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Safe Anaesthesia in Kenya

In this article, Dr Maxine Okello, Perioperative Medicine Fellow at University College London Hospitals and Dr Steve Okelo, Secretary General of the Kenya Society of Anaesthesiologists, explore anaesthetic practice in Kenya.

As you read through this article reflect on which safety aspects you recognise. Think back to the Airway Spider diagram and see which elements you can find.

Mortality in Africa is twice the global average despite the patients having low risk profiles, and most deaths are preventable. Scarce workforce resources and poor early warning systems to detect physiological deterioration in patients during the intraoperative period partially contribute to the high mortality in the post-operative period [1].

Anaesthesia practice in Kenya has evolved over the decades to try to ensure safe delivery of services and care to all Kenyans. Anaesthesia providers in Kenya are currently 182 physician anaesthetists and 586 non physician anaesthetists catering to a population of over 45 million. A great number of the non-physician anaesthetists, who consist of clinical officers and registered nurse practitioners, provide services in county hospitals that have limited access to the physician anaesthetists. The workforce density is very low and there is a need to increase the number of physician-anaesthetists and improve training of non physician anaesthesia providers to improve patient safety and surgical outcomes [2].

The Kenya Society of Anaesthesiologists is the main professional body that spearheads safe practice and delivery of anaesthesia in Kenya. Associate members include registered clinical officers in anaesthesia, nurse practitioners in anaesthesia and students in training in anaesthesia. The training curriculum of post graduate registrars training in Nairobi and Eldoret encompasses minimum requirements of safe anaesthesia delivery recommended by the WHO. Not only are trainees taught how to deliver safe anaesthesia in the ideal set up similar to world standards but also in hospital facilities with limited resources. The WHO has provided guidelines for low- and middle-income countries to implement in order to provide safe surgical care and the Kenya government has incorporated these guidelines to align with her mission to build a progressive, responsive and sustainable health care system for accelerated attainment of the highest standard of health to all Kenyans[3].

The surgical safety checklist is mandatory in operating theatres and the Kenya Society of Anaesthesiologists have encouraged anaesthesia providers to be checklist coordinators to ensure the surgical team has completed the listed tasks before it proceeds with the procedure. This has improved team dynamics, provided confidence in patients and minimized avoidable risks. For example, at The Aga Khan University Hospital, Nairobi surgical theatres, all patients received into theatre reception are signed in to confirm identity, surgical procedure, surgical site marking is done, consent is signed, fasting guidelines, comorbidities and related anaesthesia equipment, airway risks, concerns and estimated blood loss. This is done by the anaesthesiologist and receiving theatre nurse. The patient is wheeled into theatre and prior to the surgical incision the checklist is done by the running nurse, confirmed by the surgeon and anaesthetist. The last checklist is done prior to the patient leaving the operating room by the same team[4].

The Kenya society of Anaesthesiologists have partnered with the World Federation of Societies of Anaesthesiologists and the Association of Anaesthetists of Great Britain and Ireland in providing SAFE- Safer Anaesthesia From Education courses in Kenya. This project started in 2013. The courses main participants are clinical officer anaesthetists, nurse practitioners and have attracted senior house officers working in various counties in the country. The courses include Safe Obstetrics, Pediatrics and Life Box. The society has successfully trained 282 obstetric anaesthesia providers and 59 pediatric anaesthesia providers since 2016. This aligns with the Ministry of Health goal of reducing maternal mortalities in Kenya and transforming health systems for universal health care.

The 2009 safe surgery guidelines have recommended a minimum of pulse oximetry when monitoring patients having surgery as evidence has shown it can detect hypoxaemia and related events. Capnography has added benefits as well in anaesthesia monitoring. Having the two modalities have shown to improve safety of patients [4]. The Global oximetry project has greatly impacted anaesthesia Kenya: Life Box pulse oximetry is actively being used in level 4 hospitals and surgical centres that lack standard equipment. Currently there are 261 Life Box oximeters which have been distributed and in use within Kenya. Capnography is actively used as well in level 5 and 6 public hospitals and major private hospitals within the county. Similar facilities that lack minimum monitoring equipment have pulse oximetry as standard monitoring which is also used in the post anaesthesia care unit [7].

The Ministry of Health in collaboration with the Kenya Medical Practitioners and Dentist Board approved the Kenya Society of Anaesthesiologists National Anaesthetic Guidelines. They aim to assist and guide all anaesthetists who have received at least basic training in anaesthesia. The guidelines cover the essential anaesthetic objectives for safe surgery as per the WHO second global safety challenge [8]. It includes recommendations on the minimum facilities for safe delivery of anaesthesia, pre-operative review, monitoring during the perioperative period, obstetric anaesthesia and checking of anaesthesia equipment.

In the next step we will explore another example from Tanzania; again we would like you to look out and determine how Human Factors and Ergonomics principles are used in that context.

References

  1. Biccard BM, Madiba TE, Kluyts H-L, Munlemvo DM, Madzimbamuto FD, Basenero A, et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet [Internet]. 2018 Apr 21 [cited 2019 May 27];391(10130):1589–98.
  2. Epiu I, Tindimwebwa JVB, Mijumbi C, Chokwe TM, Lugazia E, Ndarugirire F, et al. Challenges of Anesthesia in Low- and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa. Anesth Analg [Internet]. 2017 Jan;124(1):290—299
  3. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis [Internet]. 2016;16(12):e288–303
  4. Organization WH. Safe Surgery Concept . WHO Surgical Safety [Internet]. 2009.
  5. GOK MoH. Refocusing on quality of care and increasing demand for services; Essential elements in attaining universal health coverage in Kenya. 2018
  6. House A. Kenya Quality Assurance Model for Health Quality Standards for Kenya Essential Package of Health LEVEL 4 Ministry of Medical Services Ministry of Public Health and Sanitation. 2009
  7. World Health Organization. Global Pulse Oximetry Project: First Consultation Proceedings. 2008
  8. Kenya Medical Practioners and Dentist Board First Edition. 2016

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