From the Institute of Global Surgery, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland.
Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland.
Anesth Analg. 2020 Apr;130(4):845-853. doi: 10.1213/ANE.0000000000004363.
District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs.
We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision.
Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment.
Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists-measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies-are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA.
在撒哈拉以南非洲（SSA），区级医院（DLH）是农村人口提供外科服务的主要提供者。熟练的团队对于外科护理至关重要，而麻醉方面的差距会对手术能力和结果产生负面影响。本研究是在马拉维、坦桑尼亚和赞比亚扩大安全外科和麻醉护理项目的基础上进行的，说明了 DLH 中麻醉护理的不足。
我们采用混合方法，于 2017 年 7 月至 11 月，对 3 个国家的 76 家 DLH 进行了深入的麻醉能力调查。定量部分使用基于经过改编和扩展的人员、基础设施、程序、设备和用品（PIPES）指数的标准化评分系统评估地区级麻醉能力。定性部分涉及对来自 33 家 DLH 的提供者进行半结构化访谈，探讨麻醉方面的弱点如何影响地区外科团队的实践以及质量、数量和服务范围。
在这些国家，区级的麻醉护理仅由非医师麻醉师提供，其中一些人没有接受过正规培训。所有医院都广泛使用氯胺酮麻醉，以弥补其他形式麻醉的短缺。儿科大小的供应/设备经常缺失。马拉维（M = 8.0）、赞比亚（M = 8.3）和坦桑尼亚（M = 8.4）的麻醉 PIPES 指数得分相似（P =.59），但对个别 PIPES 成分的分析显示出重要的国家间差异。在马拉维，可靠设备和供应的供应不规律是一个特别优先考虑的问题，只有 29%的设施可以不间断地使用电力，23%的设施可以持续供水，以及其他挑战。赞比亚主要受到人员短缺的影响，30%的调查医院缺乏麻醉提供者。坦桑尼亚突出的挑战是经常缺乏工作人员和其他设备，导致麻醉机无法正常运行。
坦桑尼亚、马拉维和赞比亚在确保为农村地区和农村人口提供安全、负担得起的手术和麻醉护理方面远远落后。需要与麻醉专家合作进行混合方法的情况分析，衡量和了解地区医院麻醉人员、设备和用品的不足，以解决对农村人口的外科需求至关重要的麻醉服务严重不足的问题。
