malawi) we were pleased to read the study of Aveling and colleagues [1]. They demonstrated in a clear, quite comprehensive and critical manner challenges involved with the surgical safety checklist in resource poor situations.

  Continuously experiencing the real life situation in Africa we do think that there is an important consideration still lacking when we discuss challenges for the implementation of the surgical safety checklist, challenges which are not the same in low-income and high-income countries.

  Many of the surgical safety checklists items [2] are not really part of the surgical, but much more of the anaesthesiological field. This is true for the check of the anaesthesia machine, the pulse oximeter, the difficult airway, the aspiration risk, the i.v. access, the application of the antibiotic prophylaxis, the treatment in the (usually anaesthetic) recovery room etc. Excluding the not immediately life threatening problems we count 11 of 18 (61%) questions to be answered by the anaesthesiologist [2].

  When anaesthesia plays such a crucial part than it is evident that we have to consider anaesthesia mortality in Africa as an integral part of the surgical safety checklist. In many sub-Saharan countries pure anaesthesia mortality is incredibly high. It was shown to be for Togo 1 death per 133 anaesthesias given [3], for Malawi 1 avoidable death per 504 [4] and for Nigeria 1 avoidable death per 387 obstetric interventions [5]). Added surgical mortality than accounts for an overall mortality for caesarean section e.g. in Malawi of 1 death in 95 operations [6].

  These results have to be compared with the pure anaesthetic mortality of 2.5 per 100,000 found by Bainbridge et al. [7] for countries with a high "Human development Index", the findings of Lienhart et al. for France with 0.68 deaths per 100,000 [8] and Vila et al. for Florida with 0.78 deaths per 100,000 [9].

  Even when all these numbers have to be evaluated cautiously - exactly here we find the reasoning for the different impact the surgical safety checklist will have in low and high-income countries. To improve the low mortality in high-income countries is difficult and we need to ask e.g. whether a pneumonectomy is done on the correct side. In the poor countries these questions might reduce to a minimal degree mortality too, but they do not really address the reason why our patients die hundreds of times more often than in the high-income countries (and that is still not the whole truth, because for the fit and young patients anaesthesia mortality decreases drastically in the high-income countries and some high risk procedures are almost never done in most low-income countries [10]).

  Besides the many challenges mentioned by the authors as specific to low-income countries we experience further problems which interfere with the surgical safety checklist but are not represented there. Often no pre- anaesthetic visitations are possible, we often are unable to diagnose the cardiovascular or respiratory condition of the patient, antibiotics are not only not available but actively embezzeled in the procurement process, patients travel for hours or even days to the hospitals, almost no postoperative ICU care is available and we might have an anaesthesia machine to check but no oxygen to use etc.

  But even with these problems we can deal and they are not the frontline were we have to fight for the life of our patients - when one other condition is fulfilled:

  In order to prevent patients from harm through their disease or the medical intervention we need first and foremost - anaesthetic and surgical staff. We need much higher numbers of well trained, dedicated non-physician anaesthetists and surgeons as the backbone of service provision, university trained Bachelors committed to the management of all the above daily life problems in our theatres and intensive care units in the large district hospitals (maybe including an adapted version of the surgical safety checklist) and finally specialists, trained in our own African Master of Medicine (MMed) programmes, for the central hospitals supervision, the implementation of new ideas and the sustainable countrywide development of the specialties.

  The limited usefulness of the surgical safety checklist in its current form - as useful it might be in the high-income countries - will distract our attention and our extremely limited personal resources from the really important tasks for anaesthesia and surgery in the low-income countries of the world.

  References: 1. Aveling E-L, McCulloch P, Dixon-Woods M: A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries, BMJ Open 2013 3: doi: 10.1136/bmjopen-2013- 003039

  2. Hynes AB, Weise GT, Berry WR Surgical checklist to reduce morbidity and mortality in a global population. N Engl J med 2009; 360:491 -499

  3. Ouro-Bang?na Maman AF, Tomta K, Ahouangb?vi S, Chobli M: Deaths associated with anaesthesia in Togo, West Africa. Trop Doct 2005; 35:220- 25

  4. Hansen D, Gausi SC, Merikebu M. Anaesthesia in Malawi: complications and deaths, Trop Doct 2000; 30: 146

  5. Enohumah KO, Imarangiayo CO : Factors associated with anaesthesia relatedmaternal mortality in a tertiar hospital in Nigeria ; Acta Anaesthesiol Scand 2006; 50: 206-210

  6. Fenton PM, Whitty CJM, Reynolds F: Caesarean section in Malawi: prospective study of early maternal and perinatal mortality, BMJ, Volume 327, 13. September 2003

  7. Bainbridge D et al.: Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis The Lancet, 380, 9847, pp 1075 - 1081, 2012

  8. Lienhart A, Auroy Y, Pequignot F et al (2006): survey of Anaesthesia-related Mortality in France. Anesthesiology 105: 1087-1097

  9. Vila H Jr, Soto R, Cantor AB, Mackey D (2003) Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch surg 138:991-995

  10. Cohen MM, Duncan PG, Tate RB (1988) Does anaesthesia contribute to operative mortality? JAMA 260: 2859-2863

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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