The Global Anesthesia Crisis and Continuous Quality Improvement

Kathryn Ann Kelly McQueen, MD, MPH Vanderbilt Anesthesia Global Health & Development, Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee

The concept of quality improvement has been successfully applied to western medicine, with the result of improved practice patterns, changes in behavior, and improved outcomes. Applying this important concept to low-income (LICs) and middle-income countries would be valuable, and one can imagine similar improvements once the outcomes have been studied and appropriate adjustments made. But the current constraints secondary to the anesthesia crisis in LICs and middle-income countries provide huge challenges and obstacles for accessing and tracking data, and providing feedback to a dwindling workforce. This chapter seeks to describe the global anesthesia crisis and its contributors. Secondarily, this chapter also proposes solutions for the data gap, which if closed would potentially provide valuable insight into current anesthesia outcomes as well as the means to impact change in process, behavior, and patient safety. ’

Background

In a majority of LICs and many middle-income countries worldwide, few measures of quality or effectiveness in health care are captured. Anesthesia and surgery are no exception. In fact, generally the only collection of outcomes related to surgery and anesthesia exists in the omnipresent paper OR log, which is religiously kept. This alone is remarkable. In a world of pervasive technology and electronic medical records, it is difficult for physicians in developed countries to imagine the reality of health care in LICs and to appreciate the challenge of change. In many LICs there is no written record at all and no institutional memory of the care a patient receives from one visit to the next. This is light-years from REPRINTS: KATHRYN ANN KELLY MCQUEEN, MD, MPH, DEPARTMENT OF ANESTHESIOLOGY, VANDERBILT ANESTHESIA GLOBAL HEALTH & DEVELOPMENT, VANDERBILT INSTITUTE FOR GLOBAL HEALTH, VANDERBILT UNIVERSITY MEDICAL CENTER, 1301 MEDICAL CENTER DRIVE, #4648 TVC, NASHVILLE, TN 37232. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 1, 109–119 r 2014, Lippincott Williams & Wilkins

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health care documentation in developed nations. Figure 1 illustrates the percentage of deaths that are recorded in any kind of database in countries around the world. In the developed world, registration of death certificates is pervasive, but in less developed regions there is less attention to this process and less infrastructure to enable it. To illustrate the depth of the data void, it is necessary to step back and understand contributors to the lack of progress in this area of medicine and data in Africa, South East Asia, and other low-income areas where the surgical burden of disease is large. Even before the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic that ravaged LICs, a majority of patients avoided the hospital, and those known to be infected during the epidemic were not welcome in many hospitals. Therefore most people died at home, and their deaths were known only to their family, friends, and neighbors. There are no death certificates in most of these underserved communities and countries,1 so the ability to track outcomes, complications, and mortality is next to impossible. The power of anesthesia outcomes when followed and benchmarked against are well known in North America and Europe.2 Physicians in LICs must begin to collect and analyze these data points to increase support for better systems and methods of safe anesthesia and to improve practice patterns with objective information.



Introduction

A global anesthesia crisis has been ongoing in LICs for decades. The crisis—loss of physician leadership, few educated providers, limited safety equipment and oxygen supplies, and unpredictable drug availability—has recently become amplified, as noncommunicable diseases (NCDs) have eclipsed communicable disease, including HIV, as contributors to global mortality rates.3 It is estimated by the World Health Organization (WHO) that by 2020, the leading causes of global mortality will have shifted to include cardiovascular disease, trauma, and many cancers (Fig. 2).4 Many NCDs, including the leading contributors to global mortality, are positively impacted by surgical intervention, which in turn necessitates the availability of safe anesthesia. A similar situation exists in obstetrics. Maternal mortality rates (MMRs) in LICs have plateaued,5 but are still unacceptably high. The MMR will only be further improved with surgical intervention for maternal hemorrhage and obstructed labor, again with a necessity for safe anesthesia. Improved availability of surgical procedures, and improved outcomes, cannot be achieved without addressing the availability of anesthesia in LICs. The contributors to the anesthesia crisis include too few trained anesthesia providers caring for patients, fewer physicians involved in www.anesthesiaclinics.com

Figure 1. Countries registering vital statistics including death. World Health Organization. Figure adapted with permission from World Health Statistics 2011. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

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Figure 2. The shift toward communicable diseases and accidents as causes of death (selected causes). World Health Organization. Figure adapted with permission from World Health Report 2010. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

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anesthesia leadership and education,6 limited available safety monitors,7 unpredictability of available oxygen and appropriate anesthetic medicines, and substandard postoperative care. Although datum from LICs is limited, what exists suggests that all of these contributors have resulted in high anesthesia-related mortality rates and unacceptable patient safety and care.8–10 In Malawi in 2000 for example the preventable mortality rate was estimated at 1 in 275 patients—up to 100 times greater than in developed countries—with airway management difficulties and inadequate volume resuscitation noted as the leading anesthetic variables.10 The success of surgical interventions in LICs depends in large part on the effective provision of anesthesia. Emphasizing the team nature of perioperative outcomes will be important in designing measures to track the effectiveness of interventions.



Importance of Quality Improvement for LICs

The power of data is obvious to all working in science and technology. Emphasis on data collection and analysis does not exist in LICs, and therefore provision of much-needed data to illustrate specific needs and issues requiring improvement does not occur. Often there are no resources to collect information, and when collected the information is often so discouraging or embarrassing to institutions and governments that it goes unutilized and unreported. Despite these barriers, there have been successes. The mandatory reporting of MMR is one example of success.11 The collection and reporting of MMRs demonstrated shocking and unacceptable levels of maternal death in many LICs worldwide.12,13 The public health community was galvanized by these statistics and quickly strategized to improve this important health indicator. In 2000, the United Nations (UN) recognized decreasing the MMR as one of the 10 most important global health goals.14 Tracking and reporting MMR allowed each government and health system to compare its rates with its neighbors and with other countries with similar gross domestic product, etc. It also allowed governments and the international public health community to monitor the progress of the interventions aimed at improving MMR. Governments were incentivized to report MMR through funding programs targeting the health of mothers. Capturing surgical and anesthesia complications and related mortality rates is not yet a global health priority. As NCD grows and the need for surgery for trauma, cardiovascular disease, and cancer increases, the related mortality rates are important to the progress of safe anesthesia and surgery in LICs. Currently, the only perioperative complication routinely captured is intraoperative death, which is typically recorded in www.anesthesiaclinics.com

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the Operating Theater Log book but seldom examined locally or aggregated at the national or international level. In the few LICs where data collection has been successful, the preventable anesthesia-related death rates are appalling.8,15,16 The conditions that exist in LICs include providers with limited education, little or no safety monitoring, unpredictable oxygen and medication supply, and an absence of vigilance as a cultural norm. This leads to numerous preventable deaths, including young and healthy patients with curable surgical conditions. This unacceptable and preventable mortality must be addressed at the local, national, and international level.



Role of the World Health Organization (WHO)

The WHO plays a large role in supporting public health in each of its 169 member countries. Historically, the interests of WHO have been prioritized to disease states contributing to the greatest morbidity and mortality worldwide. Until recently, very few of the WHO priorities related to surgery and anesthesia. In the past decade, programs in trauma, surgery at the district hospital, and emergency and essential surgical care have emerged as small but growing efforts within WHO.17–19 Of note is the Safe Surgery Saves Lives Initiative that focuses on surgical safety.20 Even this focused safety strategy, based on a preoperative safety checklist, was only able to collect information on the numbers of available pulse oximeters.7 No information was forthcoming on surgical or anesthesia complications and outcomes. Identifying and promoting a perioperative mortality rate (POMR), defined as the number of ASA Classification I and II deaths/100,000 population, has the potential to become a WHO-supported health indicator and an index by which surgical and national health care systems could be monitored and compared with other LICs. The POMR of course is not specific for cause or etiology, and it will report mortality related to both surgical and anesthesia contributors. Although this lack of specificity is not ideal, the outcome is definitive and not subject to subjective interpretation, and the collection and reporting is not onerous for an already overburdened system. Counting and reporting deaths must occur in order for the global health community to take interest and Ministries of Health to take action. International reporting of the POMR will be an important metric for tracking worldwide improvement in perioperative care. It has been hypothesized that progress will follow the curve shown in Figure 3. As a nation’s human development index increases, the POMR will decrease sharply, until reaching a plateau state in which further gains in patient safety are “reinvested” in extending surgery to more complex patients and operations. www.anesthesiaclinics.com

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Mortality

Human Development Index

Figure 3. The anticipated rate of change in the perioperative mortality rate as a function of increasing human development index. Figure courtesy of Richard P. Dutton, MD. ’

Capturing Data

Even with few resources in an already overburdened system, tracking the mortality rates in the first 24 hours is feasible. Most operating rooms worldwide, even those remotely located, have paper logbooks. These books for the most part are diligently completed, and often include not only the procedure and anesthetic, but often a column for complications including intraoperative death. This is frequently the only capture of any surgical or anesthesia data. After the patient leaves the operating room there is no further tracking of complications or outcomes. The mechanism by which the data are reported to the national Ministry of Health and later to WHO could follow a similar mechanism as the current mandatory reporting system for MMR. WHO tracks and maintains a database of health indicators21 on each member state. This information is used by the WHO and by many other agencies and organizations for population-based health comparisons within and between countries. The respect for these indicators as reliable comparisons for population health is obvious when reading the global public health literature. Rarely is a population mentioned or described without mentioning life expectancy, under-5 mortality rates, MMRs, and road traffic mortality. The global surgical community has sought an indicator that would be as meaningful as the MMR has been for obstetrics. But surgical disease is complicated. Surgical disease impacts every age group, both sexes, and every organ system in the body. Therefore finding an indicator, or a group of indicators, that represents the spectrum of disease has proved challenging. The POMR is not a perfect indicator for surgery and anesthesia, but it does represent the overall status of population health as it relates to surgical intervention—ASA I and II patients should not die in the perioperative period in the presence of www.anesthesiaclinics.com

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appropriate surgical skill and safe anesthesia. It is a nonspecific measure of the ability of a system and country to provide safe anesthesia and surgery to the average, healthy patient with surgical disease. Similarly, mothers should not die in childbirth, and, although the MMR is not specific for etiology, it does reflect the ability of a country to provide adequate peripartum care, and it has shown improvement in response to public health interventions. The POMR, if implemented now with the increasing NCD and a growing need to provide surgical services and safe anesthesia for cardiovascular disease, trauma, and cancer as well as for obstructed labor and postpartum hemorrhage, will be as valuable to surgical disease as the MMR has been to maternal health. It has the potential to become the first and most important measure of surgical and anesthesia safety, and to influence such important benchmarks of public health as the Millennium Development Goals (MDGs).22 Of course, other outcomes must be followed for the impact of safe surgery and anesthesia to be fully evaluated. Outcomes such as hemorrhage, myocardial infarction, wound infection, dehiscence, and a number of other complications related to adequate surgical care and safe anesthesia must eventually be tracked and reported. But for now, in the absence of any public health indicator reflecting surgery and anesthesia, the POMR is the best option.



The POMR as an Indicator of Adequate Surgery and Safe Anesthesia Within the Post-2015 Health Agenda

The MDGs, proposed in September 2000 as part of the United Nations Millennium Declaration, committed nations to reduce extreme poverty with a deadline of 2015.23 These goals were embraced by the global health community and donors alike, and have been a singular focus since being commissioned by the UN Secretary-General in 2002. The impact of the MDGs is controversial, but even without reaching their ultimate goal by 2015, they have changed the global health agenda and altered the investment in health in the poorest countries. The UN is already looking beyond completion of the MDGs to the post-2015 health agenda. The UN states that “efforts to achieve a world of prosperity, equity, freedom, dignity and peace will continue unabated. The UN is working with governments, civil society and other partners to build on the momentum generated by the MDGs and carry on with an ambitious post-2015 development agenda.”24 They opened a channel of public discussion, by inviting the citizens of the world to participate in the World We Want Platform.25 Many anesthesiologists and surgeons participated in this discussion, including representatives of the World Federation of Societies of Anaesthesiologists and the American College of Surgeons. www.anesthesiaclinics.com

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NCDs, neglected tropical diseases, HIV/AIDS, malaria, tuberculosis, and childbirth will undoubtedly influence the post-2015 health agenda. Surgical intervention and safe anesthesia have an important role in prevention, mitigation, treatment, and palliation for all of these disease states. MMRs have plateaued in LICs, and without the universal availability of emergency cesarean section for obstructed labor and eclampsia, and surgical intervention for postpartum hemorrhage, these rates will remain unacceptably high. Trauma and cancer will be leading causes of disability and premature death by 2020, and without timely diagnosis and surgical intervention the burden of these diseases will remain significant. Surgery and safe anesthesia must be part of the post-2015 global health agenda, and the POMR will be a valuable indicator for evaluating the state of surgical services and safe anesthesia at the outset and a benchmark of intracountry improvement and intercountry comparison going forward. It is time for the UN to acknowledge the need for the POMR and mandate its collection and reporting from LICs.



Conclusions

Anesthesiology in the developed world is an example of the best in patient safety and has significantly contributed to improved surgical outcomes and to a culture of safety within medicine in general. These achievements have been related to a culture of vigilance, improved monitoring since the 1970s, review of closed-claim data for the purpose of education, and the process of anesthesia continuous quality improvement. LICs have fallen off the curve in terms of keeping up with these innovations. Certainly, many of the problems with surgery and anesthesia safety, and poor outcomes in LICs are related to the lack of resources and available education and training. The HIV/AIDS epidemic and other infectious diseases appropriately usurped resources for nearly 25 years to address the leading causes of death, especially among children and working age adults. Recovery from the HIV epidemic and a decrease in infectious disease contributors to premature death have increased life expectancy, and the growth of NCD has changed population health priorities. Surgery and safe anesthesia must rise on the agenda of global health, and resources must be provided by health care systems with government support to address the growing burden of surgical disease. Simultaneously, safe anesthesia and surgical care must be evaluated and benchmarked for improvement. The POMR is easily collected and reported and will serve as the initial indication of the quality and safety of surgery and anesthesia by country. In time a complete system of www.anesthesiaclinics.com

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outcomes measurement will be possible and will enable the same robust quality improvement efforts as in the developed world.

The author has no conflicts of interest to disclose.



References

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