WHO Regional Workshop on Patient Safety: Integrated Management for Emergency & Essential Surgical Care (IMEESC) Report 15-17 January 2008 Bentota, Sri Lanka 1
1. BACKGROUND Statement of the problem Many patients who present to district (first-referral) level health facilities require emergency surgical and anesthesia interventions for trauma, obstetric, abdominal, or orthopedic emergencies. Often surgery cannot be safely postponed to allow for transfer to a secondary or tertiary-level hospital, particularly in life threatening emergencies. Injuries kill more than 5 million people a year, accounting for nearly 1 in 10 deaths worldwide. An estimated 500,000 women die from pregnancy related complications each year. In children between the ages of 4 to 14 years, road traffic injuries are the second leading cause of death. Death and disability in each of these groups can be prevented or treated providing emergency and essential surgical intervention is delivered in a timely manner. Many district hospitals in developing countries have no specialist surgical and anesthesia teams and are staffed by general doctors, nursing and paramedical personnel who perform a wide range of surgical and anesthesia procedures, often with inadequate training. The quality and safety of surgical and acute care is often further constrained by poor facilities, inadequate technology devices and limited supplies of medicines and supplies. Needs assessments conducted by WHO/HQ/Essential Health Technology/Clinical Procedures Unit at selected health facilities in Bangladesh, India, DPR Korea, Maldives, and Nepal have shown that many facilities are unable to carry out even the most basic emergency and surgical interventions. The underlying reasons appeared to be a shortage of resources in trained personnel and lack of policies and procedure guidelines. The establishment and maintenance of quality and safe surgical services at district level hospitals requires: Personnel with appropriate education and training in Emergency & Essential Surgical Care (EESC) Appropriate physical facilities Appropriate equipment (in good working order) and instruments A reliable system for the supply of blood & blood products, medications, surgical, anesthesia materials and other consumables A quality system, including standards, clinical guidelines, standard operating procedures, records and audit. This WHO workshop was held for participants representing 10 SEARO countries and Sri Lanka MoH. 2. OPENING SESSION 2. 1 Introduction Dr. A. Kahandaliyanage, Secretary of the Ministry of Healthcare and Nutrition welcomed participants to the Regional Patient Safety Workshop on the Integrated Management of Emergency and Essential Surgical Care. Dr. S. Puri, WHO/Sri Lanka delivered an opening message on behalf Dr. Samlee Plianbangchang, Regional Director of WHO/SEARO which was followed by an overview of the objectives of the workshop by Dr. Doris Mugrditchian, WHO/SEARO. 2
2.2 Workshop objectives The overall purpose of the workshop is to improve the quality and safety of Emergency and Essential Surgical Care (EESC) at the district or first referral level in the context of patient safety. The specific objectives are: To introduce the WHO Integrated Management for Emergency & Essential Surgical Care (IMEESC) and other relevant tools To discuss and acquire an in-depth understanding on the use of these tools To develop an outline of country action plans to build EESC capacity at the first level of care 3. PRESENTATIONS 3.1 Setting the context After an overview of regional EESC activities and challenges, each SEARO country presented a brief country summary, based on previous WHO EESC project guidelines, on the current situation of emergency and essential surgical care. A discussion on potential collaborative initiatives to address shared issues related to EESC was held afterwards. 3.2 Global Initiative for Emergency and Essential Surgical Care WHO/HQ/EHT/HSS/EHT/CPR presented the WHO Global Initiative for Emergency and Essential Surgical Care and shared country experiences in the implementation of WHO Integrated Management for Emergency and Essential Surgical Care toolkit (IMEESC), available at http://www.who.int/surgery/publications/imeesc/en/index.html. An open discussion on application of IMMESC followed. 3.3 Optimizing Resource Planning and Management for Emergency and Essential Surgical Care WHO/HQ/HSS/TFP presented methodologies to improve resource planning and physical asset management: the integrated Healthcare Technology Package (ihtp) software and the Technology Management Package (TeMP) tool. Sri Lanka's work with the TeMP tool was presented, including inventory of the 'line hospitals' under the national MoH and use of this data to improve management, maintenance and use of equipment, and recommend equipment-related training modules for clinical personnel. 3.4 Safe Practices in the Transfusion of Blood and Blood Products in the Operating Room WHO/SEARO/HSS delivered a presentation on Global Patient Safety Challenge 'Safe Surgery Saves lives.' A lecture on the appropriate use of blood and blood products and blood transfusion safety measures was given by WHO/SEARO/BCT. 3. DISCUSSION After each session, participants were invited to discuss topics presented. A synopsis of discussion points follows: Recently in some countries, non-specialists perform life saving surgical and anesthesia interventions and get sued by consumers, when the surgical interventions cause complications. Therefore, some SEAR countries have professional societies which do not allow non-specialists to perform surgical and anesthesia procedures. Although medical schools teach essential surgical procedures for reducing death and disability, insufficient exposure and hands-on training in this area is provided before 3
graduation. Anesthesia occupies very minimal role (average of 10-15 hrs) in the medical school teaching curriculum. Various programs for trauma, pre-hospital care, disasters are currently ongoing, but no national standards exist to stipulate the types of procedures that can be performed at a given level of care (i.e. primary, secondary, tertiary). There is a need to assess the availability of emergency, anesthetic, and surgical interventions in developing countries to raise awareness of the need for EESC services at the primary health level. The WHO Tool for Situational Analysis is short and simple survey of the situation that can provide data. - WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care is available at http://www.who.int/surgery/publications/imeesc/en/index.html. - Deviation from the simple format of the tool with addition of more parameters to the survey instrument may duplicate efforts of existing surveillance and data collection by various programs e.g. blood, trauma, HIV, disasters, maternal and child and lengthen data processing. Solutions focusing solely on providing ambulances and creating specialized centers (trauma, obstetrics) will not effectively solve problem of access to care, rather the issue should be addressed through a comprehensive, primary health care approach. Some countries (e.g. Bhutan) were observed to have only tertiary care hospitals and very difficult terrain (causing transport delays of 7-8 hours); basic surgical interventions should be provided at the peripheral health facilities to reduce morbidity and mortality related to referral delay. Equipment donation procurement is often not appropriate for the primary health care facilities, e.g. endotracheal tubes, without connections to oxygen supply (cylinder, concentrator), lack of training in use and maintenance. Providing training to communities in first aid is important. The WHO-IMEESC toolkit was introduced through joint MoH workshops and can be used towards implementation of a comprehensive package for capacity building at Primary Health Care facilities. 4. CONCLUSIONS The meeting concluded with a group work session to formulate recommendations for the improvement of emergency, anesthetic, and essential surgical quality of care and safety and to develop an action plan with follow-up. 4.1. Recommendations To enable general doctors and trained, non-specialist health personnel to perform life saving surgical and anesthesia interventions, policies should be developed to address security for the health providers in conjunction with policies on patient safety, to avoid litigations, when the surgical interventions cause complications. Policies should also be developed to emphasize in the curriculum strengthening surgical and anesthesia skills. This will require medical schools to give hands-on training on emergency surgical and anesthesia procedures towards safety, reducing death and disability. Need to have a standardized training, the WHO IMEESC toolkit can be adapted to country needs through bringing together key persons from the MoH and Education and professional societies (surgical, anesthesia, obstetrics, emergency) Policies should be developed through dialogue with MoH, adoption and adaption of WHO IMEESC guidelines, to define types of surgical procedures that can be performed at various levels of care (centers) and by various health providers (general doctor, nurses, technicians) 4
Urgent need for emergency guidelines for disaster situations (natural, major accidents, wars), when health system operations are threatened. Basic emergency and surgical interventions should be performed at the peripheral health facilities in countries with barriers to accessing tertiary care (due to difficult terrain, delays referral time) or few tertiary care centers. Therefore, building up human resources is a priority and IMEESC toolkit can be adapted to country needs. WHO-GIEESC, in collaboration with related NGO's, should assist countries seeking to strengthen further surgical and anesthesia training of medical staff at district and subdistrict hospitals. Sample data on district hospitals and primary health care facilities should be collected. WHO can assist in data analysis and publication though: http://www.who.int/surgery/publications/imeesc/en/index.html State-level policies should encourage involvement of local communities in training for appropriate referral, first aid etc. Policies should also be developed for equipment procurement, use and maintenance. 4.2 Action Plan and Follow-up Assist in the preparation of the draft report of SEARO workshop and dissemination to all GIEESC members on http://www.who.int/surgery/activities/en/ site. Assist countries in drafting their emergency and essential surgical care action plans Extend TeMP implementation in Sri Lanka to include spare parts management and plan for a focused training workshop in Colombo Spring 2008. Follow up with SEARO to put resource planning and equipment management on the agenda for the Regional Ministers' Meeting in the Spring 2008. Follow up with the Sri Lankan MoH regarding the full-scale implementation of ihtp initiated in 2005 for post-tsunami reconstruction. Follow up with SEARO on the implementation of ihtp in countries which requested or initiated it, i.e. Bangladesh, Bhutan, India, Indonesia, Nepal, Thailand Follow-up on the interest to introduce the WHO IMEESC tools in the remaining SEARO countries and support the existing training in Maldives, India and Nepal. 4.3 Acknowledgement Dr. Dula DeSilva concluded the session by emphasizing the need for integrated management of basic emergency, anesthetic, and surgical care at primary health care centers as a way to increase health equity for all. Appreciation was expressed to participants from Bangladesh, Bhutan, DPR Korea, Indonesia, India, Maldives, Myanmar, Nepal Sri Lanka, and Thailand for their time, efforts and contributions. The Ministry of Healthcare and Nutrition of Sri Lanka as well as representatives from WHO Sri Lanka country office, WHO SEARO, and WHO Headquarters were recognized for their collaborative efforts and continued support of improvements in emergency and essential surgical care in Sri Lanka and SEAR countries. 5
Annex I AGENDA AND PROGRAMME OF WORK 09.00 13.00 14.00 17.30 DAY 1 DAY 2 Opening Ceremony Welcome/Opening remarks Objectives of the meeting Session 1: Setting the context Regional context HSD Country presentations Discussion on emerging issues and areas for regional collaboration Session 3: Optimizing Resource Planning and Management for Emergency and Essential Surgical Care An overview on resource planning and management What methodologies and tools exist for resource planning and management? How can we apply these tools for emergency and essential surgical care? Status quo and capacity identification (with country examples) Planning and costing for resources (with country examples) Interpretation of results Policy dialogue and decisionmaking; Analysis of options Session 2: Global Initiative for Emergency and Essential Surgical Care Introduction to the Global Initiative for EESC and the IMEESC e-learning tool kit Application of WHO IMEESC tool to policy and daily practice Group discussion Session 4: Safe Practices in the Transfusion of Blood and Blood Products in the Operating Room An introduction to WHO Strategy for Safe Blood Clinical interface for safe blood transfusion - Definition of the clinical and Importance of an effective clinical interface - Role of the BTS/hospital blood bank and hospital blood transfusion committee - Hospital transfusion process - Appropriate clinical use of blood - Effective collaboration between the BTS and prescribers of blood - Designing a blood request form and Requests for blood - Storage of blood components - Administration of blood - Post transfusion care - Haemovigilance Discussion and sharing of experiences DAY3 Session 5: Group Work to develop an outline of country action plans Session 6: Closing Session Recommendations for improving the quality and safety of emergency surgical care at first level referral health facility Summary of action points Closing remarks Group photo 6
WHO Workshop on Patient Safety: Integrated Management for Emergency & Essential Surgical Care (IMEESC) 15-17 January 2008 Bentota, Sri Lanka, LIST OF PARTICIPANTS Bangladesh Dr Md Ataur Rahman Vice-Principal and Associate Professor (CC) Department of Surgery Comilla Medical College Dr Abul Bashar Md. Maksudul Ala Prof (Anesthesia), and OSD, DGHS Attachment Sir Salimullah Medical College Mitfort Dhaka Dr K.M. Ashraf Ali Associate Prof (CC) Department of Surgery Comilla Medical College Mrs Aleya Ferdoshi Nursing Supervisor Shador Hospital Manikgong Bhutan Ms Rinzin Wangmo OT Incharge JDWNR Hospital Dr Grajaman Rai Anaesthesiologist Gelephu Hospital Ms Tandin Pemo Nursing Superintendent Ministry of Health 7
Dr Tshering Wangden Gynecologist JDWNR Hospital Dr Mahrukh Getshen Blood Bank JDW National Referral Hospital Thimphu, Bhutan DPR Korea Dr. Choe Il Medical Officer Department of Prevention and Treatment Ministry of Public Health Dr. Kang Kum Sun Surgeon Pyongyang city No.1 Hospital. Ms. Choe Myong Hui Researcher Korea Red Cross Hospital (interpreter) India Dr Jagdish Prasad Medical Superintendent Safdarjung Hospital New Delhi Dr Mridula Pawar Ram Manohar Lohia Hospital New Delhi Dr S. Jagdish JIPMER Pondichery Dr K.N. Srivastava Ram Manohar Lohia Hospital New Delhi Indonesia DR Dr Tri Wahyu, Sp. BTKV Head, Emergency Unit Dr Hasan Sadikin Hospital, Bandung West Java Dr I Nengah Kuning Atmadjaya, SpB Surgeon Sanglah Denpasar Provincial Hospital 8
Dr Andi Wahyu Ningsih, Sp.An Anaesthesiologist Fatmawati Hospital Jakarta Dr Nella Abdulah, Sp.An. Anesthesiology Coordinator Fatmawati Hospital Jakarta Drs Saraswati RSPI Sulianti Soroso Jakarta (Infectious diseases Control) Dr Wuwuh Utami Ningtyas, MKes Chief Sub-Directorate of Emergency and Evacuation Directorate-General of Medical Care Ministry of Health Jakarta Maldives Dr Abdulla Ubaid Senior Registrar in Surgery Indira Gandhi Memorial Hospital Ms Fathmath Moosa Ward Sister Indira Gandhi Memorial Hospital Ms Hasrath Waheed Ward Sister Kulhudhuhfushee Regional Hospital Ms Latheefa Mohamed Practical Nurse Hithadhoo Regional Hospital Myanmar Dr Win Myint Thein Senior Consultant Orthopaedic Surgeon Myitkyina General Hospital Kachin State Northern Myanmar Dr Kyaw Win Senior Consultant Orthopaedic Surgeon Sao San Htoon General Hospital 9
Taunggyi Shan State Eastern Myanmar Dr Wuwuh Utami Ningtyas, MKes Chief Sub-Directorate of Emergency and Evacuation Directorate-General of Medical Care Ministry of Health Dr. Pracha Chayapum Senior Medical Officer Yala General Hospital, Myanmar Dr Naw Mar They Junior Consultant Surgeon 300 Bedded General Hospital Naypyitaw Central Myanmar Dr Naw Mar They Junior Consultant Surgeon 300 Bedded General Hospital Naypyitaw Central Myanmar Nepal Dr Krishna Prasad Khanal Surgeon Lumbini Zonal Hospital Dr Nirmal Kumar Gnawali Anesthesia Bheri Zonal Hospital Ms Sita Aryal Metron Western Regional Hospital Pokhara Sri Lanka Dr Piyasena Samarakoon Director (Medical Services) Ministry of Healthcare and Nutrition Dr. Jayatilaka Muditha Director of Biomedical Engineering 10
Deputy Minister of Health Care and Nutrition Sri Lnaka mudithaj@gmail.com mudithaj@hotmail.com Dr Rathansena Consultant Surgeon National Hospital of Sri Lanka Dr Dula DeSilva Adviser & Head of Health, Social Transformation Programmes Division - Health Section +44 (0) 20 7747 6290 Dr E.H.M.G. Premarathna Anaesthetis Base Hospital Balapitiya Dr P. Aluthge Consultant Anaesthetist National Hospital of Sri Lanka Mrs I.H.I.H. de Silva Nursing Sister Castle Street Hospital for Women Thailand Dr Anurak Amornpetchsathaporn Assistance Director Bureau of Emergency Medical Services Ministry of Public Health, Thailand Dr Surachet Satitniramai Director, Bureau of Emergency Medical Services (Narenthorn) Dr Prapa Ratanachai Senior Medical Officer Hat Yai Hospital, Songkhla Dr Ekachot Peradhammanon Chief of Emergency and Forensic Department Phrachomklao Hospital Phetchburi Province Ms Bubpha Noppawon Head Nurse 11
Sri Ayutthaya Hospital Ayutthaya Province Observers Dr Lalith Priyalal Chandradasa Director Community Health Unit Lanka Jatika Sarvodaya Shramadana Sangamaya No. ¼, Nanda Mawatha Nugegoda Western Province Ms Christine Perera Joint Secretary People s Movement for the Rights of Patients 27/1 Andarawatta Road Polhengoda Colombo 5 Mr J M Ashraff B7/2/4 National Housing Scheme Colombo 10 WHO Secretariat WCO/Sri Lanka Dr S Puri Technical Officer (Programme & Management) WHO Country Office WHO/SE/ACO/SRL Sri Lanka Dr Harischandra Yakandawala WORLD HEALTH ORGANIZATION 226, Bauddhaloka Mawatha Colombo 07 Sri Lanka Tel: +94 11 2502319, +94 11 2502842 GPN: 24664 Fax: +94 11 2502845 Sri Lanka Ms Geethani Dissanayake Secretary World Health Organization WHO/SE/ACO/SRL Sri Lanka 12
SEARO Dr Doris Mugrditchian Organizing Officer and Regional Focal Point -QSH WHO South-East Asia Regional Office WHO/SE/RGO/HSD IP Estate, Ring Road New Delhi 110002 India Tel : 0091-11-23309330 Fax: 0091-11-23370252 Email: mugrditchiand@searo.who.int Dr Rajesh Bhatia Regional Adviser Blood Safety and Clinical Technology WHO South-East Asia Regional Office WHO/SE/RGO/CDS/BCT IP Estate, Ring Road New Delhi 110002 India Tel : 0091-11-23309122 Email: bhatiaraj@searo.who.int HQ Mr Sunil Kumar Jain Secretary WHO South-East Asia Regional Office WHO/SE/RGO/HSD/HSY IP Estate, Ring Road New Delhi 110002 India Tel : 0091-11-23309330 Fax: 0091-11-23370252 Email: jains@searo.who.int Dr. Meena Nathan Cherian Emergency and Essential Surgical Care Clinical Procedures Unit (CPR) Department of Essential Health Technologies WHO/HQ/HSS/EHT/CPR Geneva, Switzerland Tel: +41 22 791 4011 Fax: +41 22 791 4836 Email: cherianm@who.int; Dr Dheepa Rajan Health Technology and Facilities Planning (TFP) Department for Health Policy, Development and Services (HDS) WHO/HQ/HSS/HDS/TFP Geneva, Switzerland Tel.: + 41 22 791 5874 Fax: +41 22 791 41 53 E-mail: rajand@who.int 13