SURGICAL QUALITY ASSURANCE IN PUBLIC HEALTH...

SURGICAL QUALITY ASSURANCE IN PUBLIC HEALTH INTERVENTIONSStephanie Parker

After training on surgical simulators, are surgeons performing high-quality surgeries on live patients?

SURGICAL QUALITY ASSURANCE

The MMDP Project’s evidence-based approach

to surgical quality assurance:

establishing postoperative feedback loops that ensure

high-qualitytrichiasis and hydrocele

surgeries

ENSURING HIGH-QUALITY TRICHIASIS SURGERY

What preferred practices are internationally recommended?

• All individuals receive follow-up examination 3-6 months after surgery, and receive treatment for complications as needed

• Use surgery outcome data to assess surgeon performance, and strengthen capacity as needed


What did we do?

• Active follow-up(household visits)

• Target of at least10-15% of surgeries

• Designed follow-upteam composition to:– build feedback loop– reduce potential bias– strengthen MOH capacity

• Incorporated surgical audit elements


What were the results of our initial follow-up?

• Postoperative complication rates are low overallMain complications tracked:

eyelid margin abnormalitygranulomapostoperative trichiasis


What did we learn?• Follow-up is an important

tool for identifying surgeon capacity building needs

• Time- and resource-intensive nature of active follow up can make it difficult to reach a large percentage ofoperated cases


How are we adapting in response to lessons learned?• Refresher trainings for surgeons as needed, based on results

• Expanding our approach to encompass two distinct activities:

1. pilot new approach of “centralized follow-up” to reach as many operated TT cases as possible during the critical 3-6 month postoperative window

2. continue actively seeking outcases through routine targetedsurgical audits (sample) to provide robust review ofindividual surgeon performance

• Re-examining categories ofcomplications tracked


ENSURING HIGH-QUALITY HYDROCELE SURGERY

What preferred practices are internationally recommended?Recommended postoperative follow-up schedule:

– DAY 1-2: Observation, check for hemorrhage or hematoma.– DAY 3: Aseptic change of dressing. Check for infection.– DAY 5: Aseptic change of dressing. Check for infection.– DAY 7: Aseptic change of dressing, remove supportive taping. Check for infection.– DAY 14: Examination of scrotum. Check for infection.– MONTH 1-3: Monthly examination of scrotum. Check for recurrence.– MONTH 6: Examination of scrotum. Check for recurrence.– MONTH 12: Examination of scrotum. Check for recurrence.


What preferred practices are internationally recommended?• Current guidance from WHO’s Global Programme to

Eliminate LF provides indicators for monitoring the qualityof hydrocelectomy:

Number and percentage of patients…

… with infection within5 days of surgery

… with hematoma within5 days of surgery

… who have a recurrenceof hydrocele after surgery


What did we do?• Aligned project indicators

with WHO-recommended indicators:

– Tracking infection, hematoma, & hemorrhage within 5 days after surgery

– Tracking recurrence atleast six months after surgery

• Trained clinical workers in hydrocele surgery postoperative care


Example: EthiopiaWhat did we do?• First campaign: 175 surgeries

• Supported incorporation of preferred postoperative practices into national policy

• Follow-up of patients at health facility, with health workers visiting homes of those who did not return

• Additional follow-up of 20 men(1-2 months after surgery)


Example: EthiopiaWhat did we learn?• Low rates of postoperative

complications show surgerieswere of high quality– Zero complications at Day 5– Slight increase at Day 7 & Day 14,

to ten complications (primarily infections)– Additional follow-up of 20 men (1-2 months after surgery)

showed only three cases of mild persistent swelling

• Following up with a large portion of patients after hospital discharge requires active strategies


How are we adapting?• If infections are occurring postoperatively, how can we

strengthen postoperative care?– Developed training modules for postoperative care, in

collaboration with local authorities and healthcare staff

– Greater emphasis in FASTT Training Package on postoperative components

• Looking across project forstrategies to increase returnto health centers for follow-up

• Data on recurrence forthcoming


THANK YOU“Although the world is full of suffering, it is also full of overcoming it.”-Helen Keller

Lessons Learned In Developing Tools To Improve Trichiasis Surgery QualityEmily W. Gower, PhD

• Leading infectious cause of blindness globally

• Disproportionately affects women• Blindness leads to a cycle of poverty

impacting all family members

TRACHOMA

About 450,000 people are blind and 1.4 million people are severely visually impaired as a result of trachoma

A HYDROCELE SURGERY TRAINING PACKAGE

Zeina Sifri, Senior Technical Advisor

Globally, an estimated 120 million people are infected with lymphatic filariasis: ~25 million men have a hydrocele and 15 million, mostly women, have lymphedema of the leg

LYMPHATIC FILARIASIS: LYMPHEDEMA/HYDROCELE

• Health staff who perform hydrocele surgery in LMIC are urologists, general surgeons, and surgical assistants

• Training package developed based on the HEAD START model

HYDROCELE MANAGEMENT: SURGERY

• The goal of the training package is to strengthen and standardize surgical quality and surgeon skills according to international recommendations for hydrocele surgery

HYDROCELE SURGERY TRAINING PACKAGE

AFMP and MMDP Project joined hands to develop a Hydrocele Surgery Training Package (and ToT):

A facilitator’s Guide for hydrocele surgery training;

A proposed agenda;

An instructional video on hydrocele surgery;

PowerPoint presentations;

The Filaricele Anatomical Surgical Task Trainer (FASTT);

Tools to assess use of standardized technique;

A hydrocele surgery reference manual.

HYDROCELE SURGERY TRAINING PACKAGE

The training package is divided into one theoretical session and two practical sessions:

Theoretical session from patient exam to discharge (PPT and videos): surgical technique, complications infection control, health care waste management, follow-up

Practical session on: the Filaricele Anatomical Surgical Task Trainer (FASTT)

Practical session on live patients

• Shot on location in Ghana

• Divided into 18 stand-alone sections (video clips) that include: Lymphatic Filariasis Overview Clinical assessment Pre-operative Care Anesthesia Resection technique Eversion technique Dressing and bandaging Post-operative care Follow-up care

HYDROCELE SURGERY TRAINING VIDEO

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HYDROCELE SURGERY TRAINING VIDEO: INTRODUCTION

EXAMPLE FROM HYDROCELE SURGERY TRAINING MANUAL

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• Development/testing/finalization: March – December 2016 with makers of HEAD START

• AFMP, HKI, national program staff (Burkina Faso, Cameroon, Ethiopia)

FASTT DEVELOPMENT

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FASTT: TABLE TOP SIMULATOR

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BURKINA FASO/ETHIOPIA FASTT TRAINING EXPERIENCE

• Training of trainers: National trainers from Burkina Faso, Cameroon, Ethiopia (testing of training package) 2016-2017

• Training of surgeons recently started in Burkina Faso and Ethiopia

• ToT & Surgeon training package refined, development of training package for post-operative care

• Surgical quality assessment survey/quality of life

• Positive feedback from trainers, surgeons, MoH: FASTT training in Burkina Faso (April 2017), Ethiopia (May 2017), Cameroon (June 2017)

• Technical Assistance requests

• Upcoming evaluation of the effectiveness of the FASTT training package in Mali

IMMEDIATE NEXT STEPS

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•Evaluate the FASTT training package (Burkina Faso, fall 2017)

•As requested, support Ministries of Health and Ministries of Education in integrating the package in the preservice training of surgeons and surgical aides

•Provide Short term technical assistance as needed

NEXT STEPS

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THANK YOU.“Although the world is full of suffering, it is also full of overcoming it.”-Helen Keller

TRICHIASIS SURGERY

• Can be performed in many settings

• Relatively inexpensive • Quick recovery

SURGERY

PROBLEM 1: LIMITED SURGEONS

Trachoma- endemic Countries

Countries depicted with proportion of physicians in the world

www.worldmapper.org

www.trachomaatlas.org

STANDARD TRAINING APPROACH

• Millions of surgeries to be performed• Few people trained to do surgery• Rates of recurrence up to 50% within 1 year• Other poor outcomes

PROBLEM 2: POOR QUALITY OUTCOMES

Surgical Training And skills Reinforcement in Trachoma

HumanEyelidAnalogDevice

TRICHIASIS SURGERY TRAINING

• Involved lots of local stakeholders

• Conducted multiple training/testing sessions

• Elicited feedback from trainers and trainees

• Modified and re-tested

• Developed a training protocol

• Developed requirements for trainers

DEVELOPMENT PROCESS

• Demonstration: trainer performs surgery

• Familiarization: trainer and trainee perform side-by-side

• Practice: trainee performs with guidance from trainer

• Observation/Certification: trainee performs surgery independently

STANDARD HEAD START TRAINING APPROACH

• 3 hr initial training session

• Review and assessment for further practice

• Solo practice while others are trained

• Standardized training format

• Standardized grading system

FINAL APPROACH

• Provides for methods to maintain quality of training

• Encourages external supervision

• Offers objective assessment tool for determining whether candidates qualify to be independent surgeons.

• Permits regular practice

BENEFITS

• Involve local stakeholders

• Be prepared to fail/make mistakes

• Plan for modifications

• Evaluate method of introducing new approaches; attitude is key for good uptake

• Don’t give up

WORDS OF WISDOM

THANK YOU!

SURGICAL QUALITY ASSURANCE IN PUBLIC HEALTH...

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