Upcountry Anesthesia Support Program

AAU-IRC UPCOUNTRY ANAESTHESIA MENTORSHIP PROGRAM
IMPACT EVALUATION REPORT
THE CASE OF JINJA AND MASAKA REGIONAL REFERRAL HOSPITALS
BY
MANTAH RESEARCHERS
JANUARY 2021
EVALUATING COMPANY

The impact evaluation was carried out by MANTRAH researchers, a research consulting organization in Uganda
Contact:
MANTRAH Researchers
Sserumaga road, Bukoto 1
Kampala, Uganda
Tel: +256 700 593 117
The lead researcher for the evaluation: Caroline Komukama (MA.SOC)
Copyright (C) at MANTRAH Researchers 2021

Acknowledgements
MANTRAH researchers recognize the Association of Anaesthesiologists of Uganda (AAU) and its partners the IRC of the Association of Anesthetists (UK and Ireland) the implementers of the program that was evaluated.
We appreciate the involvement of all participants in the evaluation who shared their experiences openly and honestly.
We thank Jinja and Masaka regional referral hospitals for availing us of the necessary information and to access their databases to aid the evaluation.

Abbreviations
KI Key informant
KIG Key informant guide
JRRH Jinja Regional Referral Hospital
MRRH Masaka Regional Referral Hospital
IRC International Relations Committee
AO Anaesthetic Officer
CME Continued Medical Education
AAU Association of Anaesthesiologists of Uganda
OR Operating Room

Executive summary
Jinja and Masaka regional referral hospitals had been operating without an anesthesiologist until two years before the program. One anaesthesiologist had since been employed by the government of Uganda for each hospital. The AAU-IRC of the Association of Anaesthetists (UK) partnership supported an additional anesthesiologist at each hospital to ensure full-time duty coverage and improved direct supervision in addition to the mentorship of lower cadre anaesthesia providers.
The report presents an analysis of the impact of the presence of an additional anesthesiologist at Jinja and Masaka Regional Referral Hospitals. The analysis is based on the routine activities the anaesthesiologists engaged in while at the hospital, review of hospital records and interviews of stakeholders.

The anaesthesiologists placed at the hospitals by the AAU boosted clinical work, improved the quality of care of patients and reduced the rate of perioperative death. The evaluation also revealed that the presence of an extra anesthesiologist at the two hospitals had a tremendous positive impact on the general surgical pathway that their absence by the time of the evaluation was felt by other hospital staff.

A summary of the findings in key areas that were assessed are given below:
Skills and knowledge transference
While most Anaesthetic Officers (AOs) were unwilling to participate in lectures and other kinds of formal training, they still gained hands-on skills particularly during the informal interactions during surgery. As a result, has gained confidence in administering regional anaesthesia. The number of patients who had a regional anaesthetic but otherwise would have received general anaesthesia increased significantly. During the period of the program, AOs switched from using large-bore I.V cannulas to small gauge spinal needles for spinal anaesthesia. This was a direct outcome of the presence of an anesthesiologist.

Leadership
The government leadership structure is in such a way that anesthesiologists are the leads whenever they are. The anesthesiologists posted to the two hospitals engaged in supervising students and participating in CMEs (specifically at JRRH) and hospital/ department meetings. The presence of anesthesiologists also improved the drug and sundries in-hospital supply chain which improved surgery start times.

Anaesthesia care practice
Generally, patient care was greatly improved through perioperative practices that resulted in the reduction of perioperative mortality, especially for maternal and paediatric patients.
The quality of anaesthesia care improved significantly by the introduction of regional anaesthesia, especially spinal anaesthesia which many providers lacked the skill and knowledge to deliver safely. By the end of the program, the AOs had the confidence to perform spinal anaesthesia safely.
Similarly, significant changes in anaesthesia practice occurred in the areas of preoperative assessment and medication safety.

Introduction
Uganda has close to 70 actively practising anaesthesiologists for a population of 45 million. This means that the bulk of anaesthetics are delivered by the anaesthetic officers (over 600 in number) who are distributed widely in the regional referral hospitals and lower health centres. The statistic of perioperative mortality is still high with many intraoperative incidents of cardiac arrests and other poor perioperative outcomes. The lack of anaesthesiologists causes operational constraints and impedes the efficient running of surgical and critical care services in public hospitals. With the growing number of patients that require complex surgeries, a certain level of skilled health workers is needed to properly manage and promote quality health care.
The Association of Anaesthesiologists of Uganda (AAU) in conjunction with the International Relations Committee (IRC) of the Association of Anaesthetists (Great Britain and Ireland) sought to improve and change this statistic through a pilot that would ensure the full-time presence of an anesthesiologist at two regional referral hospitals (Masaka RRH and Jinja RRH) for a period of twelve months from March 2019 to April 2020. The program placed an anesthesiologist at each hospital and supported their stay.
The objective was to increase anaesthesiologist presence and pilot robust support supervision and mentorship model for AOs in upcountry health facilities to improve patient care and access to safe anaesthesia care.
This report is an impact evaluation of the presence of anaesthesiologists at Jinja and Masaka regional referral hospitals. Its findings are to help inform policymakers and decision-makers on the necessity of having such skilled health personnel in public hospitals.

METHODOLOGY.
This was an impact evaluation assessing the impact of the presence of an anesthesiologist at JRRH and MRRH placed there by the AAU in cooperation with their partner, the IRC. JRRH had only two anaesthesiologists one employed by public service and the other was by AAU. MRRH had one anesthesiologist who at the time of AAU project implementation was a way for further studies. Therefore, the program anaesthesiologist was the only physician at MRRH during the program period.
The evaluation employed both quantitative and qualitative methodologies.

Quantitative
Quantitative data were collected from theatre records; log books and any other written information that related to what was needed. While we had planned to review patient clinical records, COVID 19 precautions at the time of the evaluation could not allow this. Additionally, the hospitals were transitioning to electronic medical records from paper records.

Qualitative
Qualitative data were collected through key informant interviews. The key informants were purposively selected. They either directly worked with the anaesthesiologists or were persons in authority that indirectly impacted their work and or the program.

EVALUATION SITES
MASAKA REGIONAL REFERRAL HOSPITAL (MRRH)
It is located 132 Km (82miles) southwest of Kampala and has a catchment area that traverses eight districts. Except for critical care and complex surgical services, the hospital offers all other clinical services. It has an admission rate of more than 25,000 patients per year and more than 5,000 of these require surgical interventions. It has one anaesthesiologist and three anaesthetic officers.

JINJA REGIONAL REFERRAL HOSPITAL
Jinja Regional Referral Hospital is in the city of Jinja with a bed capacity of 600. It admits about 45000 patients and performs over 8000 surgeries in a year. The hospital has six Anaesthetic Officers and one anesthesiologist.

FINDINGS AND DISCUSSIONS
Motivation for anaesthesiologists to be part of the program.
The program was able to identify anesthesiologists at an early stage (just after graduation and without employment). Those involved thought it was a good opportunity to earn but also learn from the senior anaesthesiologists that have been in the field. The possibility of working on a good case-mix motivated the anesthesiologists.
The anaesthesiologists’ presence at JRRH and MRRH had a tremendous impact on the whole, and the following were the common themes; quality of patient care and clinical practice, capacity building, night duties and relief services, professionalism, leadership, management of the critically ill patients and research. All participants that were involved in the evaluation process attest to improvements in these areas.
Manpower
Firstly, hospital manpower was increased. This meant that cases that would have been differed or referred would be operated on. The placement was timely for AO mentorship and helped to reduce the workload on the few AOs. They helped cover perioperative medicine, critical care and Accident & Emergency services.
Quality of patient care
The quality of patient’s care is a broad concept encompassing pre-operative, intraoperative, perioperative and post-operative care, referrals and follow up. In general, there was a remarkable improvement in the anaesthesia of the hospitals especially pediatric anaesthesia and good outcomes after surgery:

Pre-operative care
At JRRH, all patients that were on the ward for planned surgery were assessed by the program anaesthesiologist. All the participants in the evaluation attest to this as voiced by the senior anesthesiologist at JRRH.
“She introduced a better needs-assessment tool and patient pre-operative evaluation on the ward. She would review a patient understand her/his operative and post-operative needs and create anaesthetic plans. She would discuss with surgeons to get to know their plans. She would make consultations with me where the need arose”.
Machine check: Before conducting an operation, she would do machine checks to be sure they were in good functioning condition to handle the patient.
Complicated cases: At JRRH, these were managed after a detailed discussion and analysis with all the concerned parties. This reduced the referral rate.

Intra-operative
The presence of anaesthesiologists leads to a reduction in the case of cancellations due to the lack of an anaesthesia provider. All patients on the theatre list would be operated on.
Drug check: The anesthesiologist did a drug check before the operation to ensure whatever was needed was available or requested in time. Her presences encouraged the use of isoflurane, intraoperative monitoring in the theatre and the recovery room.

Post-operative
Vitals of patients in HDU and ICU were taken by the anesthesiologist and offered advice on the management and drugs to be used. Patients recovered smoothly with better outcomes.

Access to perioperative care
With the anaesthesiologists in place, MRRH case complexity (ASA class mix) improved and patient outcomes for both paediatrics and the elderly was much better.
The critical care unit (ICU) at the hospital was under construction, although other departments like the Accident & Emergency (A&E) were operational

Standards of perioperative care
Many nurses and doctors involved in the perioperative care of patients reported great strides towards improved patient outcomes arising from practices instituted by the anaesthesiologists. Some practices like the implementation of the surgical safety checklist, preoperative assessment, patient optimization before the anaesthetic and use of a proper spinal needle for spinal anaesthesia were adopted at the hospitals.

Mortality rate
Anaesthesiologists presence helped reduced the perioperative mortality rate mainly because of their advanced understanding of the disease conditions and implementation of their skills.

Clinical practice
The practice of checking for the available drugs in theatre especially after a surgery to restock was adopted
Recording and labelling of drugs to be used. The practice was emphasized. “Drugs would not be labelled because we knew them off the head, but with her, you had to label. She would ask us to the label to avoid making mistakes. She often told us that we were not computers for which to press a button and the label shows up”. Senior AO (JRRH)
AOs developed a step by step management of a patient not just merely getting the job done with an emphasis on the use of monitors and use of checklists.

Attitude towards patients. AOs attitude toward patients was rudeness, carelessness and shouting but her way of handling patients modelled to them a new attitude at JRRH. They are calm and composed with a friendlier attitude.
Multidisciplinary discussions
The presence of anesthesiologists in these hospitals introduced multidisciplinary discussion where all specialists came together including paediatricians, obstetricians, anaesthetists and surgeons to plan for the patient and come up with an effective management plan.

Leadership
Anesthesiologists by virtual of their training as doctors are by leaders by default. During the program period, anaesthesiologists took on the informal supervisory role to the AO’s and anaesthesia students. They also acted in delegated leadership roles as and when requested.

Professionalism:
Previously, it was not clear the roles and capabilities of anesthesiologists and AOs. During the program, however, it was clear the roles and responsibilities of these two groups who
worked in support of each other. With the anesthesiologists working together with AOs, patient care was improved.
“Have you been to JRRH? JRRH is unique. The paediatric unit is a distance away from the main hospital. When you call AOs they won’t come. The hospital anaesthesiologist is extremely busy and overwhelmed. He will usually be engaged in running CMEs. In fact, when you called him he would say liaise with my colleague (program anaesthesiologist). She was very swift, all she would ask for is for you to arrange for transport to pick her up and she will be there in a minute. She would help assess the patient and advise accordingly and if the child is for the operation she will be there with you”. Paediatric surgeon
These and other voices indicate better teamwork and exhibition of different roles as well as a high degree of professionalism.

Capacity building
Capacity-building or skills transfer was done throughout the process of patient management. The learning took place in theatre as the operation went on and also occurred after or even before the operation based on the available time and the different patient conditions to be operated on. The 6 AOs at the hospital (JRRH) have been working for a long time and not open to formal learning. For example, none of the AOs could remember the topics taught in CMEs even though they agree that they were taught. The anaesthesiologist developed ways of passing on her skills and knowledge informally by practically showing, guiding, advising during a procedure. Some of the skills and knowledge she passed to the AOs included management of emergencies, administration of anaesthesia particularly spinal and intubation.
She instilled confidence in the AOs, empowered them mentally and offered psychosocial support especially when surgeons bullied them. Today, they have a voice of confidence and can be listened to by those in positions higher than them and with more qualifications.

It was different at MRRH. There was an icy relationship between the AOs and anaesthesiologists trashing any innovations or knowledge from the anaesthesiologists. No CMEs were organized and reportedly AOs and the anaesthesiologists rarely worked in the same OR. The Bachelor of Science in Anesthesia students from Busitema University benefited the most as they were closely supervised during perioperative patient management by both AOs and anaesthesiologists.
Night duties and relief services.
Because the hospital had an anesthesiologist at all times, cover for night and weekend duties improved especially at JRRH. The anesthesiologist offered relief services when there was a human resource gap say if AOs were off duty or on leave including night shifts.

Critical patients
Patients with co-existing diseases such as Pneumonia, heart failure, kidney and liver diseases were being operated on. In addition, those with critical illness and paediatrics could access surgery without the need for referral. This was only possible due to the presence of anesthesiologists. At the same time, AOs were equipped on how to handle critical patients more specifically the resuscitation and titration of adrenaline skills. Improvement in Obstetric and paediatric anaesthesia led to a reduction in maternal and pediatric perioperative mortality.
With MRRH, Paediatric surgery, laparotomies, thyroid surgeries and surgery in geriatric patients was highly improved with increased improved patient outcomes.

 

QUANTITATIVE DATA FOR JRRH FOR THE PROJECT PERIOD
From theatre records, the anaesthesiologist solely anaesthetized 72 patients. However, all surgeries they were involved in could not be ascertained since AOs would only write their names in the register and not that of the supervisor.
We could not access patient records since there was a ban on the access of files by non-staff date no change yet. The keeping of records practice is not quite clear at the hospital so data may not be very accurate.

QUANTITATIVE DATA FOR MRRH FOR THE PROJECT PERIOD
The records department at Masaka Regional Referral Hospital was transitioning from paper to electronic documentation. Due to this ongoing switch, it was very difficult to get any quantitative data during the evaluation. There was a reported increase in the total number of surgical cases done with most having an anesthesiologist directly involved especially for surgical operations during the day although they could also be accessed at other hours if required.

Challenges identified by the program
1. Irregular supply of drugs and other anaesthesia sundries which causes delays in surgical care and hence poor outcomes. In both hospitals, they were no monitors in the recovery rooms. The checklist and preoperative assessments are difficult to implement due to understaffing.
2. All AOs are generally demotivated since most are still paid as clinical officers or nurses and not as anaesthetic officers. Even in service, they do not have opportunities for career and personal growth. This demoralizes them.
3. The failure by the health service commission to fill the positions according to the structure in place. This causes a work overload on the available AOs that compromises the quality of patient care. At the moment, the hospital wage bill is only sufficient to employ two anaesthesiologists.

 

Requests to AAU from JRRH
1. To ease anaesthesia work, AAU could help provide equipment such as laryngoscopes, endotracheal tubes, ventilators, theatre logbook and all emergency equipment for the pediatric section.
2. The hospital would do quite well with two extra anaesthesiologists supported by AAU.
3. AOs requested unique anaesthesia training because they do not get as much.

Recommendations
1. The program model is adopted by policymakers and the health system in the country. The AAU could seek more funding to keep this program running in several other hospitals.
2. Funding for the anesthesiology program is prioritized to encourage more physicians to take it on as a speciality. Facilitation is improved in terms of the time of payment for the participating anesthesiologists.
3. Better orientation of the host hospital staff and participating anesthesiologists on the purpose and expectations of the placement program. This will improve the working relationship between AOs and anaesthesiologists.
4. AAU being an association could have a better voice in getting the hospital officials to improve medical supplies at the hospital in liaison with the administration and hospital pharmacist to make anaesthesia work easier and encourage proper record documentation.
5. AAU could build a resource centre and a guest house at these model hospitals to encourage anaesthesiologists to go upcountry as well as attract international anesthesiologists who would be very beneficial in capacity building.

Conclusion
This partnership between the IRC of the Association of Anaesthetists and the Association of Anaesthesiologists of Uganda to foster mentorship and training at the regional referral hospitals yielded great strides in the improvement of perioperative outcomes at the two sites. It offers an opportunity for fresh graduates to practice leadership skills while training teams in perioperative medicine.
Generally, the program has an impact on many aspects of the hospital. Currently, Jinja RRH has lobbied for a second anaesthesiologist while the one for Masaka RRH returned from fellowship training.