ORIGINAL ARTICLE
Challenges of Organizing Mission Surgery in Resource Limited Environments Sebastian M. Brooke, MD, Thomas D. Samson, MD, and Donald R. Mackay, MD Abstract: Interest in global burden of disease that can be surgically treated is on the rise, and plastic surgeons, with a wide scope of practice, have the tools that make them integral in providing much of the needed surgical support in the world. Since the 1950 s, plastic surgeons have been closely involved in volunteer surgery, and it is through the success and growth of organizations such as Interplast and Operation Smile that we are able to take part in the current paradigm shift to local empowerment and self-sufficiency instead of service delivery alone. This kind of growth started with medical mission work that fostered international partnerships and that remain an important aspect of addressing the unmet surgical burden of disease. Building a mission comprised of an international team of volunteers that travels to a resource-limited environment and provides top-quality surgical care is not without challenges. The aim of this article is to discuss some of these challenges and how they might be overcome. Key Words: Mission surgery, global surgery, medical volunteerism (J Craniofac Surg 2015;26: 1075–1078)
T
he surgical burden of disease in the world has typically taken a backseat to communicable and medical diseases such as HIV, tuberculosis, and malaria and has been called the ‘‘neglected stepchild of global public health.’’1 More recently, there are increasing awareness and interest in the scope and impact of noncommunicable diseases. This includes the surgically treatable burden of disease, which is estimated to account for 11% of the global burden of disease.2 A need for accessible and safe surgery has been recognized as an integral part of any health system including those in low- and middle-income countries (LMICs). This kind of growing interest is demonstrated in The Lancet Commission on Global Surgery, which aims to incorporate the concepts of essential surgical care into the global health agenda alongside with the World Health Organization (WHO).3 As our global community continues to shrink, and attention and interest in access to safe surgical care in From the Division of Plastic and Reconstructive Surgery, Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA. Received November 30, 2014. Accepted for publication January 26, 2015. Address correspondence and reprint requests to Sebastian M. Brooke, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, College of Medicine, The Pennsylvania State University, Mailbox H071, 500 University Dr, Hershey, PA 17033; E-mail:
[email protected] No financial support was needed for this original piece of work. D.R.M. serves as the chief medical officer for Operation Smile, the organization upon which the experience in this invited article is based. The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001659
The Journal of Craniofacial Surgery
our global society grow, the contribution to global health by plastic surgery may be significant.4 It is timely then to provide our insights on developing surgical mission programs, which remains an important step in addressing surgical needs in LMICs and developing local long-term, self-sustaining surgical programs. Although such endeavors often start with an exciting and seemingly simple idea, there are numerous challenges that require consideration for such work to be both safe and effective. These challenges relate to personnel, infrastructure and equipment, education for both team and patient population, and developing standards that need to be incorporated into all of the above. First, however, an organization must have clearly defined goals. In this article, we address some of these challenges and how they might be overcome based on the experience of Operation Smile and their more than 30 years of success in treating cleft lip and palates (CLPs) globally.
SETTING GOALS AND STANDARDS A medical mission at its core is the provision of safe surgery to the otherwise disadvantaged. This is achieved through incredible collaboration and a framework in which all the components, although they may be very different, aim to achieve the same thing. At the core, there must be a commitment to the highest possible standards for each individual component. This ensures that each patient receives the same high level of care in every situation, regardless of their location or circumstance. For example, Operation Smile was the first international volunteer cleft organization to adopt the WHO Surgical Safety Saves Lives campaign, which included the WHO Surgical Safety Checklist (Fig. 1), which has been shown to improve morbidity and mortality on a global population.5,6 In addition, ‘‘Operation Smile’s 14 Global Standards of Care’’ was established and outlines their commitment to safety and quality care throughout all areas of a CLP surgical mission.7 These global standards include requirements that need to be met for (1) patient screening and assessment, (2) anesthesia equipment and supplies, (3) surgical equipment, (4) the recovery room/postanesthesia care unit (PACU); (5) postoperative intensive care, (6) patient consent, (7) surgical priority, (8) preventing transmission of blood borne pathogens, (9) pain management, (10) Operation Smile team, (11) volunteer credentials, (12) minimum patient follow-up, (13) proper translation, and (14) standard documentation (Table 1). This provides the architecture for addressing the challenges that one is faced when building a CLP mission. As there are increasing recognition and interest in the importance of surgical care globally, there has also been a change in the paradigm of surgery volunteerism, with a growing emphasis on long-term collaboration with local organizations, local education, and ultimately self-sustainability.8– 12 These standards can and should be applied to the development of such programs or freestanding cleft centers. Although beyond the scope of this discussion, the WHO provides a series of tools and guidelines for Emergency and Essential Surgical Care across multiple levels of health care facilities. This is found in the WHO Integrated Management of Emergency and Essential Surgical Care Toolkit, where the minimum standards of care in the preoperative, intraoperative, and
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current working experience within their specialties. After an initial review, which verifies a volunteer’s credentials, on-sight evaluation and proctoring should also occur to ensure that all members of the team are held to the same high standards. Team leaders are then also responsible for mentoring and performing such on-sight evaluations of their specialty volunteers. Not only are missions performed in geographically, culturally, socially, and politically different environments, but also the members of an international volunteer team come from similarly varied backgrounds. Preparing such a diverse group of people to come together and function as a team when the stakes are high, as they are in surgery, is also a challenge. This is important for both patient and volunteer safety. Premission planning and coordination is an important part of meeting this challenge. All members of the team should receive and review the expectations of their roles, which need to be clearly outlined in premission information packets. In addition to role-specific information, these packets should also assist volunteers in travel preparations to the mission location. Location-specific information on the geopolitical environment, recommended vaccinations, food expectations, local customs, safety precautions, currency, and arrival transportation, to name a few, should be provided to all volunteers. The logistical coordinator with the assistance of administrative support can then liaise with in-country hosts to work through the local political climate and bureaucracy. The safety of patients in mission work is always emphasized, but it must not be forgotten that the safety of the mission team is also critical to mission success.
Patient Safety FIGURE 1. Operation Smile safety checklist for CLP missions.
postoperative periods that are essential to providing safe surgical support are outlined.13
Personnel The personnel that makes up a CLP medical mission is large and includes physicians (surgeons, anesthesiologists, and pediatricians), nurses (preoperative and postoperative ward, PACU, and operating room), dentists, speech pathologists, audiologists, child-life specialists, biomedical technicians, medical record and media specialists, clinical and logistical coordinators, and a host of in-country local volunteers. Although these volunteers have vastly different experiences, backgrounds, and personalities, it is important to remember that one does not take time off to work with poverty-stricken populations in challenging environments without a tremendous sense of service or passion for our fellowmen. This is the common conviction that brings a mission team together. That said, there is the inherent challenge in managing a team of peers within their given areas of expertise, and thus clearly defined leadership roles within the team need to be established before each mission. Such hierarchy provides a system to manage team conflict or differences of opinion on clinical decisions that may be less straightforward. The leadership team is completed by both clinical and logistical coordinators who ensure that the goals of the mission are achieved. Another obvious challenge of assembling such a team is that the areas of expertise are varied, and with an international volunteer base, the educational background within even one of these varied groups may be different. Verification of credentials and professional experience within each volunteer’s discipline is paramount. Volunteers must have achieved the highest level of certification within their fields and demonstrate competence and
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For a CLP mission to be successful, the organization has to be able to demonstrate a commitment to patient safety. This fosters a trusting relationship with the patient population and host country partnership organizations as well as the political leadership. A major part of meeting this challenge is having a zero tolerance for major adverse events. Understood and accepted practices for patient selection that is conservative and safe must be put in place prior to any mission. Every component and step of operative medical care should be addressed prior to starting any mission so that every patient receives the same high standard of care every time. First, facilities must have intensive care capabilities or have a documented arrangement with a partner facility that allows for transfer if needed. In addition, age is considered. There is a high incidence of malnutrition and failure to thrive in LMICs.14 Such children may have electrolyte imbalances or anemia and low weight for age with less reserve. This may place them at increased perioperative risk for adverse events. To mitigate these risks in such populations, for example, on Operation Smile missions, no patient younger than 3 months should be considered for surgery. Cleft lip patients should be 6 months or older, and palate repairs should be done in patients older than 12 months. Exceptions to these 2 age requirements may be considered for surgery only if the anesthesia and plastic surgery team leaders, pediatric intensivist, and the clinical coordinator are in total agreement with such agreement clearly documented. In addition to age requirements, patient scheduling is also done with patient safety in mind. Higherrisk patients or procedures such as palate repairs should not be performed on the final day of surgery as the team begins to scale down and volunteers begin to travel home.15 Providing anesthesia is arguably the highest-risk component of mission surgery, and safety in this regard can be most challenging in resource-limited environments. Operation Smile has clear requirements for anesthesia safety on missions, which includes equipment requirements as indicated in the Global Standards of Care. Anesthesia machines are standardized throughout the organization and #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Mission Surgery Challenges
TABLE 1. Operation Smile 14 Global Standards of Care 1 2
Requirements for preoperative patient screening and assessment Required anesthesia equipment and supplies
3
Required surgical equipment
4
Requirements for the recovery room—PACU
5
Postoperative intensive care
6
Patient consent
7
Surgical priority
8 9
Preventing transmission of blood-borne pathogens Pain management
10
Operation Smile team
11
Volunteer credentials
12
Minimum patient follow-up
13
Proper translation
14
A standard of documentation
Appropriate equipment, laboratory support, and trained personnel will be available to perform comprehensive screening and evaluation in order to properly assess our candidates’ indications for any possible risks of surgery Only state-of-the-art, currently calibrated anesthetic delivery and support equipment, supplies, and pharmaceuticals will be used by our medical professionals to provide the safest in reliable anesthesia. Comprehensive, well-maintained surgical instruments, sutures, and supplies will be provided for each patient, customized to the particular operative procedure received by each of our patients. All our patients will receive specialized recovery care as they awaken from anesthesia, in an environment fully equipped with specialized instrumentation, personnel, and pharmaceuticals. Any of our patients requiring additional postoperative care to support their successful recovery will be managed in a suitable, well-staffed intensive care environment. All of our patients and their families will receive understandable information and education in their native language, allowing them to make an informed decision about surgery. Our patients will receive surgery based on appropriate, well-tested, and proven priority systems, developed to maximize the expected benefit with primary consideration to safety and the allocation of time and resources. Universal precaution protocols will be followed to help minimize infection, transmission of disease, and wrong-site surgery Alleviation of pain and anxiety during every phase of our perioperative care is of primary concern. Each patient will receive the safest, most effective analgesic medication under strict monitoring from our doctors and nurses. Operation Smile believes a team approach to the care of our patient provides the highest level of care and safety. Team compositions are comprehensive, deep, and broad in their expertise; drilled in fluid teamwork and effective communication; and most importantly unified by the single desire to achieve the very best outcome for each of our patients. Each of our volunteers is extensively interviewed, credentialed, and proctored prior to joining an operative team. Skills required from each of our specialists meet or exceed those of his/her core discipline. Ongoing mentoring, evaluation, performance review, and professional growth are central to maintaining a top volunteer corps. Effective postoperative care is essential for a good surgical result and effective planning for further treatment. Postoperative care requires good documentation and extensive education of parents and clinicians to be effective. When and wherever possible, our patients will receive short, intermediate, and long-term follow-up and care. Operation Smile missions will have sufficiently qualified translators to ensure proper communication among team members, support personnel, families, and patients. Proper translation is considered to be a matter of safety, quality, and respect of our patient’s rights. The purpose of documentation is to protect the patient, protect the health care personnel, and provide an accurate record for the basis of outcome assessment. Each of our patients will be monitored through a well-documented and protected medical record, whether paper or electronic.
transported to mission locations. They must be able to deliver oxygen, accommodate volatile agents, be calibrated annually, be capable of monitoring oxygen concentrations, and have access to backup power and oxygen supply. In addition, a biomedical specialist is an important member of any mission to ensure proper setup and troubleshooting these and other monitoring devices. Surgical mission teams may also be faced with the challenge of screening more patients than can be safely or practically scheduled for surgery. This is sometimes the aspect of mission work that can be most heart-wrenching and certainly gives the team a personal experience that is frequently foreign in the developed world— difficult resource allocation. Premission planning that sets goals and prioritizes patients for surgery helps meet this challenge because it sets an unbiased and thus fair framework for offering surgery or not to patients who may otherwise meet the safety requirements. First, the number of general anesthesia operating tables should be determined, which will then determine the necessary manpower within each role (Table 2). On a CLP mission for instance, patients can be
prioritized into primary lips followed by primary palates in younger children and then older primary palates. Lip and palate complications by a given organization can be prioritized along with the respective primary repairs followed by lip and palate complications from other organizations. Other conditions that can be safely managed by the CLP mission team are then prioritized last (Table 3). This allows for all screened patients to be fairly and safely addressed with a clear understanding why some patients may not receive surgery on the given mission. Patients who are not offered surgery are given clear classifications that indicate why and determine their eligibility on future missions, such as a primary lip patient who does not yet meet the age requirement. Some conditions or patients may be considered for transfer to the organization’s TABLE 3. Operation Smile (OS) Patient Priority Classifications for Selection and Scheduling on CLP Missions Priority
Summary
1
TABLE 2. Mission Staffing Chart 5 GA Tables
6 GA Tables
7 GA Tables
6 6 1 1 4 4 3
7 8 1 2 5 5 4
8 9 1 2 6 5 5
Surgeons Anesthesiologists Pediatric intensivists Pediatricians Operating room nurses Postoperative nurses Recovery nurses GA indicates general anesthesia.
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Primary repair of cleft lip—aged 3–6 mo, patients returning with surgical complications from OS lip repair 2 Primary repair of cleft palate—aged 1–6 years, patients returning with surgical complications from OS palate repair 3 Primary repair of cleft palates—aged 6 y to adult 4 Secondary repairs of lips and palates—all ages 5 Other conditions—all ages Not candidate Does not fall within any of the above conditions and not candidate for current or future missions or world care Potential world care Candidates for surgery whose condition is too complex to be treated during mission but may be candidate for transfer to the United States for charity-based care. Submitted to Operation Smile International Headquarters for review by the chief medical officer
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home country for charitable surgery on a case-by-case basis but must be reviewed by the organization’s headquarters and chief medical officer. Some patients may not be considered for surgery on any future missions dependent on their condition and whether it is treated by the mission organization. Although this kind of clarity is helpful for patients in understanding why they may not receive surgery, it is most helpful for the mission team in managing the denial of surgery to sometimes desperate and hopeful patients. Most importantly, though, these guidelines maintain safety and help ensure the success of the mission and possibility of future missions. Despite every attempt to mitigate risk, adverse events do occur, in both the resource-rich and resource-poor environments. Such events create an entirely new and different set of challenges that are beyond this discussion, but some points that we feel are important for the longevity of an organization and its opportunities to continue good work should be highlighted. A system must be in place to address such events in the acute setting with regard to the patient care, need for transfer to appropriate care if needed, family support, and possible temporary suspension or cancellation of the mission. In addition, clearly established organizational oversight of adverse events provides an opportunity to evaluate current practices and prevent future occurrences. Documented and transparent review such as this is also the best means of maintaining the credibility of the mission organization with the patient, their families, and the host country.
Logistics and Local Partnerships There are many logistical challenges to running a mission, and this is not meant as an exhaustive list of solutions but rather some of the considerations to have when planning a mission. First, a mission requires a relationship with the host community, which includes the patient population, the political leadership, the host facilities’ administrative and medical leaders, and in-country volunteers. Navigating these relationships successfully is essential for a mission to operate. One solution used by Operation Smile is the recruitment and engagement of in-country foundations or Global Resource Chapters. These formal organizations, under the shared Operation Smile name, have a shared vision with Operation Smile International and are responsible for the logistics of hosting a medical mission. For example, given that safety is the highest priority of bringing surgical care to resource-limited environments, Operation Smile transports all of the essential surgical and anesthesia equipment along with a biomed technical expert to every mission. Large volumes of medical equipment can be difficult to get through customs in some locations, and there may be licensing requirements to practice medicine. The local foundation becomes the liaison between the mission organization and the host country. The development of a local foundation under the shared name not only is useful to the mission organization operating, but also can be the first step to demonstrating a desire of the organization to support local development and, ultimately, self-reliance. These Global Resource Chapters, with the support of Operation Smile, for example, are the relationships that encourage local community, government, and private sector investment into the development of locally run cleft centers such as the Comprehensive Cleft Care Center in Guwahati, India. In addition, an established in-country foundation enhances the postoperative follow-up and outcomes-monitoring capabilities of a CLP mission organization. As these relationships grow, the short-term goals of a specific mission are achieved in concert with the development of long-terms goals that strive to enhance the CLP treatment capabilities of LMICs in what has been termed ‘‘diagonal development’’ in global surgery.12 This kind of empowerment also has the advantage of carrying over the enhancements in infrastructure, education, and access to other surgically treatable diseases within a given country.
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CONCLUSIONS The surgical burden of disease in the world is significant, and plastic surgeons have been involved in global volunteerism for decades. This is in part because of the wide range of surgical problems we frequently address and also because of the significant impact that in some cases a single surgery might have, such as an isolated cleft lip repair. This has enabled organizations such as Operation Smile, Smile Train, and Resurg International (formerly Interplast), to engage local communities in all corners of the world and foster the relationships that are needed in order to successfully empower LMICs to provide the education, training, and infrastructure, to address their unmet surgical burden of disease. Although this is the ultimate goal, mission surgery remains an important component of surgical outreach as it is frequently the introduction needed to develop self-sustaining programs. There are numerous challenges to overcome in providing safe and quality surgical care on missions in resource-limited environments, but these can all be met with careful planning and absolute commitment to surgical safety.
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2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.