KATH outcomes reporting was limited in surgical logbooks and departmental end-of-year reports, where only all-cause, all-comer mortality was tracked. Deaths were only recorded if they occurred in ORs or PACUs, and timing after surgery (ie, 24 hours or 30 days postoperation) was not specified. From 2011 to 2015, there were 299 deaths recorded per 45,940 anesthetics (including nonoperative cases done for radiologic imaging). POMR was thus 0.65% or 1 death per 154 anesthetics. Only 2 patients died in ORs, whereas 297 died in PACUs. Observations and interviews suggest that PACU mortality was high due to care of critically ill patients in under-resourced PACUs for extended periods of time.
At KATH, there were 10 AAPs, 7 ARPs, 2 physician medical officers (equivalent to interns in the United States), 61 NAs, and 0 anesthesia technicians. All WFSA-recommended personnel for a level 3 hospital8 were present, including clinical officers and specialists in anesthesia and surgery. In 2016, there were 70 AAPs and 22 ARPs in the 10 administrative regions of Ghana, all practicing in urban centers (Figure 2). There were 565 NAs in Ghana also concentrated in major cities.
Interviews provided additional details about KATH workforce. Provider shortage was considered the greatest limitation to safe care. There were too few AAPs to fulfill clinical duties while allowing time for teaching, research, administrative responsibilities, and professional development. Students and physicians reported that anesthesia was an unpopular career choice because earning potential was less than in other specialties. For instance, KATH surgeons could moonlight at private hospitals for additional income, whereas these hospitals preferentially hired NAs instead of AAPs because NA salaries were less expensive. Also, there was less perceived prestige associated with anesthesia because it was viewed as “a job that nurses can do.” Several KATH physicians migrated in recent years: 2 AAPs to the United Kingdom, 1 AAP to Germany, and 1 ARP to Germany. Several ARPs indicated they would migrate if they had the means.
GCPS (a national entity established in 2003) and WACS (a West-African organization established in 1975) were the accrediting bodies for postgraduate anesthesia training. They prescribed standardized curricula based on the British system taught by local faculty at KATH and Korle Bu Teaching Hospital in Accra. WACS required a 3-month rural rotation, which was not adhered to at KATH. Both colleges offered a 3-year membership program for general training leading to the title “specialist” and an optional 2 years advanced or subspecialty fellowship instruction leading to the title “consultant.” Standardized examinations were required for graduation from both colleges, and residents paid testing fees. The Ministry of Health paid residents’ salaries, and the hospital traditionally paid GCPS tuition (WACS tuition was free). Applicants could apply to 1 or both colleges, and completion of either program was equally sufficient to practice in Ghana. Some residents enrolled with GCPS because testing fees were cheaper. Other residents enrolled in both colleges to maximize their likelihood of matriculation. However, a recent increase in GCPS tuition made hospital tuition sponsorship uncertain, which may influence future residents’ preferences. A Continuing Professional Development program was started by Medical and Dental Council in 2008 and requires AAPs earn 15 credits annually participating in various educational activities, professional meetings, and research.
At KATH, 4 AAPs completed postgraduate training in Germany and were consultants of GCPS and/or WACS (by examination). There were 6 specialist AAPs trained in Ghana through GCPS. Lectures based on curriculum content were given by faculty, but residents reported OR teaching infrequent. Independent study resources were scarce. The resident library held a few hard-copy text books, but these were difficult to share. Unreliable Internet access made studying on campus difficult. For these reasons, residents expressed interest in electronic resources that could be used remotely or without Internet access. In addition to lectures, residents benefited from international partnerships. Interviewees appreciated visiting anesthesiologist Jeffrey Peters teaching at KATH the past 18 years. Dr Peters also led an educational exchange program between KATH and University of Utah. One Ghanaian medical student pursued a career in anesthesia after participating in this program.
Two-year Bachelor of Science programs were recently introduced in Ghana to train NAs and were available at 3 institutions: Ridge Regional Hospital in Accra, KATH, and Tamale Teaching Hospital in Tamale. Entry into NA school required high school and nursing school diplomas, as well as 2 years nursing experience. Curricula differed between institutions, but all 3 centers offered training led by physicians and required a passing score on a Medical and Dental Council examination for graduation. NAs were recognized for independent practice in Ghana, though some form of physician leadership was present at most teaching institutions.
Teaching Hospital Resources
KATH anesthesia practice and administration incorporated many key elements. Still, AAP oversight was inconsistent, and NAs and ARPs sometimes cared for patients without supervision. Availability of a preanesthesia clinic is uncommon in LMICs but was useful at KATH to prepare patients for surgery. The same level of physician involvement was not observed in PACUs, where nurses took responsibility for patient management due to a shortage of AAPs. PACU nurses did not have specialized training and often looked after several patients simultaneously. Extended PACU stays, due to CCU deficiencies, increased patient exposure to this hazardous environment. Because almost all recorded deaths occurred in PACUs, routine physician involvement is needed.
KATH infrastructure, while not meeting high-income country standards, was formidable compared to other LMICs.5,19 Improving CCU resources can protect patient safety and alleviate PACU congestion, but funding is presently unavailable. A central oxygen supply was in place, but sporadic failures resulted in patient deaths because backup oxygen cylinders were empty. Prioritizing oxygen tank maintenance is critical to protect patient safety. Obtaining an oxygen concentrator may be helpful. KATH purchased an oxygen concentrator in 2015, but it was lost in a fire before transport to Kumasi.
The supply of WFSA-recommended equipment8 at KATH was good compared to other LMICs.5,19 Notably, disposable items such as masks and endotracheal tubes were cleaned and reused. Devices to warm patients were not available, but ORs were hot due to the tropical climate. Working ventilators in PACUs and the CCU were the most important nonmonitor equipment needed to protect patient safety, and greater funding is needed for their maintenance. Because essential monitors were not always available at KATH, providers consistently relied on physical examination skills to assess patient well-being. While most WFSA-required monitors8 were available in ORs, capnography was absent due to a shortage of disposable components. PACUs were not as well appointed. Increasing the supply of vital signs monitors is an affordable way for the hospital to safeguard patients. A few pulse oximeters produced by Lifebox Foundation had been donated to the hospital. These oximeters cost $250 per unit and come with educational materials.20
KATH had an ample supply of medicines compared to other LMICs,5,19 and most anesthetic and emergency drugs were found without difficulty. A basic supply of medicines and monitors meant providers were not reliant on ketamine-based anesthesia, a practice common in low-resource settings.21 Propofol and thiopental were typically used for induction and isoflurane for maintenance of anesthesia. Halothane was only used for pediatric inhalational inductions. While essential medicines were present, a greater supply of analgesics and antiemetics is needed in PACUs where patients frequently reported poorly controlled pain and nausea. Implementing a nursing protocol can improve postoperative analgesia, but adequate staffing and vital signs monitors are necessary to ensure narcotics are given safely. A modest supply of blood products meant transfusions were limited to a few units per patient, which was inadequate in many cases. High prices and limited funding were obstacles to obtaining medicines. Prices can be 4–5 times higher in Ghana because drugs are not purchased in bulk.22 KATH also had little cash reserve and relied on patient payments for drugs administered today to buy tomorrow’s supply. While National Health Insurance Scheme reimbursed hospitals for anesthesia services, these claims took time to process and covered only a fraction of expenses. Accordingly, patients undergoing elective surgery were regularly asked to purchase drugs at an outside pharmacy before surgery, and providers were disincentivized to administer medicines to patients who could not pay for them out-of-pocket.
KATH performed all WFSA-recommended procedures.8 Obstetric and gynecologic was the most common surgery type, and most cases were cesarean deliveries. Anesthesia providers were rarely involved in labor analgesia, and interviewees reported parturients in Ghana were largely unaware neuraxial blocks were possible. A recent study at a large hospital in Ghana found spinal blocks with 2.5 mg of bupivacaine were effective, safe, and acceptable to laboring parturients; nevertheless, staffing the labor and delivery ward proved difficult.23 At KATH, involvement in labor analgesia would be challenging given the shortage of anesthesia providers and specialized nurses, shortage of vital signs monitors, and high cost of equipment and medications. General surgery was the next most common surgery type and incorporated a diverse range of procedures. Providers were adept at using spinal blocks for major open abdominopelvic operations that would typically be done under general anesthesia in the United States. Providers considered spinals easier to perform and safer than general anesthesia. Orthopedic surgery was the third most common type of operation. Many were done for injuries resulting from road traffic crashes.24 Ultrasound-guided peripheral nerve blocks of the brachial plexus (interscalene, supraclavicular, and axillary) were increasingly used as the primary anesthetic for upper extremity surgeries by AAPs familiar with these techniques. Spinals were still preferred for lower extremity operations because of perceived ease of block placement and the low cost of small volumes of local anesthetic used. In 2012, KATH was designated a WFSA regional anesthesia training center for West Africa because it is one of the region’s only institutions to perform ultrasound-guided techniques and have expert faculty to teach them. We found monthly block volume is rapidly increasing, doubling from 12 to 24 between 2015 and 2016.
From 2011 to 2015, all-cause POMR at KATH was 0.65% or 1 death per 154 anesthetics, with 99% of deaths occurring in PACUs. POMR (with variable definitions) was similar in other LMICs, ranging from 1 death per 74 anesthetics in Liberia6 to 1 per 504 anesthetics in Malawi.25 In sharp contrast, anesthesia-related POMR in the United States was 1 death per 47,800 hospital discharges.26 Inadequate supervision by senior anesthetists, airway mismanagement, aspiration, and insufficient monitoring (especially in recovery areas) were the most common causes of mortality in other LMICs studied.27 Causes of death were not recorded at KATH, but observations and interviews suggest that high PACU mortality was commonly the result of critically ill patients being cared for in understaffed and underequipped PACUs over extended periods of time. KATH leadership recognizes improved PACU and CCU resources can prevent numerous deaths, but limited funding prevents these improvements. Recording causes of death and extending outcomes tracking beyond PACUs has the potential to further elucidate the role of anesthesia in mortality in Ghana.
We describe teaching hospital resources using data sourced from a single tertiary center in West Africa. In contrast, previous capacity reports largely focused on community or district hospitals where patient populations differ and anesthesia physicians are scarce or absent. As such, our results and interpretations may differ from findings at smaller hospitals in Ghana or referral institutions in other LMICs. Nevertheless, many of the challenges present at KATH result from a lack of resources, which is common to LMIC institutions everywhere.
National Workforce and Education
This is the first account of anesthesia physician workforce size and distribution in Ghana. A previous study of 17 district and nongovernment hospitals reported 25 NAs and 0 AAPs.28 We found 70 AAPs in Ghana, with a provider-to-population density of 0.26 per 100,000. Other LMICs surveyed had densities from 0 to 4.9 per 100,000,4 compared to 9 per 100,000 in the United States.29 We also found 565 NAs administered most of the country’s care independently. The problem of too few providers was magnified by their concentration in urban areas. No national entity tracked anesthesia physicians. While a national reporting scheme is advisable, we believe data obtained from Ghana Anaesthetists Society are accurate or within a narrow margin of error because its members are located throughout the country and collectively aware of the countrywide scene.
KATH personnel suggested the provider shortage was the greatest obstacle to safe anesthesia in Ghana. Even though WFSA-recommended personnel8 were present at KATH, their numbers were insufficient to tackle the clinical workload while allowing time for nonclinical pursuits. While AAP-led anesthesia was observed (to a degree) at KATH, NAs practiced independently at outside teaching institutions out of necessity. The unsupervised or partially supervised provision of care by nonphysicians, termed “task shifting” or “task sharing,” respectively, is common in LMICs but controversial; although it may improve access to care and decrease training times and costs, the potential risks to patients are not well understood.2,30
Possible causes of the anesthesia workforce shortage were identified in our study. Interviewees reported anesthesia was an unpopular career choice compared to other specialties, a trend reported in other LMICs.31 At KATH, this unpopularity was related to confusion and controversy about the roles of AAPs and NAs in the provision of care. To improve the perception of anesthesiology in Ghana, it is imperative physicians promote AAP-led care as the gold standard through actions to champion quality education and safe care, lead development of practice guidelines, and participate in health care policy construction. “Brain drain” has been cited as another reason for limited physician numbers.32 This is the phenomenon of LMIC doctors migrating to wealthier countries in search of improved training opportunities, better working conditions, higher wages, and greater political and economic freedoms. Physician migration rates in Ghana are among the highest in the world, with up to 75% of medical school graduates leaving home to practice abroad.33 This is due in part to a medical culture in Ghana promoting migration.34 At KATH, 4 anesthesia physicians left Ghana in recent years to practice in Europe. The WHO introduced a voluntary code of conduct for ethical recruitment of physicians across borders in 2010,35 but migration rates have not fallen.36 To counter migration in Ghana, greater financial investment in the anesthesia workforce is needed to create more training opportunities and provide careers with better pay and access to equipment and medications so that in-country practice is desirable.
Few publications describe postgraduate anesthesia training in LMICs. These reports are necessary to understand the institutions that build workforces. Our research characterizes training in Ghana, which is accredited by GCPS and WACS and administered at KATH and Korle Bu Teaching Hospital in Accra. At KATH, international partnerships supplement formal education.37 Relationships formed between authors of this article led to a contract between KATH and KUMC to share information and resources between institutions. To date, this agreement resulted in 2 residents from KATH travelling to KUMC for clinical observerships and 2 medical students from KUMC visiting KATH for elective rotations.
While standardized, accredited postgraduate anesthesia training in Ghana was present, there is room for improvement. At KATH, residents desired more hands-on teaching by faculty in ORs and PACUs. Faculty dedicated to clinical instruction are crucial to ensure residents master decision-making, procedural, and interpersonal skillsets. Additionally, KATH did not follow WACS requirement for rural training which, if enforced, could lead graduates to practice in these settings where the shortage of physicians is most desperate. The WHO recommends several educational strategies to encourage rural work.38 Hospital sponsorship of postgraduate training was traditionally an asset in Ghana. Regrettably, a recent hike in GCPS tuition threatens this support. KATH is now considering requiring medical officers to work additional years before residency to offset higher tuition costs, a change that could dissuade Ghanaians from pursuing a medical career and worsen migration. KATH residents pointed to a shortage of electronic resources for independent study as another barrier to learning. In response to our inquiry, Stanford Anesthesia Informatics and Media lab generously donated a subscription of Learnly39 to KATH. Learnly is an online curriculum of daily case vignettes with corresponding content lessons, review questions, and flashcards. While this course requires a subscription and Internet access, Update in Anesthesia and Tutorial of the Week are free, downloadable resources available from WFSA.40
Surgical and anesthetic care is inadequate in LMICs, yet little research exists to depict the problem. We describe a teaching hospital’s resources and the national workforce and education in Ghana. Important capacity strengths and weaknesses are presented and discussed. While many necessary improvements require considerable funding and organizational efforts, practical and affordable measures to increase physician oversight, maintain uninterrupted oxygen supplies, keep ventilators operational, make vital signs monitors ubiquitous, and improve outcomes reporting can save lives today.
We thank Society for Education in Anesthesia-Health Volunteers Overseas (SEA-HVO) and Foundation for Anesthesia Education and Research (FAER) for sponsoring this research. We thank Jeffrey L. Peters, MD, PhD, Professor Emeritus at the Department of Anesthesiology, University of Utah for assisting with results interpretation and manuscript review.
Name: Mark A. Brouillette, MD.
Contribution: This author helped design the protocol, with IRB submission, collect/interpret data, and prepare/revise the manuscript.
Name: Alfred J. Aidoo, MBChB.
Contribution: This author helped design the protocol, with IRB submission, collect/interpret data, and review the manuscript.
Name: Maria A. Hondras, DC, MPH, PhD.
Contribution: This author helped with methodological support, data interpretation, and manuscript preparation/revision.
Name: Nana A. Boateng, MGCS, MBChB.
Contribution: This author helped collect/interpret the data and review the manuscript.
Name: Akwasi Antwi-Kusi, FGCS.
Contribution: This author helped with IRB submission, data collection/interpretation, and manuscript review.
Name: William Addison, FGCS, FWACS.
Contribution: This author helped with IRB submission, data interpretation, and manuscript review.
Name: Alec R. Hermanson, BA.
Contribution: This author helped collect/interpret the data and review the manuscript.
This manuscript was handled by: Angela Enright, MB, FRCPC.
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Copyright © 2017 International Anesthesia Research Society
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