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Introduction

In the wake of the Lancet Commission on Global Surgery (2015), it is recognized that 5 billion people lack access to safe, affordable surgical and anesthesia care. However, access alone is insufficient. If surgical care is provided without a rigorous focus on quality and safety, it can lead to increased morbidity, mortality, and economic catastrophe for the patient.

For surgeons in resource-limited settings (RLS), “Quality and Safety Improvement” (QSI) is often perceived as a luxury of high-income systems. This chapter argues that QSI is, in fact, an essential ethical and clinical requirement that can be achieved through evidence-based, low-cost interventions.

The Framework of Surgical Quality

The standard framework for assessing quality is the Donabedian Model, which categorizes indicators into three domains:

  1. Structure: The environment in which care is delivered (e.g., presence of pulse oximetry, sterile supply chains, reliable electricity).
  2. Process: The actual delivery of care (e.g., adherence to the WHO Surgical Safety Checklist, antibiotic prophylaxis timing).
  3. Outcome: The effect on the patient (e.g., perioperative mortality rate, surgical site infection rates).

The Three Delays Model in Surgery

In global surgery, quality is also viewed through the “Three Delays” framework, adapted from maternal health: * Delay 1: Delay in seeking care (cultural or financial barriers). * Delay 2: Delay in reaching care (transportation and geography). * Delay 3: Delay in receiving high-quality care at the facility (lack of staff, supplies, or safety protocols).

Evidence-Based Interventions for Safety

1. The WHO Surgical Safety Checklist (SSC)

The most significant evidence-based tool for surgical safety remains the WHO Surgical Safety Checklist.

  • The Evidence: A landmark study by Haynes et al. (2009) across eight global sites (including LMICs) demonstrated that implementation of the checklist reduced the rate of major complications by 36% and death by 47%.
  • Recommendation: Every surgical facility, regardless of resource level, must implement the SSC.
  • Practical Tip: Successful implementation requires “buy-in” from the entire team (nurses, anesthesiologists, and surgeons) rather than a top-down mandate.

2. Surgical Site Infection (SSI) Prevention

SSIs are the most common postoperative complication in LMICs, with rates significantly higher than in high-income countries.

  • WHO Guidelines (2016): The WHO issued 29 recommendations for SSI prevention. Key evidence-based actions for RLS include:
    • Antibiotic Prophylaxis: Administer within 120 minutes before the incision.
    • Skin Preparation: Use alcohol-based antiseptic solutions with chlorhexidine gluconate.
    • Surgical Hand Prep: Use of alcohol-based hand rubs is as effective as traditional scrubbing and more feasible in areas with poor water quality.
    • Avoid Hair Removal: If necessary, use clippers; never use razors, as they cause micro-abrasions that increase infection risk.

3. Safe Anesthesia and Monitoring

The Lifebox Foundation has highlighted the “oximetry gap.” Thousands of operating rooms in RLS operate without continuous pulse oximetry.

  • Consensus: The WHO-WFSA (World Federation of Societies of Anaesthesiologists) International Standards for a Safe Practice of Anesthesia lists pulse oximetry as a mandatory “highly recommended” monitor.

Monitoring and Evaluation (M&E)

You cannot improve what you do not measure. In RLS, data collection is often manual and burdensome.

Key Performance Indicators (KPIs)

The Lancet Commission recommends six core indicators, of which three are specific to quality/safety: 1. Perioperative Mortality Rate (POMR): The number of deaths before discharge or within 30 days of a procedure. 2. Surgical Volume: Total number of procedures performed per 100,000 population. 3. Access to Surgery within 2 Hours: A proxy for the functionality of the referral system.

Morbidity and Mortality (M&M) Conferences

The M&M meeting is a low-cost, high-impact tool for quality improvement. * Recommendation: Conduct weekly or monthly multidisciplinary meetings. * Culture Shift: Move from a “Blame and Shame” culture to a “Systems Improvement” culture. Focus on why a mistake happened (e.g., poor lighting, fatigue, lack of equipment) rather than who made it.

Implementation Science: The “How-To” for Global Surgeons

Improving safety in RLS is rarely about lack of knowledge; it is about implementation.

The Plan-Do-Study-Act (PDSA) Cycle

For any quality initiative (e.g., reducing SSI), use the PDSA cycle: 1. Plan: Identify the problem and plan a change (e.g., “We will start using the SSC tomorrow”). 2. Do: Implement the change on a small scale. 3. Study: Analyze the data (e.g., “Did we actually use the checklist in all cases?”). 4. Act: Refine the process based on what was learned.

Contextual Adaptation

Guidelines from high-income countries often assume resources that are not present. * Consensus Recommendation: Adapt international guidelines to the local context. For example, if single-use drapes are unavailable, focus on the validated sterilization protocols for reusable linens.

Recommendations for the Global Surgeon

  1. Advocate for Data: Support the development of local surgical registries.
  2. Multidisciplinary Training: Quality is a team sport. Train the perioperative nurse and the anesthesia provider alongside the surgeon.
  3. Address the “Gap”: Focus on the “Safe Surgery Saves Lives” pillars: Safe Anesthesia, Surgical Teamwork, and Infection Prevention.
  4. Sustainability: Ensure that any safety intervention is integrated into the local Ministry of Health framework rather than existing as a standalone “siloed” project.

Conclusion

Surgical quality improvement in resource-limited settings is not achieved by high-cost technology, but by the disciplined application of evidence-based processes, team communication, and consistent data monitoring. By implementing the WHO Surgical Safety Checklist, optimizing SSI prevention, and fostering a culture of safety through M&M conferences, surgeons can significantly reduce the burden of preventable surgical harm globally.

References and Further Reading

  1. Haynes, A. B., et al. (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine.
  2. Meara, J. G., et al. (2015). Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet.
  3. WHO (2016). Global Guidelines for the Prevention of Surgical Site Infection.
  4. Weiser, T. G., & Gawande, A. (2015). Excess Surgical Mortality: Strategies for Improvement. Disease Control Priorities (3rd Ed).
  5. Allegranzi, B., et al. (2011). Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet. ```

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