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Planning and organising trichiasis surgery in the community
Read this article to discover the key steps in planning a district level trichiasis surgery service.
By the end of this presentation you should be able to: Select and plan community mobilisation for static and outreach trichiasis surgery services Identify the surgical team and its members’ roles in implementing trichiasis surgery Assess outreach facility organisation in community locations Manage patient flow during the surgical day and organise post-surgical follow up Trichiasis surgery can be most easily provided to patients in endemic communities at an established static unit such as a health centre or hospital. However, trichiasis patients are less likely to come to the unit if they have to travel for 2 hours or more to reach it. To address this, eye care programme managers use outreach campaigns to take trichiasis surgery services closer to people in their communities.
To achieve a minimum target of 15 trichiasis surgeries each surgery day in outreach,
one team can be organised as follows: Day 1 Travel to location Day 2 Set up, assess and counsel patients Day 3 Carry out surgeries and post-surgical care Day 4 Complete remaining surgeries and post-operative care Day 5 Pack up and reporting The number of surgery days will vary depending on the distance the team has to travel. Outreach campaigns need to be planned at least a year in advance, setting clear dates for visits. First, assess the area to be served using a district map. It is important to identify the facilities available, roads and the numbers of trichiasis patients and their locations.
The numbers of outreach visits needed at each site depends on the number of patients and the ability of the surgical teams to reach them. Community mobilisers are often from the local area or the primary health clinic, and will liaise with local health, political and religious authorities setting out exactly the time and length of each visit. Various venues are suitable for outreach surgery - for example, health facilities, schools and community buildings.
The building selected must have: Good light Space for one or more operating tables and trolleys Space to move around those operating tables once they are set up. And ideally, two or more rooms for surgery and assessment The venue is selected well in advance of the outreach campaign and its location is announced during mobilisation activities.
Outreach teams need to manage a wide range of tasks: Registering, examining, selecting and counselling patients Carrying out the surgery Escorting patients in and out of surgery Providing post surgical care instructions and follow up guidance Instrument and equipment sterilisation Data recording. These tasks are shared amongst the team. For example, community mobilisers can escort patients in and out of surgery. Efficiency is achieved when each team member is clearly informed and trained to take on their assigned responsibilities. Within an outreach setting patient flow
is set up and managed to include: An area for registration, assessment and counselling A clean bright surgical area, for the surgeon And a post-surgical return area for care instruction, medication and follow up advice. A good mobilisation campaign ahead of the outreach will mean a large number of people arriving at the facility. A good way to start the outreach is to introduce the team and inform people about the organization of the camp, ideally using a loudspeaker.
Co-ordination and communication with the local eye department is an important component of a trichiasis surgery outreach campaign. Patients without trichiasis but with another vision-impairing condition (e.g. cataract), should be referred for further assessment and treatment Trichiasis surgery in an outreach campaign does not require a special room. The available space must be dust free (clean), bright and large enough to allow the patient to walk in and lie down and to allow the surgeon to work.
The surgery room should be prepared with the following: A sterile equipment table A stool and operating bed with good light A rubbish container for clinical waste A rubbish container for clinical waste A sharps bin for disposing of needles and blades The surgeon’s sterile trolley with all the required instruments on it And a surgical instrument kit. The contents of the kit depend on the method of surgery that the surgeon is trained to perform. Sterilisation is the destruction of viruses, bacteria and spores. By sterilising instruments before surgery the team minimises the risk of infection from the surgery for their patients.
Sterilisation is carried out in two ways: By pressurised steam for 15 minutes at 121 degrees celsius and 101 kilopascal pressure. By dry heat in an electric or gas oven for 2 hours at 170 degrees celsius After each surgery, it is very important that the surgical team follows a strict process
to reduce risk of infection: 1 Wash instruments in a soap solution to remove blood and debris. 2 Wash instruments in clean water to remove soap from step 1. 3 Dry the instruments thoroughly before sterilising. 4 Sterilise the instruments At the end of the outreach day, the surgical team must oil and check all the instruments and wash and clean the surgical site. Post-surgery recording and counselling tasks.
For each patient, the outreach team must: Clearly log the details of the surgery and the patient information, in a written or electronic log book Provide pain relief (e.g. paracetamol) to the patient or family member and clearly communicate the post-surgery care information Instruct the patient not to rub their eyes and to keep the eye pad on for 24 hours Tell the patient about follow up care for - the day afterwards, 7-14 days later and 3-6 months after the operation. The team may also give the patient a single dose of azithromycin (1 gram) before they leave the facility. Otherwise they should give the patient tetracycline ointment or drops and demonstrate how to use them.
The required surgical output is achieved through a balance between demand for services (numbers of patients accepting trichiasis surgery) and efficiency of service provision (numbers of surgeries done per outreach). Regular monitoring enables managers to support their teams. In summary Locations and length of trichiasis surgery outreach campaigns, and the annual output target for trichiasis surgery, are planned at least a year in advance at district level The surgical team must be equipped to deliver the planned numbers of surgeries Managing outreach includes mobilisation; liaison with the local eye care department; preparation of the surgery location; setting up patient flow; patient assessment and counselling; trichiasis surgery; and post-operative care and counselling High quality trichiasis surgery is achieved through thorough attention to sterilisation and instrument care Recording and monitoring surgical outputs in outreach helps to maximise team efficiency and community demand for services.
This ensures targets can be achieved.
In trachoma endemic areas, trichiasis surgery can be provided at static units, through outreach campaigns, and by individual surgeons on motorbikes travelling to the most hard-to-reach communities.
The first step in planning a district level trichiasis surgery service is mobilising the community to raise awareness and estimate how many trachomatous trichiasis (TT) patients there are in the catchment area (the TT backlog).
Trachoma programme managers then use this estimate to determine the surgical output target. This is the number of surgeries that must be done in the district to reduce the prevalence of trichiasis to < 0.2% in adults aged 15 years and above. Ideally, this target is set at the national level in a Trachoma Action Plan.
Once the surgical output target is known, the manager can then determine:
- The number and composition of the surgery teams required in the district
- The requirements for consumables and number of instrument sets to prepare
- The number of days to be spent at each outreach.
To achieve the surgical output target the manager, surgery teams and community stakeholders work together to:
- Determine the locations for outreach campaigns and appropriate community mobilisation
- Reach and manage the surgery location
- Undertake clinical assessment, counselling and surgery for each individual patient
- Undertake and make arrangements for post–surgical- and follow-up care for patients
- Feed back to the community.
As you watch the video, consider the possible challenges to maintain and manage surgical outputs in outreach settings.
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