- Question: What is the prevalence of intraoperative adverse anesthetic events when anesthesia is administered by medical providers with no >3 months of informal training in the specialty?
- Findings: We found the reported prevalence of intraoperative adverse anesthetic events to be 10% when anesthesia is administered to low-risk patients in district hospitals in Namibia by medical officers with no >3 months of informal training in the specialty.
- Meaning: While this rate may be less than that from anesthesia provided by nonphysician anesthetists in other parts of Africa, if Namibia is to improve surgical capacity at the district hospital level, then better training of anesthesia providers is needed.
Recent publications by the Lancet Commission on global surgery1 and the World Bank2 have drawn needed attention to the current global crisis in surgery and anesthesia and highlighted the need for building capacity in these areas. A critical shortage of anesthesia providers is a significant contributor to patient suffering, and the passing of resolution 68.15 by the World Health Assembly in 2015 aiming to improve access to surgical care and in particular, to “ensure that appropriate core competencies are part of relevant health curricula, training and education,” has highlighted the role of education and training in expanding the anesthesia workforce. However, the best path forward to increase the global anesthesia workforce remains open to debate.3
Many developing countries have no information on the number of surgical procedures performed every year and even fewer attempt to assess surgical or anesthetic outcomes.4–8 Reports have indicated perioperative mortality in low- and middle-income countries (LMICs) to be static over the last 30 years,9 and the incidence of cardiac arrest, possibly a surrogate for anesthetic care more broadly, has been found to be at least twice as high in low–Human Development Index compared to high–Human Development Index countries.10 Research examining system interventions that strengthen surgical capacity and in particular, examination of the safety and quality of various models for provision of anesthesia in LMICs, is desperately needed.5,10–12
Namibia is a politically stable, English-speaking upper middle–income country of South West Africa with a growing economy and good health care infrastructure. However, its sparse population and large distances between population centers mean access to health care is often difficult or delayed, and the quality of care received can often be highly variable. Namibian health indicators such as maternal mortality ratio and under-5 mortality ratio are higher than some low-income countries such as Cambodia, Nepal, and Rwanda.13 Currently there are no specialist training programmes for any medical providers in Namibia, and the majority of health care is provided in rural district hospitals by generalist medical officers. In anesthesia, these medical officers work unsupervised and unsupported after typically 3 months or less of general and informal training in the specialty. While this should be considered inadequate, there are few data available documenting patient outcomes in association with such training. This study was undertaken in an attempt to address this deficiency in the data by assessing the incidence of perioperative anesthetic complications from a low-resource district hospital setting when care is provided by such medical officers.
Approval for the project was granted by the Namibian Ministry of Health and Social Services (Ref 17/3/3) and by the Chief Medical Officer of each of the district hospitals involved, with the requirement for written informed consent by patients waived. Data collection occurred prospectively in 4 study hospitals for a period of 7 months, from June 1, 2016, to December 31, 2016. A standardized protocol was applied to all patients undergoing a surgical procedure at each of the 4 hospitals during the study period, with a range of information collected concerning intraoperative adverse events and perioperative outcomes.
Country-wide Namibia has a system of 29 district hospitals, 3 intermediate hospitals (1 located in the capital Windhoek), and 1 tertiary-referral hospital capable of providing surgical services. A needs assessment was initially conducted at a regional meeting of the Health Professions Council of Namibia, at which representatives of 19 of these hospitals were in attendance. Through this process, 6 hospitals were identified where research into intraoperative anesthetic events, surgical volume, and outcomes could be conducted. Two of these hospitals declined to participate due to inadequate human resources, leaving 4 hospitals that were able to be recruited to the study. These hospitals represented distinct patient populations from geographically separate parts of the country.
Gobabis District Hospital is a 170-bed hospital located to the east of the capital Windhoek and is the only hospital capable of providing surgical services to a regional population of just fewer than 73,000. It is staffed by 5 general medical officers, of whom 3 routinely provide anesthesia, and none have had >3 months of informal training in anesthesia.
Mariental State Hospital is a 120-bed hospital located in the central south of the country and is one of 3 hospitals in the region capable of providing a surgical service. Of these hospitals, Mariental is the least busy in terms of its surgical caseload. It is staffed by 5 medical officers, of whom 2 provide anesthesia, and none have had formal training in this specialty.
Otjiwarongo District Hospital lies in the mid-north of the country and is a 170-bed hospital staffed by 8 general medical officers. It is the largest of 3 hospitals providing surgical services to a regional population of approximately 140,000. Similar to other district hospitals in the study, none of its medical officers have had >3 months of informal training in anesthesia.
Tsandi District Hospital services a small town of approximately 20,000 people in the far north of the country. Normally, it is staffed by 3 medical officers; however, after successful data collection for the month of June, one of the doctors resigned, which forced the closure of its single operating theater. Subsequently, another medical officer has now also left the country, and no further surgery occurred at this hospital during the study period.
The study hospitals were all government-funded district hospitals of comparable size and staffed by nonspecialist medical officers in surgery and anesthesia. These medical officers have undergone 2 or 3 months of work experience in anesthesia at either the tertiary-referral hospital in the capital Windhoek or at an intermediate-level hospital in the north of the country. Their experience comprised clinical service provision supervised by other nonspecialist anesthesia providers of varying (but often limited) experience, and informal tutorials in topics relevant to anesthesia practice. No formal curriculum for training was followed, and at the completion of their clinical rotation, there was no formal assessment of knowledge or skills acquired. The medical officers providing surgery at the district hospitals were similarly trained, undergoing clinical rotations of 2–3-month duration at the larger hospitals in the country, with an apprenticeship-style experience based around supervised clinical service provision. They also completed no formal assessment of knowledge or skills before working unsupervised in the district hospital setting.
All patients undergoing a surgical procedure at each of the 4 hospitals during the study period had a range of information collected via a standardized protocol and data entry form. A hospital record number was the only patient identifier recorded at the time of data collection, and this was removed when the data were subsequently collated into a spreadsheet for analysis. For the purposes of the study, a surgical procedure was defined as “suture, incision, excision, manipulation, or other invasive procedure that usually, but not always, requires local, regional, or general anesthesia.”6
The recorded information consisted of patient demographics including age, gender, American Society of Anesthesiologists (ASA) status, and comorbidities including human immunodeficiency virus status. Information concerning the surgery included the type of surgery (by surgical specialty) and body region, urgency of the procedure (as either routine/elective or urgent/emergency), and the type of anesthesia given. Recording of intraoperative events included the occurrence of difficult or failed intubation, hypoxia, aspiration, hypotension, hemorrhage, arrhythmia, and/or cardiac arrest. Hypoxia was defined as a drop in oxygen saturation below 90% on pulse oximetry for any length of time, and hypotension was defined as a drop in systolic blood pressure ≥20% of the patient’s preoperative value. Hemorrhage was defined as blood loss >10% of the patient’s weight-based calculated blood volume.
Postoperatively, the occurrence of complications was recorded as diagnosed clinically by the treating medical officers. Cardiovascular complications recorded were myocardial infarction, pulmonary edema, stroke, arrhythmia, pulmonary embolism, and cardiac arrest. Other complications recorded included postoperative hemorrhage, pneumonia, kidney injury or failure, and “other complication.” Finally, overall patient outcome was recorded as death on the day of surgery, death in hospital, or discharge home alive, with this outcome being applied to all patients who had undergone a surgical procedure during the study period.
Physical collection of data occurred in a paper-based format. An electronic data collection tool was specifically written for this study for use on Android mobile phones, but uptake by the medical officers involved was negligible and it was abandoned. Paper-based data collection consisted of a 2-page questionnaire completed by the anesthesia provider during surgery and placed into the patient’s medical record. The final page of the questionnaire was completed at the time of patient discharge from the hospital by the responsible medical officer. Not all hospitals in the study had the capacity to print their own data collection forms and to input the data into a spreadsheet for analysis, so this part of the process occurred at Gobabis State Hospital. The data collection forms were printed at Gobabis and sent by mail to the participating hospitals, and after completion at the end of each month, they were returned by mail to Gobabis for input into an Excel spreadsheet. Where possible, the data entry person at Gobabis attempted to correct missing data before entry into the spreadsheet by seeking a review of the patient’s medical history from the contributing hospital. However, this practice was not consistent, and some deficiencies in the data remain.
Collected data were entered into spreadsheets using Microsoft Excel (Microsoft, Redmond, WA), then collated centrally and analyzed using STATA/SE-14 statistical software (StataCorp, College Station, TX). Analysis is presented as descriptive statistics, with the exception of assessment of intraoperative events. Here, hospitals were compared using 1-way analysis of variance with Bonferroni correction due to 3 primary end points.
Table 1 presents a summary of the surgical data. A total of 737 surgical procedures were performed in the study hospitals over the period June through December, which included a nationwide theater closure of 3 weeks for the Christmas period. Gobabis and Otjiwarongo State Hospitals both averaged 44 procedures per month, while Tsandi District Hospital performed 40 procedures in the month of June before its operating theater closed. Mariental Hospital was the quietest, with an average of 12 procedures per month, the majority of which were related to obstetrics. Across all hospitals, the average patient age was 27 years, with a range from 1 to 77 years, and 98% of patients were classified as ASA I or II. The majority of patients requiring surgical procedures were female (83%). Table 2 illustrates the number of procedures performed at each hospital by month.
A significant proportion of the surgical workload of these hospitals (72%) was in the area of obstetrics and gynecology, consistent with the high proportion of females in the patient population. Of this caseload, more than half (51%) were treated for urgent obstetrics (Table 3). General surgery and orthopedics constitute a relatively small proportion of the surgical caseload (12% and 3%, respectively). In the case of general surgery, this was usually in the context of an elective/planned procedure (70 of 89 total procedures), whereas orthopedic procedures were usually more urgent (12 of 22 total procedures).
Adverse intraoperative events occurred in 76 (10%) surgical procedures; of these, 53 (70%) were due to intraoperative hypotension, occurring in 7% of all surgical procedures. Seventy percent of the incidents of hypotension were in the context of obstetrics and spinal anesthesia. Other intraoperative events were less common and included hypoxia (9), hemorrhage (10), arrhythmia (7), and difficult or failed intubation (4).
As illustrated in Table 4, of the 9 reported incidents of hypoxia, only 1 occurred in association with a difficult or failed intubation, which was in the context of an elective cesarean delivery. One incident of hypoxia occurred in association with spinal anesthesia (Table 5), also in the context of a cesarean delivery. Of the 8 reported incidents of hypoxia in association with general anesthesia, 4 occurred during cesarean delivery, 3 were related to urgent gynecological procedures, and 1 was in the case of a 3-year-old boy having an elective circumcision. Of the 4 reported incidents of difficult or failed intubation, 3 were in the context of anesthesia for cesarean delivery, and another was related to a 5-year-old girl having an elective ear, nose, and throat procedure. There were no recorded incidents of aspiration and only 1 reported incident of cardiac arrest intraoperatively. The cause of this cardiac arrest was not recorded, but the patient was resuscitated successfully.
There were no recorded incidents of intraoperative events occurring at Mariental State Hospital, which is statistically significant when compared to the other 3 hospitals in the study (P < .01). It is worth noting that of the 82 surgical procedures performed at this hospital during the study period, 81 were performed for obstetric reasons, and of these, 89% were performed under spinal anesthesia. The incidence of intraoperative events was not statistically different between the other 3 hospitals.
Postoperative complications were reported infrequently with surgical infections occurring in 3 cases, subclassified as 2 superficial and 1 deep surgical infection. There was 1 case of postoperative hemorrhage and another 2 cases of an undefined “other complication.” Overall, the reported surgical complication rate was 1.6%.
There were no reported patient deaths during the study period, although anecdotally, there was 1 death that was not captured in the data. This patient was a male in his early 30s who underwent exploratory laparotomy in which advanced metastatic malignancy was diagnosed and was subsequently provided with palliative care before dying in hospital several days after surgery. Discussion with the medical officers involved with the study at the participating hospitals has anecdotally confirmed that no other patient deaths occurred. If this anecdotal death is included, the overall perioperative in-hospital mortality rate across all 4 hospitals is 1.4 per 1000 surgical procedures.
This study contributes important information regarding intraoperative anesthetic events and surgical volume from a high middle–income country of sub-Saharan Africa. The main finding of our study was that an anesthetic event occurred in 10% of surgical procedures when anesthesia was provided by medical officers with no >3 months of informal training in the specialty. These events all had the potential to contribute to an adverse outcome for the patient, and a proportion may have been avoidable with greater training of the anesthesia providers involved.
The literature describing complications in anesthesia and potential “near misses” from LMICs is sparse. A systematic review performed by Bainbridge et al10 included 87 studies, but few, if any, had sufficient details of outcomes beyond mortality and cardiac arrest. A more recent publication by Gibbs et al14 found respiratory and/or airway events to occur in 27% of anesthetic incidents; however, no denominator was available to give a proportion of anesthetics given. Other studies have found that the incidence of hypoxemia under ketamine anesthesia administered by nurses to be 17% in the absence of supplemental oxygen15 or 6.5%–17% when administered by nonphysician anesthetists in Malawi.16 In our study, hypoxia and/or difficult intubation occurred in 4.3% of all general anesthetics given and comprised 17% of anesthetic incidents. Globally, the anesthesia workforce is highly variable and includes clinical officers, nurses, general medical officers, and medical specialists providing anesthesia with varying levels of supervision and support.17,18 To our knowledge, this is the first publication describing intraoperative adverse events when anesthesia is provided by informally trained medical officers in LMICs.
The occurrence of hypoxia intraoperatively warrants further consideration and discussion. Pulse oximetry monitoring and supplementary oxygen were routinely available in the study hospitals, and the occurrence of hypoxia intraoperatively is unexplained. Esophageal or endobronchial intubations are potential explanations, although the choice of general anesthesia for an elective cesarean delivery that resulted in a difficult intubation and hypoxemia may indicate a lack of formal training in anesthesia as a contributing factor.
The majority of intraoperative events were due to hypotension, occurring most often in the context of obstetrics and spinal anesthesia. Left-lateral tilt is used routinely for cesarean deliveries, but vasopressors were limited to ephedrine only in district hospitals. This rate of hypotension may reflect a lack of choice in vasopressor or a lack of its use appropriately.
While there is little published literature pertaining to perioperative outcomes from anesthesia in LMICs, what information does exist is often restricted to describing mortality.9,19–21 This study found a perioperative death rate of 1 per 737 surgical procedures, and importantly, the avoidable anesthetic death rate was zero.
Surgical volume recorded was highly variable between district hospitals (Table 2), ranging from a maximum of 102 cases in 1 month at the largest hospital in Otjiwarongo to 8 cases in the smaller hospital in Mariental. An absence of surgical capacity occurred for 6 months at Tsandi Hospital after staff resignations forced the closure of its operating theater, and while not contributing any quantitative information to this study, nevertheless qualitatively reflects the reality of surgery in Africa and the many complex factors that may have an influence on surgical capacity and patient outcomes.
Significant variation occurred in the surgical caseload undertaken by Otjiwarongo State Hospital, ranging from 102 cases in September to 17 cases in July. Variability of surgical need in the local population is unlikely to account for such a range, and while under-reporting during the quiet months is another potential explanation, more likely is the limited reserve in surgical capacity often encountered at the District Hospital level. If the number of medical officers with the skills and training to perform surgery and anesthesia at these hospitals are limited, as they often are, then surgical capability may be severely affected by staff absences due to sickness or leave. In these circumstances, the surgical need by the patient population is not altered, but rather transferred to other hospitals at increased burden to the health care system. Staff absences at Otjiwarongo and neighboring hospitals may account for the wide range in surgical cases performed between September and July.
The Lancet Commission findings suggested a minimum of 5000 surgical procedures per 100,000 population as a goal for expanding surgical services at the district hospital level.1 Both Gobabis and Otjiwarongo District Hospitals are 170-bed facilities that performed an average of 44 surgical cases per month for the study period. Gobabis is the only hospital within the government municipality of Omaheke capable of performing surgery, serving a population of approximately 73,000 people. Based on these numbers, this represents an average of 726 procedures per 100,000 population per year. In comparison, Otjiwarongo District Hospital is the largest of 3 hospitals in the region able to provide surgery to a population of approximately 140,000. Assuming its surgical capacity was equal to, and not larger than, the other hospitals in the region, it would be performing an average of 1116 procedures per 100,000 population per year. While comparable to, if not slightly better than, retrospective estimates of surgical volume in other sub-Saharan countries,22 these figures are still significantly below that recommended by the Lancet Commission.
The Lancet Commission has also suggested that 3 key procedures are identified to reflect surgical capacity more generally at the district hospital level; these being cesarean delivery, laparotomy, and treatment of open fracture.1 While reasons for low surgical capacity are often multifactorial, the low volume of orthopedic surgery combined with a high proportion of cesarean deliveries23 is another indicator that the district hospitals involved in this study are failing to meet the Lancet Commission goals. It should be noted that 98% of patients receiving surgery in this study were classified as ASA I or II. This is a result of patient selection by the medical officers responsible, as patients with more comorbidities are likely to be referred to intermediate- or tertiary-referral hospitals elsewhere for surgical care. If Namibia is to reach the Lancet Commission goals of surgical volume and procedure type at the district hospital level, intraoperative adverse anesthetic events and poor patient outcomes are likely to increase unless improved training of anesthesia providers is addressed.
A significant limitation of this study is the reliability of data collection, with likely underreporting of adverse anesthetic events and outcomes. Reporting bias is also a potential limitation of this study, and the recording of intraoperative events at Mariental State Hospital is an example. In a hospital with a high proportion of obstetric surgery under spinal anesthesia, the absence of intraoperative hypotension is surprising. While this may reflect exceptional clinical management, it is perhaps more likely to be due to reporting bias. However, the involvement of >1 hospital with deidentified information that was collected prospectively serves to reduce this source of bias. It is possible that deidentifying the hospitals in addition to the patients may have further reduced this source of bias. Finally, the involvement of 4 different hospitals serving diverse and geographically separate patient populations, and over a prolonged period of 7 months, increases the applicability of our findings to the wider population of Namibia more generally.
Information concerning intraoperative events and complications of an anesthetic nature from LMICs is severely lacking in the literature. We found the reported prevalence of intraoperative adverse anesthetic events to be 10% when anesthesia is administered to low-risk patients in district hospitals in Namibia by medical officers with no >3 months of informal training in the specialty. While this rate may be less than that from anesthesia provided by nonphysician anesthetists in other parts of Africa, if Namibia is to improve surgical capacity at the district hospital level, then better training of anesthesia providers is needed.
The investigators would like to acknowledge the medical officers and staff who facilitated data collection: Dr Shekimweri, Dr Lumbala, Dr Mutombo, Dr Tshibumbu, Dr Limo, and Sr Haingero, as well as the administrative staff at Gobabis State Hospital for facilitating the process. The authors would also like to thank Professor J. Sharman at the School of Medicine, University of Tasmania, for his help and input into the writing of the manuscript.
Name: Andrew J. Ottaway, BMBS, MPH, FANZCA.
Contribution: This author helped design the study, perform the data analysis, and write the manuscript.
Name: Leonard Kabongo, MD, MPH MGH(C).
Contribution: This author helped design the study, collect the data, revise the manuscript, and helped with hospital recruitment,
This manuscript was handled by: Angela Enright, MB, FRCPC.
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