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HSS Training in Ghana Shows Remarkable Results in Expanding Use of Regional Anesthesia During Surgery

Outcomes of the Global Regional Anesthesia Curricular Engagement (GRACE) program at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana

The Global Regional Anesthesia Curricular Engagement (GRACE) program has shown great success in increasing knowledge, clinical skills and use of peripheral nerve blocks for extremity surgeries at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, according to researchers at Hospital for Special Surgery (HSS) presenting at the 2019 ASRA Annual Meeting.1

The Global Health Initiative of the Department of Anesthesiology, Critical Care, and Pain Management at HSS was founded by anesthesiologist Swetha R. Pakala, MD to support global health ventures such as the GRACE program.

In 2018, Dr. Pakala and anesthesiologist Mark A. Brouillette, MD, (then an HSS fellow) and fellow Patrick Laughlin, MD, took two Hospital-sponsored trips to KATH to pilot GRACE, in which they designed and implemented a tailored teaching program for limited-resource settings; in this case, in Kumasi, Ghana.3

“The great majority of global surgical need is found in limited-resource settings, and many of these conditions are musculoskeletal diseases with which HSS physicians have the expertise to manage,” said Dr. Brouillette. “In today’s world, unfortunately, most healthcare spending is targeted only at high-income populations that can pay for the requisite medical education, research and clinical care. This inequity in resource distribution can result in perioperative mortality rates 100 fold higher in poor countries as compared to the United States. HSS is uniquely poised and committed to provide useful perioperative services in places that are receiving little attention from the rest of the world.”

The impact of the teaching program in Ghana was assessed by examining trainees’ satisfaction with the program, changes in their learning and behavior, and the number and variety of peripheral nerve blocks performed three months before and after the GRACE program.

Before training, KATH and HSS researchers conducted a needs assessment to determine the hospital’s baseline practices as well as what the trainees wanted to learn. An expert panel then made recommendations based on the needs assessment results about which nerve blocks and other topics to teach. The researchers used this information to develop the final curriculum, which included lectures, simulation modules and hands-on instruction during patient care. Out of 15 KATH physicians, 14 participated in the training program.

The researchers found that the training program had excellent results. After the training program, all participating physicians agreed that the training was applicable and worthwhile to their practice, and their pass rate on the clinical pre- and post-test increased from 29% to 86%.

In terms of patient care, use of peripheral nerve blocks as the primary anesthetic for upper extremity surgery increased from 44% to 63%, and the overall number of nerve blocks increased from 48 to 118.

In addition, “while not directly part of the study, one of the most rewarding aspects of the GRACE program was the opportunity to interact with patients and hear their stories,” said Dr. Brouillette. “Seeing patients safe and comfortable after major surgery made the effort worthwhile for many of our KATH and HSS investigators.”

Researchers also found that this program effectively reduced patient costs in this limited-resource setting.2 The gross national income per capita in Ghana is $1,490, and the cost of surgery can often be overwhelming for patients and their families.

Examining hospital price lists and the Ghana National Health Insurance Scheme (NHIS) reimbursement for these procedures, the researchers found that the patient cost of general anesthesia for a three hour procedure with insurance is $101.13, and without insurance is $163.38. In contrast, patient cost of a peripheral nerve block for a procedure lasting three hours is $33.26 with insurance and $64.76 without; patient costs for spinal anesthesia is $32.23 without insurance and $59.36 without.

In conclusion, “the pilot GRACE program at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana was well received by physicians, resulted in higher knowledge and clinical exam scores, and was associated with an increase in the number and variety of peripheral nerve blocks performed,” said Dr. Brouillette. “While these initial results are promising, training and research will need to continue for several years to determine if these changes are sustainable and associated with improved patient-centered outcomes.”

“Our results show that investment in collaborative programs such as GRACE can make a difference in medical education in limited-resource settings. All too often, governments and healthcare institutions undervalue healthcare investments in low/middle income communities. High-income countries do not have direct financial incentive, and low/middle income countries often do not recuperate costs directly from patients. However, if the benefits of programs like ours continue to be measured and reported, we begin to take the necessary steps to change this mindset,” Dr. Brouillette concluded.

The abstract “Design, implementation and measurement of a regional anesthesia training program for limited-resource settings” was highly scored and chosen as a podium presentation for ASRA 2019, and was rated as one of the top 3 abstracts and is being considered for the Philip Liu Award for the Society for Education in Anesthesia (SEA) meeting, which will be held in Denver from April 26, 2019 to April 28, 2019.


1. Benjamin Johnson, Alfred J. Aidoo, Maria A. Hondras, Nana Boateng, Akwasi Antwi-Kusi, William Addison, Swetha Pakala, Patrick Laughlin, Mark Brouillette. “Design, implementation and measurement of a regional anesthesia training program for limited-resource settings.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.

2. Joseph Keaveny, MD, Alfred J. Aidoo, MBChB, Akwasi Antwi-Kusi, FGCS, Mark A. Brouillette, MD and Swetha R. Pakala, MD. “Comparison of Cost for Patients Undergoing Regional Anesthesia Versus General Anesthesia for Orthopaedic Trauma Surgery at Komfo Anokye Teaching Hospital Ghana.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.

3. Brouillette MA, Sakala S, Laughlin P. A Global Regional Anesthesia Curricular Engagement (GRACE) in Ghana. American Society of Regional Anesthesia and Pain Medicine. November 2018. Accessed April 1, 2019.

About HSS | Hospital for Special Surgery

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 14th consecutive year), No. 2 in rheumatology by U.S. News & World Report (2023-2024), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2023-2024). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a fourth consecutive year (2023). Founded in 1863, the Hospital has the lowest readmission rates in the nation for orthopedics, and among the lowest infection and complication rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. In addition, more than 200 HSS clinical investigators are working to improve patient outcomes through better ways to prevent, diagnose, and treat orthopedic, rheumatic and musculoskeletal diseases. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 165 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.