36.01 Pediatric Surgical Outreach Camps in Uganda: Results and Use of Guidelines for Quality Improvement

Posted on January 31, 2019

D. F. Grabski1, N. Kakembo2, M. Cheung3, I. Okello2, A. Shikanda5, M. Langer7, M. Nabukenya4, M. Ajiko8, G. Villalona6, T. Fitzgerald9, G. Kateregga10, J. Tumukunde4, A. Muzira2, P. Kisa2, M. Situma5, J. Sekabira2, D. Ozgediz3  1University of Virginia School of Medicine,Department Of Surgery,CHARLOTTESVILLE, VIRGINIA, USA 2Makerere University, Mulago Hospital,Department Of Surgery,Kampala, KAMPALA, Uganda 3Yale University School of Medicine,Department Of Surgery,New Haven, CT, USA 4Makerere University, Mulago Hospital,Department Of Anesthesia,Kampala, KAMPALA, Uganda 5Mbarara University of Science and Technology, Mbarara Hospital,Department Of Surgery,Mbarara, MBARARA, Uganda 6Saint Louis University School of Medicine,Department Of Surgery,Saint Louis, MO, USA 7Northwestern University School of Medicine,Department Of Surgery,Chicago, IL, USA 8Soroti Regional Referral Hospital,Department Of Surgery,Soroti, SOROTI, Uganda 9Duke University School of Medicine,Department Of Surgery,Durham, NC, USA 10Mbarara University of Science and Technology,Department Of Anesthesia,Mbarara, MBARARA, Uganda

Introduction:
Pediatric surgical resources are significantly limited in Uganda, especially in rural areas.  The result is a back-log of elective cases and emergency procedures performed by general surgeons or medical officers in rural hospitals.  Surgical camps run by local and international partners have historically assisted with rural service delivery.  We describe the effectiveness of locally led rural pediatric surgical outreach on service delivery and training.

Methods:
We performed a retrospective review of data from rural outreach camps completed by the pediatric surgery and anesthesia teams at Mulago Hospital in collaboration with international partners from 2012-2017. Primary outcomes included surgical volume and immediate surgical outcomes.  Secondary outcomes included the share of elective cases and the trainee involvement in the camps.  The 2017 joint “Guidelines for Short Term Missions” (STMs) from the American Pediatric Surgery Association (APSA) were used to assess possible areas of quality improvement.

Results:
From 2012-2017, 7 surgical outreach camps ranging from 3-5 days occurred in Soroti (5/2012, 1/2013), Masaka (8/2013, 02/2015) and Mbarara (01/2016, 11/2016, 04/2017) (Table 1).  394 cases were completed, with 383 (97.2%) elective procedures.  There were 4 re-operations and 2 post-operative deaths.  48 Trainees (6 from USA) in general surgery and anesthesia were involved in the camps.  6 general surgeons and 11 anesthesia officers were additionally involved in pediatric surgical and anesthesia skill transfer.  Reduction of elective case backlog and clinical skill transfer in pediatric surgery and anesthesia were successes highlighted by the local team.  Perceived challenges included a lack of reliable intensive care, radiology and pathology.  Qualitative review by the pediatric surgery and anesthesia teams of the Day-of Surgery Checklist from published guidelines revealed several areas of potential improvement including: allergy history (specifically where language barriers exist), evaluation for clinical changes after screening, pre-operative image review, and more formal intra-operative debriefing. Participants also emphasized possible burden on local hospitals.

Conclusion:
Pediatric surgical outreach camps led by local pediatric surgeons in Uganda are safe and help to address the back-log of elective cases.  Outreach camps can be closely linked with surgical training and skill transfer.  Challenges vary by site and camps can stress the local system and must be well-coordinated with local teams. Lastly, the 2017 joint guidelines for STMs, adapted to the local context, may be a helpful tool for quality improvement and prospective evaluation is warranted. 
 

22.04 Learning from England’s Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Outcomes

Posted on January 31, 2019

C. K. Zogg1,2,3, D. Metcalfe3, A. Judge4, D. C. Perry3, M. L. Costa3, B. J. Gabbe5, A. H. Haider2  1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University of Oxford,Oxford, United Kingdom 4University of Bristol,Bristol, United Kingdom 5Monash University,Melbourne, Australia

Introduction: Since passage of the Patient Protection and Affordable Care Act in 2010, Medicare has renewed efforts to improve the quality of older adult health through the introduction of an expanding set of outcome-based readmission and mortality pay-for-performance (P4P) measures. Among trauma patients, potential P4P has met with mixed success given concerns about the heterogeneous nature of patients that trauma providers treat and resultant variations in outcome measures. A novel approach taken by the National Health Service in England could offer a viable alternative plan. The objective of this study was to assess the effectiveness of the 2007-2010 English provider consensus-driven, process measure-based P4P Hip Fracture Best Practice Tariff (BPT) on improving trauma outcomes.

Methods: Quasi-experimental interrupted time-series and difference-in-difference analysis of 2000-2014 death certificate-linked data from England (Hospital Episode Statistics), Scotland (Scottish Morbidity Records), and the United States (100% Medicare all-payer claims). The study compared before-and-after differences in English temporal trends relative to those of Scotland and the US. Outcomes included: 30/90/365-day mortality, readmission, index hospital length of stay, and time to surgery. The study also assessed projections for the number of lives saved and readmissions averted were the BPT to be implemented in Scotland and the US.

Results: A total of 878,860 English, 97,487 Scottish, and 2,994,748 US index fractures were included among adults ≥65y. Following BPT introduction in England, 30-day mortality decreased instantaneously by an absolute value of -2.6 (95%CI -3.5, -1.7) percentage-points and continued to drop by an average of -0.2 (-0.4, -0.1) percentage-points per year (DID-Scotland: -1.6; DID-US: -2.2). 90-day mortality decreased more precipitously, dropping by an absolute value of -5.6 (-7.1, -4.2) percentage-points and an annual average thereafter of -0.2 (-0.5, 0.0) percentage-points per year (DID-Scotland: -1.9; DID-US: -2.9). Similar improvements were observed in readmission (e.g. 30-day ITSA: -1.4 [-2.3, -0.5]), time to surgery, and length of stay. Projections suggest that were the BPT to be implemented in Scotland and the US (Figure), by 2030, as many as 1,377 Scottish and 11,434 US lives could be saved.

Conclusion: In contrast to outcome-based P4P, process measure P4P such as that implemented through the English Hip Fracture BPT could result in significant improvements in outcomes for US patients while remaining more applicable to heterogeneous trauma populations and acceptable to trauma providers. As efforts to improve older adult health continue to increase, there are important lessons to be learned from initiatives like the BPT

16.14 Telemedicine In Albania &Cabo Verde – 44 Centers & 4,524 Patients Later. A Critical Appraisal

Posted on January 31, 2019

R. Latifi1, R. Merrell1  1New York Medical College,Surgery,Valhalla, NY, USA

Introduction: Following the successful implementation of the Telemedicine Program of Kosovo (TPK) in 2002, the International Virtual e-Hospital Foundation (IVeH) established the award-winning Initiate-Build-Operate-Transfer (IBOT) approach in creating two additional nationwide telemedicine programs, the Integrated Telemedicine and e-Health Program of Albania (ITeHP-AL) and the Integrated Telemedicine and e-Health Program of Cape Verde (ITeHP-CV). Based on IBOT strategy and its time line the ITeHP-CV was transferred to the Ministry of Health of Cape Verde in August 2014 and the ITeHP-AL to the Ministry of Health of Albania in January 2017. The aim of this paper is to review the impact of these two programs on increasing access to care using telemedicine programs and identifying the most common clinical disciplines used by telemedicine, in order to predict the needs for further country investment medical healthcare system. 

Methods:  Review of processes of implementation of IBOT and analyses of clinical applications of telemedicine in each country with different clinical specialty needs. 

Results: During the study period (2009-2018) two national telemedicine programs became independent of the initial funding sources, with 44 telemedicine centers covering the two countries (30 Al and 14 CV). During this time, 4,524 patients were managed via telemedicine (Albania: 2,366), Cabo Verde: 2,158). The most common clinical disciplines in Albania were teleradiology (677), teleneurotrauma (677) and telestroke (498), while neurology (599), cardiology (319), dermatology (173), orthopedic surgery (160) and general surgery (160) in Cabo Verde. 1809 (76.45%) patients (Albania) and 1630 (75.53%) (Cabo Verde) were not transferred to tertiary centers of the country.  Furthermore, teleconsultation that the number of such events has remained stable or has increased since transfer to the national counterparts was completed.

Conclusion: The IBOT model of telemedicine has advanced the quality and availability of necessary medical services in in Albania and Cabo Verde. By studying the clinical disciplines that used telemedicine mostly, the countries can predict the healthcare needs in the future. We conclude that IBOT represents a mature and field-tested implementation approach for establishing telemedicine programs in developing countries, as form of sustainable surgical volunteerism
 

105.12 What Is Global Surgery? Identifying Misconceptions Among Medical Students and Health Care Professionals

Posted on January 31, 2019

M. N. Abraham2, P. J. Abraham1, H. Chen1, K. M. Hendershot1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, AL, USA

Introduction:  Over the last five years, global surgery has emerged as a new field within academic surgery. Global surgery has been defined as “an area for study, research, practice, and advocacy that places priority on improving health outcomes and achieving health equity for all people worldwide who are affected by surgical conditions or have a need for surgical care.” Despite such unifying attempts to provide a common definition, it is unclear whether health care professionals and medical students understand what is meant by the term “global surgery.” This study aims to characterize the understanding of global surgery and what it means to be an academic global surgeon.

Methods: One hundred medical students, residents, physicians, nurses, and allied health care professionals were interviewed on their perceptions of global surgery using a six-question qualitative survey. Respondents were categorized based on gender and apparent age <40 or >=40 years old. Survey responses were coded and analyzed for common themes by two reviewers independently. SPSS was utilized for statistical analysis.

Results: Of the 100 health care professionals surveyed, 61% did not know the meaning of global surgery. While there was no difference between men and women, participants under age 40 were significantly more likely to relay an accurate definition (51% vs 17%, p=0.001). Of participants with knowledge of global surgery, 44% had previous exposure to a global health field and 85% expressed interest in global health or global surgery. Respondents described components of academic global surgery as “research”, “teaching,” “practicing,” and using “evidence-based medicine.” An effective career in global surgery was most often categorized as “sustainable” and “impactful.”

Conclusion: Although often used in academic surgical settings, the term “global surgery” is not well-understood among health care professionals and medical students. Even among those who are familiar with the term, there is no clear consensus on what it means to be a global surgeon or what constitutes a successful career in global surgery.

 

105.10 Training Global Surgery Advocates: Strengthening the Global Surgery Voice

Posted on January 31, 2019

D. Vervoort1, X. Ma2  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 2Université de Montréal,Montréal, QUÉBEC, Canada

Introduction:  Five billion people worldwide lack access to safe surgery when needed, causing 17 million preventable deaths each year and responsible for one-third of the global burden of disease. Despite the increasing recognition as an indispensable part of healthcare, surgery remains perceived as a luxury, and difficulties of scaling up surgical care remain widespread. InciSioN – International Student Surgical Network – is the world’s leading trainee global surgery network comprising over 3,000 medical students, residents, and young doctors from over 70 countries. InciSioN provides a platform to foster the development of future generations of global surgeons, anaesthesiologists, and obstetricians around the world.

Methods:  To strengthen, unify, and escalate InciSioN’s voices around the world, Training Global Surgery Advocates (TGSA), a standardized three-day advocacy workshop, was created. The 27-hour workshop is built on traditional didactic lectures, role-play exercises, and small working group activities, as well as advocacy and diplomacy training to provide participants with the needed knowledge and skills to effectively advocate for global surgery. During the pilot program, participants performed a baseline elevator pitch advocating for global surgery on day 1 and a prepared elevator pitch at the end of day 3 to formally assess progress. A questionnaire on the perceived familiarity, knowledge and motivation regarding the workshop and its topics was filled by participants before the beginning of the workshop and immediately after the workshop. Assessment was done using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree) for 18 components.

Results: 25 participants were selected from a pool of 52 applicants, of which 14 medical students from 14 different countries (7 high-income countries, 7 low- and middle-income countries) were able to attend the workshop in Quebec City, Canada. 11 students were unable to participate due to restrictions by visa issues (9 people) or personal reasons (2 people). An average net increase of 1.73 points across all 18 components was observed among participants. Participants lauded the mix of theory and practical exercises to integrate knowledge into practice, the diversity of participants, and the focus on soft skills for advocacy and diplomacy. During the post-assessment, all participants agreed or strongly agreed (average of 4.64 points) on their motivation to train other medical students in their respective countries to become global surgery advocates.

Conclusion: TGSA significantly improved participants’ knowledge and advocacy skills in the field of global surgery. This type of mixed didactic and hands-on workshop appears to be feasible, enjoyable for participants, and effective in improving medical students involvement in the emerging field of global surgery.

 

105.09 In-person hemorrhage control training effectiveness and comprehension in low-resource rural Kenya

Posted on January 31, 2019

D. El-Gabri1, A. D. McDow1, S. A. Sullivan3, H. Jung2, K. L. Long1  3University Of Wisconsin,Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 1University Of Wisconsin,Division Of Endocrine Surgery/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,Division Of Trauma, Acute Care Surgery, Burn And Surgical Critical Care/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA

Introduction:
The American College of Surgeons Committee on Trauma developed the Stop the Bleed (STB) program in 2015 as a mechanism to prepare the public for response to life-threatening bleeding or mass casualty incidents. Assessments of STB in the United States (US) have shown the training’s effectiveness in improving comfort and skill in aiding a trauma victim. While the program continues to spread throughout the US, to the best of our knowledge, it has not been conducted and evaluated in low or middle-income countries. Kenya has a high burden of injuries and violence accounting for 88.4 deaths per 100,000 people. Addressing this burden is a healthcare priority in the country. STB training represents a potential intervention that could reduce trauma morbidity and mortality in a country with limited healthcare resources. The purpose of this study was to assess the effectiveness and retention of STB training in Kenya as compared to implementation in the US, the population for which it was originally designed.  

Methods:
This quasi-experimental study assessed differences between a STB intervention post-test conducted in the US and in Kenya. The two samples consisted of volunteer participants with no medical background. The STB training was advertised, and any willing participants were recruited into the study. The population of interest was recruited in Migori Kenya (n=19), the comparison population in Wisconsin, United States (n=12). Each group received the same STB training course in July 2018 by physicians trained to give STB instruction from the same US institution. After completing the course, each group received the same 5-question post-test, designed to assess effectiveness and comprehension of the material. The quizzes were anonymous and taken voluntarily. The quiz scores between each group were compared using the Mann-Whitney U Test.

Results:
There is a statistically significant (p=0.04) difference in the quiz scores between the US (n=12) and Kenya samples (n=18). The Kenyan and US mean scores were 3.9 and 4.7 out of a possible 5, respectively. If one quiz question is excluded from analysis, there is no significant difference between the two group’s quiz scores (p=0.41). The individual question that significantly lowered the mean score in the Kenyan sample was: “What is the first step when approaching an injured, bleeding person?”, which may identify a difference in interpretation of the material.

Conclusion:
In general, both samples studied demonstrated good comprehension of the STB core concepts.  In detailed review of the post-test scores, only one question was significantly different in answers among the Kenya and US participants.  Additional studies to assess long-term retention of these concepts will be necessary in both populations.  Understanding the discrepancies between the assessments in differing populations may contribute to the validation and utility of this STB post-intervention evaluation.

104.04 The Utility of an Open-Access Surgical Simulator to Train Surgeons in Developing Countries

Posted on January 31, 2019

A. S. Volk1, B. S. Eisemann2, R. P. Dibbs1, A. T. Perdanasari2, T. L. Braun2, K. P. Marsack1,2  1Texas Children’s Hospital,Department Of Plastic Surgery,Houston, TX, USA 2Baylor College Of Medicine,Division of Plastic Surgery, Michael E. DeBakey Department of Surgery,Houston, TX, USA

Introduction:  
Smile Train is an international children’s charity committed to improving cleft care around the world by empowering local medical professionals in developing countries to provide quality comprehensive cleft care in their own communities. This organization builds surgical capacity in developing countries by partnering with local hospitals and providing training opportunities for local surgeons and other medical professionals. As part of their sustainable model, Smile Train has developed a web-based, interactive virtual simulator to help improve the surgical training of cleft procedures for surgeons around the world.  The simulator replicates the anatomical and technical steps involved in cleft lip and palate surgery. The purpose of this study was to evaluate this simulator as a tool for enhancing surgical training.

Methods:
Physicians in training at an academic institution were recruited to study the educational benefits of the surgical simulator. A pre-test and questionnaire with questions addressing cleft care, surgical knowledge, and confidence level was developed and administered to all participants. Participants were then instructed to complete three simulator modules followed by a post-test and questionnaire to measure changes in knowledge and confidence levels. 

Results:
Sixteen surgeons-in-training participated in this study. The mean score on the knowledge exam improved after reviewing the modules. Junior resident scores increased from 33.1% to 64.4%, and senior resident scores increased from 46.9% to 70.8%. Survey results demonstrated that reviewing the module increased participants’ confidence in the knowledge of cleft anatomy, understanding of the surgical procedures, and ability to follow along meaningfully while assisting in surgical procedures. 

Conclusion:
This study demonstrates that the Smile Train Virtual Surgery Simulator increased knowledge and reported surgeon confidence in understanding and assisting in cleft lip surgery, signifying its usefulness as a training tool for surgeons in training. Virtual simulation may become a valuable resource for improving understanding and competence of the craniofacial surgeon while also serving as an educational resource to other members of the comprehensive cleft care team, patients, and families. 
 

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