The Basic Surgical Skills course in sub-Saharan Africa: an observational study of effectiveness

Background: The Basic Surgical Skills (BSS) course is a common component of postgraduate surgical training programmes in sub-Saharan Africa, but was originally designed in a UK context, and its efficacy and relevance have not been formally assessed in Africa. Methods: An observational study was carried out during a BSS course delivered to early-stage surgical trainees from Rwanda and the Democratic Republic of the Congo. Technical skill in a basic wound closure task was assessed in a formal Objective Structured Assessment of Technical Skills (OSAT) before and after course completion. Participants completed a pre-course questionnaire documenting existing surgical experience and self-perceived confidence levels in surgical skills which were to be taught during the course. Participants repeated confidence ratings and completed course evaluation following course delivery. Results: A cohort of 17 participants had completed a pre-course median of 150 Caesarean sections as primary operator. Performance on the OSAT improved from a mean of 10.5/17 pre-course to 14.2/17 post-course (mean of paired differences 3.7, p < 0.001). Improvements were seen in 15/17 components of wound closure. Pre-course, only 47% of candidates were forming hand-tied knots correctly and 38% were appropriately crossing hands with each throw, improving to 88 and 76%, respectively, following the course (p = 0.01 for both components). Confidence levels improved significantly in all technical skills taught, and the course was assessed as highly relevant by trainees. Conclusion: The Basic Surgical Skills course is effective in improving the basic surgical technique of surgical trainees from sub-Saharan Africa and their confidence in key technical skills

Perspectives on the state of cleft lip and cleft palate patient care in Africa.

PURPOSE OF REVIEW: Patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa. RECENT FINDINGS: To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources. SUMMARY: The replacement of CLP missions with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term

Teaching surgical skills in a resource-limited setting: Comparing massed versus distributed practice in an ultrasound-guided breast biopsy simulator

Background: Teaching surgical skills in the simulation lab has increased markedly compared to teaching only in the operating room. Although many studies have been performed investigating the optimal teaching methodology for skills acquisition, there is no consensus on the best method. Massed and distributed practices are important methods in teaching procedural skills. Considering the limited human and logistical resources in low and middle-income settings, it is valuable to understand the optimal methodology for learning and acquiring surgical skills. Methods: Thirty-two core needle biopsy-naïve first-year residents and final year medical students rotating in general surgery were enrolled in and completed the study at University Teaching Hospital of Kigali, a tertiary, teaching and referral hospital in Kigali, Rwanda. They were assigned to a “massed” group (i.e., one time, 3-hour practice) or “distributed” group (i.e., 1-hour practice per week for 3 weeks). Trainees were taught ultrasound-guided core needle biopsy on a high-fidelity breast simulator. All participants completed pre- and post-tests and an evaluation of skill retention was performed one month after completion of the training. Analysis of performance was completed, and p-value ≤ 0.05 was considered statistically significant. Results: There was no difference between performance on the pretest (p=0.985) and the posttest (p=0.680). Both groups demonstrated improvement after implementation of the simulation training when comparing pretest and posttest results (p<0.001); there were no differences in the evaluation of skills retention after one month after the training between the two groups (p=0.273). Conclusions: The results of this study demonstrate that both groups have improved significantly their knowledge and skills. Trainees have similar retention of skills in ultrasound guided core needle biopsy on a breast simulator whether trained under a massed or distributed practice schedule. Both methods may be considered in our setting for teaching surgical skills. Keywords: surgical simulation; resource-limited setting; global surgery

Improving starting time in operating rooms of a tertiary hospital in Rwanda: a quality improvement project

Background: Delay in the first surgery start time at operating room (OR) could inevitably decrease utilization, lose very expensive OR resources, reduce satisfaction of patients and staff and potentially affect quality of patient care.Objectives: This study utilized the Strategic Problem Solving (SPS) quality improvement approach to increase the percentage of first surgeries started on time at a tertiary hospital in Rwanda.Methods: A pre- and post-intervention study was conducted between March 2016 and March 2017. The intervention included developing a policy on staff arrival time, training sessions on the policy and regular supervision of OR managers to ensure staff were arriving on time.Results: Chi square tests were performed to analyze the pre- and post-intervention results. The percentage of first surgeries started on time significantly increased from 3% pre-intervention to 25% postintervention (P<0.001), average duration of delay decreased by 55 minutes (P<0.001) and the percentages of nurses, anesthetists and surgeon arrived on time also significantly increased (P<0.001).Conclusion: The SPS approach can be useful in addressing the starting time of first surgery at OR. Support from the senior management team and buy-in from staff are essential. This project cannot eliminate confounding factors and the results cannot be generalizable to other settings. Longer term evaluation on sustainability is needed.Keywords: Delay first surgery, operating room efficiency, quality improvement, strategic problem solvin

Exploring the Significance of Bidirectional Learning for Global Health Education

The value of bidirectional learning is emphasized both in global health and local community engagement. Conceptualizations of bidirectional learning for global health education are discussed, including implications when it is defined as mutual learning, codevelopment, or academic partnerships. Additionally, we review the relationship of bidirectional learning to different learning theories. Case studies from the field offer examples of how bidirectional learning can occur in the classroom, through academic partnerships, or both. Finally, recommendations are offered to facilitate bidirectional learning in global health education, including in identifying challenges faced by educators in lower-resourced settings who wish to offer bidirectional learning to their students through partnership with higher-resourced academic institutions

Environmentally sustainable surgical systems

Surgeons, anaesthetists, wider surgical teams and hospital managers are a large global group that has the capacity and power to play a leadership role to contribute to change. Hospitals are a good target for improvement since they are centres of communities, linking together surrounding healthcare facilities and influencing wider determinants of the environment. District and rural hospitals are good sites to start since they serve large populations, have the least sustained energy and clean water supplies and will benefit most from quality improvement. Within hospitals, surgeons and surgical pathways are the ideal places to start decarbonising healthcare. Surgery is a high-resource activity, but it focuses on one patient at a time, allowing measures to be introduced, and their effects closely monitored. Through a mass movement, surgical teams should be able to influence policy-makers for healthcare and industry supply chains, amplifying their effect. This article describes how we can make personal, professional and organisational changes to start creating impact. Change can be hard, especially in healthcare, so this new community needs to blend carbon literacy and behavioural change techniques for success. The article is focused on the front-line team and written by clinician experts in behavioural change and sustainable practice. As such, it will not tackle the technicalities of sustainability and carbon accounting. It intends to challenge individual readers to start making changes now, and to challenge systems leaders to start making larger-scale changes urgently.</p