HSS Training in Ghana Expands Physician Knowledge and Use of Regional Anesthesia During Surgery

• Anesthesiologists Swetha R. Pakala, MD, and Mark A. Brouillette, MD, presented research showing that the Global Health Initiative increased physician knowledge, clinical skills and use of peripheral nerve blocks for extremity surgeries at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana.

HSS Provides New Recommendations for Anesthesia Use During Total Joint Replacement

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA, and colleagues who participated in a year-long consensus project published their recommendations for the type of anesthesia that should be used during total hip replacement and total knee replacement.

Minority, Low Socioeconomic Status Pediatric Patients Getting Ambulatory/Sports-Related Surgeries Are Less Likely to Receive Regional Anesthesia

• Anesthesiologist Kate DelPizzo, MD, found that in New York state, younger pediatric patients, as well as minorities and those with low socioeconomic status, are less likely to receive regional anesthesia during ambulatory surgeries. She emphasized that this disparity in care must be addressed.

Cautious Approach Recommended for Determining Same-Day Discharge After Total Joint Replacement

• Although the overall risk for complications is low, anesthesiologist Jiabin Liu, MD, PhD, found that same-day discharge after total joint replacement may increase the risk for cardiac and pulmonary complications. He urges a measured approach and case-by-case consideration in recommending same-day discharge for patients.

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.

References

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. https://www.asra.com/asra-news/article/154/a-global-regional-anesthesia-curricular. Accessed April 1, 2019.

GRACE will create a standardized platform to design, implement and measure changes associated with a regional anesthesia training program that can be used in any limited-resource setting.

The KATH-HSS partnership was formed to increase use of peripheral nerve block for orthopedic surgical cases.

Swetha Pakala, MD, anesthesiologist at HSS, is founder of the Global Health Initiative in the Department of Anesthesiology, Critical Care & Pain Management at HSS. The Global Health Initiative leads a global health track in which regional anesthesiology and acute pain medicine fellows take part in each year. In 2018, Mark Brouillette, MD, and Patrick Laughlin, MD, joined Dr. Pakala on two HSS-sponsored trips to KATH in West Africa.

Read the full article at ASRA.com.