Recent articles have highlighted deficiencies in the anesthesia workforce in low- and middle-income countries (LMICs).1,2 There are often too few providers, who are overworked with little opportunity for development of subspecialty knowledge and skills, or for participation in other continuing professional development. It is not surprising that perioperative morbidity and mortality in this setting are high.3 Short subspecialty courses provide a potential mechanism for improving knowledge and skills in areas of anesthesia practice such as trauma management, pain management, obstetric anesthesia, and pediatric anesthesia which account for a large proportion of the workload in LMICs.
In this narrative review, we discuss 4 short-duration courses aimed at improving subspecialty practice in LMICs:
- Primary Trauma Care (PTC)
- Essential Pain Management (EPM)
- Safer Anaesthesia From Education (SAFE)–Obstetric Anaesthesia (SAFE-OB)
- Safer Anaesthesia From Education (SAFE)–Paediatric Anaesthesia (SAFE-Paeds)
We recognize that there are limited published data on the true impact of these courses, especially their ability to decrease morbidity and mortality. Out of necessity, much of this article is based on unpublished data from the World Federation of Societies of Anaesthesiologists (WFSA), personal communication from course organizers and participants, and the authors’ personal experiences.
RATIONALE
Why PTC?
Injuries kill nearly 6 million people every year—more than HIV/AIDS, malaria, and TB combined.4 Poorer countries are affected disproportionately. While LMICs account for approximately 75% of the world’s population, 90% of trauma deaths and disability occur in them. Poor preventative efforts, a higher incidence of injuries secondary to road traffic crashes, violence or war, and limited access to skilled health care all contribute to this burden.5–7
Advanced Trauma Life Support (ATLS) was developed to train health care workers in a systematic approach to trauma care. It is considered the standard of care for the first “golden” hour in trauma centers around the world.8–11 Unfortunately, it is relatively expensive to run and assumes access to advanced technology that limits its acceptance and penetration in LMICs. PTC was developed to fill this gap and provides a system for trauma management that can be fully implemented and adapted to the reality of the LMIC environment.12–14
The key aims of PTC are as follows: (1) to train front-line health care professionals in a systematic approach to caring for acutely injured patients; (2) to provide affordable, appropriate training that is adaptable to a variety of needs and resources; and (3) to create local sustainability without continued external input.12
Why EPM?
Unrelieved pain is a major global health care problem. In 2009, the World Health Organization estimated that 5 billion of the world’s 7 billion people live in countries with little to no access to controlled analgesic medicines or treatment for moderate to severe pain.15,16 This problem is magnified in LMICs because of an increased burden of painful disease. Seventy percent of the world’s cancer deaths and 99% of HIV deaths occur in LMICs, yet only 6% of the world’s opioids are consumed in these countries.17,18 What does this mean for patients living in LMICs? Each year, tens of millions of patients suffer because of inadequate treatment of painful diseases, injuries, or conditions such as terminal cancer (5.5 million), end-stage HIV/AIDS (1 million), injuries caused by accidents and violence (1 million), postoperative pain, and chronic painful illnesses such as arthritis and diabetic neuropathy. In addition, approximately 110 million women give birth each year, most with minimal or no pain relief.17,18
Pain management skills are critical to the well being of our patients yet education in pain management is often given a low priority in high-income countries (HICs) as well as in LMICs. The APPEAL study19 surveyed medical schools in 15 European countries and found that <20% of medical schools offered dedicated practical teaching in pain management. In an International Association for the Study of Pain survey of LMICs,20 the lack of pain education was identified as the main barrier to good pain management.
The EPM program was developed for health care workers and health care students working in LMICs to fill this void and to provide accessible, adaptable, and relevant education in pain management. Its aims are as follows: (1) to improve pain knowledge by teaching health care workers how to recognize, assess, and treat pain; (2) to provide a simple framework for managing pain; (3) to address pain management barriers; and (4) to train health care workers to teach pain management.21
Why SAFE-OB?
High maternal mortality rates are a major problem in LMICs. Estimates from 2015 suggest that roughly 303,000 women died during and following pregnancy and that most could have been prevented.22 Approximately 80% of these deaths occur in sub-Saharan Africa and South Asia and are comprised mainly of adolescents and poor women. The most common reasons for these deaths are severe bleeding, infections, hypertensive disorders (preeclampsia and eclampsia), complications from delivery, and unsafe abortion.23 These conditions are compounded by other factors including late presentation and inadequate care in the hospital setting.24
Skilled anesthesia providers can play a role in addressing high maternal mortality rates because they are essential for providing safe anesthesia during cesarean delivery, resuscitating the mother and newborn during obstetrical crises, and optimizing the pregnant patient for obstetric intervention.24 However, there are often not enough skilled providers in LMICs. Fully-trained physician anesthesia providers (PAPs) are scarce and usually found only in the large medical centers.1,25 The majority of anesthetic care is commonly provided by non-physician anesthesia providers (NPAPs) (eg, nurse anesthetists, anesthesia technicians, or anesthetic officers) who may have had between 6 months and 3 years of basic anesthetic training after high school or nursing school, or have just learned “on the job.” NPAPs typically work independently without supervision by a trained anesthesiologist. In general, both PAPs and NPAPs have little support, a lack of mentorship, paucity of resources to deliver a safe anesthetic,26 and few or no opportunities for continuing medical education or subspecialty training. Because of this, their ability to prepare for and manage the complications of pregnancy is limited.
The aim of SAFE-OB is to provide refresher training for both PAPs and NPAPs in the essentials of obstetric anesthesia in resource-limited countries. It is not intended as a comprehensive training course in anesthesia but emphasizes basic principles, and vigilance and competence in essential skills.
Why SAFE-Paeds?
In LMICs, over 40% of the population is under the age of 14.27 It is estimated that 85% of these children will require surgery by the age of 15.28 Children require surgery for a range of congenital conditions including anorectal malformations, clubfoot, esophageal atresia, congenital heart disease, cleft lip and palate, and increasingly, for traumatic injury resulting from burns or road traffic crashes.
Children present a challenge for many surgical and anesthesia providers, and this is especially true in the LMIC setting. Not only are there few providers but also there are even fewer who have additional training to help manage children, and hospitals are poorly equipped to care for them.29 Similar to obstetric patients, children present late and with high severity of illness. It is not surprising that perioperative morbidity and mortality are high compared to HICs.3
Based on the success of the SAFE-OB course, the SAFE-Paeds course was developed to meet the pediatric need. Its aim is to provide subspecialty training in pediatric anesthesia for both PAPs and NPAPs working in the LMICs to a level of practice whereby they can deliver vigilant, competent, and safe pediatric anesthesia for common surgical conditions.
CONTENT, STRUCTURE, AND COSTS
The content of PTC, EPM, SAFE-OB, and SAFE-Paeds is outlined in Table 1, and the course structure is outlined in Table 2.
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Table 1.: Overview of Course Topics
Table 2.: Course Structure and Information
The 4 courses have much in common with regard to their structure and educational approach. They are all short (1, 2, or 3 days), and this short duration is important in environments where participants cannot take much time off clinical work because of high workload and low staffing levels. They are all modular, allowing for flexibility and adaptation to the local setting. They are all “off-the-shelf” courses that have been designed for early handover to local instructors. Course materials are freely available for download.
The courses are designed to be interactive, with much of the learning occurring in small groups. A variety of educational modalities are used including lectures, skill stations, small group discussions, and simulated clinical scenarios. The courses all emphasize a systematic approach to caring for the patient, and the simulated scenarios provide an opportunity for participants to integrate knowledge and skills. Emphasis is placed on safety and the importance of communication and non-technical skills in the clinical setting.
PTC and EPM are often run as multidisciplinary courses and involve a range of health care workers. In many areas of the world, they are also being used to teach undergraduate medical and nursing students. SAFE-OB and SAFE-Paeds were designed as refresher courses for anesthesia providers (both PAPs and NPAPs) with practical experience. However, more recently, SAFE-OB courses in Bangladesh and Niger have also included obstetricians and midwives as participants (Angela Enright, personal communication, October 1, 2017).
The teach-the-teacher (TTT) model is a key element to the sustainability of the programs. A ½ to 1-day instructor course is an integral component of all of the short courses presented. This allows for rapid expansion of the number of local instructors and early handover to these instructors. Potential instructors are identified and invited to participate in an interactive instructor workshop where they are taught the skills necessary to run their respective course. Also included are teaching skills such as how to give a lecture, how to teach a skill, and how to lead a discussion. Ideally, these newly trained instructors have an opportunity to immediately run a follow-up course under the guidance and mentorship of their trainers. While visiting faculty often coordinate the initial training, the model encourages the newly trained local team to take ownership, adapt the course to suit local conditions, and run future courses.
By design, monitoring and evaluation are incorporated into the 4 courses. They all include pre- and postcourse tests of knowledge as well as faculty and participant feedback. PTC, SAFE-OB, and SAFE-Paeds also include a pre- and postcourse skills test or a simulated scenario where participants are able to demonstrate that they are able to put their new knowledge and skills into practice. PTC has incorporated a pre- and postcourse confidence matrix evaluating participant’s confidence managing a variety of trauma situations. EPM includes a brainstorming session to identify barriers to pain management and participants then discuss strategies for overcoming these barriers.
EPM, SAFE-OB, and SAFE-Paeds ask participants to contemplate changes they can make once back at their home hospital. Logbooks have been used with some SAFE-OB and SAFE-Paeds courses to encourage participants to actively reflect on how the course has directly impacted patient safety at their home hospitals. Peer collaboration is actively promoted during all 4 courses, and practitioners who work in close proximity are encouraged to consult one another to find local solutions to improve care.
The initial start-up costs for PTC, SAFE-OB, and SAFE-Paeds can be as high as $20,00030,31 (WFSA, personal communication, August 15, 2017), which covers airfares and accommodation for the external faculty, the venue and printing costs, and the purchase of course equipment. Subsequent courses can be run for much less as the equipment purchased for the initial course is usually left in country, and there is little to no reliance on external faculty. The cost to run an EPM course is less than the other courses because not as much equipment is required. The initial course typically costs $5000–$7000 depending on how far the external instructors need to travel; however, after the initial course, with local ownership and faculty, the cost can be as little as few hundred dollars. While these courses are usually free for the participants, course coordinators in some parts of the world may charge a nominal registration charge to cover printing and/or catering costs for participants. Local funding is sometimes provided by government or non-governmental organizations for some course costs, for example, participant travel and accommodation (ANZCA, personal communication, August 15, 2017)
COURSE PROGRESS
Primary Trauma Care
The first PTC course was held in Fiji in 1997 with the support of the WFSA. Since then, the course has been taught in >70 countries, has been translated into 14 languages, and has trained tens of thousands of people in Asia, Africa, and Latin America.13,32 The Primary Trauma Care Foundation was established as a registered UK Charity in 2006 and today provides governance for all PTC courses worldwide.14
While there are no direct patient outcome data, over the last 4 years, the course model has been validated by a number of studies.33–36 PTC participants demonstrated improved knowledge of trauma care and improved confidence in trauma scenarios. However, it is unknown how this translates into improved clinical care for trauma victims. Unlike ATLS where knowledge has been shown to begin to decline after 6 months,37 late follow-up after participating in a PTC course suggests that knowledge is retained after 1 year.33
Essential Pain Management
Since its inaugural course in Papua New Guinea in 2010, EPM has been taught in over 50 countries worldwide—the Pacific region, Asia, Africa, Europe, North America, and Central and South America. The workshop has been translated into 7 languages: Spanish, French, Russian, Mongolian, Thai, Vietnamese, and Bahasa Indonesian.
Over 8500 people have participated in the 1-day workshop and approximately 1200 instructors have been trained (ANZCA, personal communication, August 21, 2017). These numbers are likely to significantly underestimate the numbers trained because it has not always been possible to collect data on participants trained during courses organized by local instructors.
The growth of EPM in Latin America gives a good illustration of the snowball effect of the early handover to local instructors. In 2012, a series of courses was held in San Pedro Sula, Honduras, and 34 instructors from Latin American countries were trained. These instructors have subsequently introduced EPM into 13 countries in Latin America (Guatemala, Nicaragua, El Salvador, Panama, Costa Rica, Dominican Republic, Colombia, Venezuela, Ecuador, Peru, Argentina, Paraguay, and Mexico), run 35 courses with 920 attendees, and there are now 121 trained instructors (Carolina Haylock Loor, personal communication, August 15, 2017).
The ultimate goal of the EPM course is to improve pain education that results in improved care of individual patients and society as a whole. Realistically, it has not been easy to measure the impact of EPM, but there have been many anecdotal examples of its impact, for example, inclusion of EPM training in the undergraduate medical curriculum, introduction of pain management protocols for different pain types, and inclusion of oral morphine in the hospital formulary (Roger Goucke, personal communication, August 21, 2017). There is a lot of scope for good qualitative research looking at changes in pain management practice following EPM training and a number of research initiatives are in progress to better evaluate this.
Safer Anaesthesia From Education—Obstetric Anaesthesia
Since 2011, the SAFE-OB course has trained over 1500 anesthesia providers in 21 countries in Latin America, Southeast Asia, and Africa. While the data showing short-term improvements in knowledge and skills are promising (WFSA, personal communication, August 15, 2017), long-term impact related to practice improvements with improved clinical outcomes is much more challenging to assess. A 6-month follow-up study was performed in Rwanda that included site visits to participants’ home hospitals, interviews to assess the clinical impact of the course, review of logbooks, feedback, and suggestions for improvement. The data suggest that the course was well received and there were positive changes in clinical practice as well as knowledge retention. Specific areas of practice improvement identified included improved management of spinal anesthesia, improved management of the patient with preeclampsia, and a systematic approach to the difficult airway.38 A similar follow-up study in Zambia found that, although knowledge declined at 12 months, skill assessments (rapid sequence induction, maternal basic life support, newborn life support, and management of an eclamptic seizure) showed improvements compared to precourse and 6-month assessments. This was possibly due to anesthesia providers transferring new skills training during the SAFE-OB course to frequently encountered scenarios in the workplace with sequential improvements from repeated performance (Lowri Bowen, David Snell, personal communication, October 1, 2017).
These findings suggest that SAFE-OB is effective in promoting knowledge translation and positive changes in clinical practice.38 Participant feedback at the end of these courses suggests growing confidence and empowerment from the knowledge and skills learned on the course. Many participants report that they had never previously had an opportunity for continued professional development or interest in their career development. Exposure to the SAFE-OB course invigorated them and gave them a real sense of purpose and empowerment.38
Safer Anaesthesia From Education—Paediatric Anaesthesia
SAFE-Paeds is the newest of the 4 short courses presented. In 2014–2016, SAFE-Paeds trained close to 800 anesthesia providers in Southeast Asia and Africa (WFSA, personal communication, August 15, 2017) with future courses already planned for India and Latin America. Similar to the SAFE-OB course, the pre- and postcourse knowledge and skills report improvements in short-term knowledge and skills. Participant feedback at the end of the courses has been overwhelmingly positive. There is currently no published long-term evaluation of this course, but a 6-month follow-up study is currently underway in Kenya (WFSA, personal communication, August 15, 2017).
With the success of the SAFE courses and in anticipation of more being developed, a SAFE Steering Group has been established to help oversee the operational delivery of the SAFE programs, guide future SAFE course strategy, and provide governance with reporting to the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and WFSA.
DISCUSSION
Successes
Short courses such as PTC, EPM, SAFE-OB, and SAFE-Paeds offer a practical approach to delivering additional training for anesthesia providers working in LMICs. They have been rapidly adopted for use by many anesthesia providers in LMICs, and between them have trained thousands of providers in a relatively short time30,31 (WFSA, personal communication, August 15, 2017). Reports suggest that these courses are, at least in the short term, effective in improving participants’ knowledge and skills.21,32,38
The potential benefit of short subspecialty courses goes far beyond just increasing the subspecialty knowledge and skills of an individual anesthesia provider. The courses appear to have much wider benefits for the anesthesia community. For example, the TTT model, while promoting sustainability, helps to develop local educators and introduces new teaching methods into the community. With early handover, there is development of a cadre of local teaching leaders who are able to offer local input into course development. Eventual course ownership by the community is encouraged and is critical to course relevance and sustainability. This process has helped to raise the profile of anesthesiologists as teachers. For example, the development of PTC in the Pacific region saw the growth of a group of medical teachers, led by anesthesiologists, who introduced PTC throughout the Pacific. This gave anesthesiologists greater visibility in the medical school, hospital, and the region as a whole. Similarly, in Kenya, the expansion of SAFE-OB and SAFE-Paeds throughout Kenya has been led by the Kenyan Society of Anaesthesiologists.
The TTT model has resulted in a “snowball” or “cascade” effect whereby a relatively small number of courses have generated a large number of local instructors with the practical experience to run many courses with minimal or no external support. From a practical standpoint, this helps to decrease program costs because of less reliance on external faculty. After an initial series of courses, costs are relatively low, and the programs are seen as good value for money (Smile Train, personal communication, August 31, 2017). This has helped when applying for support from external funders.
In some countries, the courses have contributed to a change in educational culture and the growth of continuing professional development. For example, in Kenya, before the introduction of SAFE-OB and SAFE-Paeds, there were few opportunities for NPAPs to participate in any type of refresher course training. The introduction of SAFE courses by anesthesiologists highlighted deficiencies in NPAP education and led to the Kenya Society of Anaesthesiologists (KSA) prioritizing these educational opportunities for NPAPs (Susane Nabulindo, personal communication, October 1, 2017).
Short subspecialty courses have helped to strengthen professional networks and break down barriers between health workers. There are opportunities for mentoring and ongoing contact between external and local instructors, as well as a strengthening of networks within a country or region. The courses also provide opportunities for increased interaction, understanding, and cooperation between the PAPs and NPAPs, and, in some cases, between members of the wider health care team. For example, the involvement of the obstetricians and midwives in SAFE-OB in Bangladesh and Niger has been an important first step in improving teamwork and breaking down silos (Angela Enright, personal communication, October 1, 2017). An unexpected but positive outcome after the introduction of SAFE-Paeds in East Africa was the establishment of a WhatsApp Group, “Anaesthesiologists Africa,” following the course that allowed continued mentoring and networking, and additional opportunities for learning (WFSA, personal communication, August 15, 2017).
Challenges
Currently, the main challenge for all 4 courses is providing evidence to show that they are making a difference to patient care. A considerable amount of time and effort has gone into their development, yet there are little published data on their impact. While it is relatively easy to measure the numbers trained, or the improvement in short-term knowledge and skills, good qualitative research measuring knowledge translation and the ability to change clinical practice is much more challenging. This is true with many educational courses, including ones developed in HICs with considerably more resources. ATLS, for example, has been shown to significantly improve knowledge, clinical skills, and decision-making skills in participants, but there is no clear evidence that ATLS training reduces death and disability in trauma patients.10,11 There is some good qualitative evidence to show that SAFE-OB courses offered in Rwanda have been able to affect change in practice but it is unknown whether this translates to decreased morbidity and mortality.38 While the lack of published data does not discredit the educational value of the courses, it is important that more longitudinal research studies combining good qualitative and quantitative data are done to help us determine the true impact of the courses on patient care and patient outcomes.
Are the courses improving education and changing the culture of continuing professional development in LMICs? There are many examples of early handover to local instructors and ongoing delivery of locally run courses, suggesting that the course format and content are appropriate and helping to fill an educational need, but there is a need to document educational outcomes with good research.
Recruiting volunteers and running a course are relatively easy and inexpensive, but ongoing funding is a continuing challenging despite the relatively low costs. There is sometimes a “chicken and egg” situation where funding can be difficult to obtain because of the lack of data about course impact, but funding is required for developing good monitoring and evaluation. Organizations need to embrace the idea that recruiting volunteers and running these courses is only the first step. They must also be committed to supporting the development of expertise to appropriately evaluate short courses. An example of such an effort is Lifebox, an organization devoted to improving surgical safety, that is working to incorporate monitoring and evaluation, and long-term follow-up into its educational program in LMICs.39
Running a short subspecialty course should not be seen as an end in itself. How do we support local teachers and subspecialty leaders in the longer term? The use of videoconferencing and social media may play an increasing role in information exchange between colleagues in HICs and LMICs. How do we support and monitor the quality of locally run courses? There is likely to be a fine balance between local independence and the need to provide support and quality control.
With these challenges in mind, there is a need to be more strategic in our delivery of short subspecialty courses worldwide. Increasingly, we are seeing the development of multi-year plans that include a more formal needs analysis, course delivery, ongoing support and mentorship, and a plan for monitoring and evaluation. For example, the WFSA is currently working with the Indian Society of Anesthesiologists and Masimo to deliver SAFE courses, EPM, and PTC in Telangana State in India. The project includes an anesthesia needs analysis and an evaluation of impact and will be delivered collaboratively over 3 years.
The Educational Answer?
There are indications that short subspecialty courses are an important part of the educational answer in many LMICs, but good quantitative and qualitative data are needed to assess their true clinical impact worldwide. For now, we are confident that they are providing much needed subspecialty knowledge and skills, helping to develop local teachers and leaders, and building collaboration among health care workers locally, nationally, and internationally. There is potential for even greater impact as we improve monitoring and evaluation and develop strategic multi-year plans.
ACKNOWLEGMENTS
We wish to acknowledge the main authors of the 4 short subspecialty courses: Drs Douglas Wilkinson and Marcus Skinner (Primary Trauma Care [PTC]); Drs Wayne Morriss and Roger Goucke (Essential Pain Management [EPM]); Dr Kate Grady (Safer Anaesthesia From Education—Obstetric Anaesthesia [SAFE-OB]); and Drs Isabeau Walker and Michelle White (Safer Anaesthesia From Education—Paediatric Anaesthesia [SAFE-Paeds]). We also thank the World Federation of Societies of Anaesthesiologists (WFSA), the Australian and New Zealand College of Anaesthetists (ANZCA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Primary Trauma Care Foundation (PTCF). We also wish to thank many people who have helped with the preparation of this manuscript, including Aaliya Ahmed (WFSA), Kate Davis (ANZCA), Charles Clayton (PTCF), and Dr David Snell (Northumbria Health care NHS Trust).
DISCLOSURES
Name: Faye M. Evans, MD.
Contribution: This author helped design and prepare the manuscript.
Conflicts of Interest: F. M. Evans is a contributing author to the Safer Anaesthesia From Education—Paediatric Anaesthesia Course.
Name: Juan C. Duarte, MD.
Contribution: This author helped design and prepare the manuscript.
Conflicts of Interest: J. C. Duarte is a member of the Primary Trauma Care Foundation Board of Trustees.
Name: Carolina Haylock Loor, MD.
Contribution: This author helped design and prepare the manuscript.
Conflicts of Interest: C. H. Loor is a coordinator for Essential Pain Management courses in Latin America
Name: Wayne Morriss, MBChB, FANZCA.
Contribution: This author helped design and prepare the manuscript.
Conflicts of Interest: W. Morriss is a co-author of the Essential Pain Management course.
This manuscript was handled by: Angela Enright, MB, FRCPC.
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