Safer Surgery in Nigeria

This is a CMF Webinar Session Report 9#

 

Introduction

#CovidNigeriaMedics, now called Concerned Medics Foundation (CMF), had in focus the topic ‘safer surgery in Nigeria, where we are’. The webinar explored the extent of implementation of surgical checklists among various countries, with emphasis on low-income countries particularly Nigeria. Factors limiting the modification and adoption of safe surgery practices and checklists to improve the safety of surgery and reduce complications were discussed with available statistical evidence and opinions of the participants explored. The key speakers discussed the potential role of checklists in risk reduction and enumerated the various factors identified as possible barriers hindering the adoption and implementation particularly in low-income countries such as Nigeria. Measures to successfully the modify and implement safe surgical principles and checklists were also discussed by the speakers and participants.

 

Webinar Structure

The Webinar was organized and hosted by the coordinators of #CovidNigeriaMedics from the UK, and Nigeria.

The total duration of the webinar was 1:29:26 (89 minutes) with a total of 35 participants.

It began with opening remarks from the moderators and coordinator, followed by presentations from the two key speakers. Views of other panelist and discussants were entertained, after which the webinar session ended with closing remarks from the key speakers.

 

Coordinator                                                                        Moderators

Dr. Sadiya Gumi                                                           Dr. Muktar Ahmad & Dr. Femi F

 

Overview of Keynote Topics

The opening remark was given by Dr. Mukhtar Ahmad, who welcomed all participants to the webinar. He preceded to explain the need for the topic of discussion stating that surgery was a major contributor to medical tourism as a significant proportion of Nigerians who could afford the means to often travelled out for surgical care despite the availability of many skilled and well trained surgeons in Nigeria.

The webinar explored the principles of safe surgical practice and the extent of  implementation in Nigeria. The participants also proffered solutions to the modification and routine practice of safe surgical guidelines in Nigeria to avert undue complications and also improve confidence in this aspect of care which has become a main source of health tourism. He introduced the key speakers of the day to include Dr. Oreoluwa Bajomo and Dr. Adewale Adisa.

The introduction was followed by further comments from Dr. Femi F., the co-moderator who though being a psychiatrists, explained his involvement with surgery through organization of surgical outreaches in partnership with many surgeons based in Nigeria as a way of impacting his local society in Nigeria. The coordinator of Concerned Medics Foundation, Dr. Sadiya Gummi. gave a brief history of events leading to the formation of the group. These events she said stemmed from the impact of the Covid-19 pandemic on the Nigerian health system, particularly as it affected some close colleagues back in Nigeria, a few of whom actually lost their lives in the course of the pandemic. The short-term achievements of the organization were provision of personal protective equipment’s such as face shields to front-line heath personnel in Nigeria. She expressed the long term objectives of the organisation to include partnerships with individuals and organisations towards improving health service delivering in Nigeria.

 

Presentation by the Key Speakers

”An Invisible, Indispensable Part Of Healthcare”

Dr. Ore Bajomo a surgical registrar, Northwest deanery, UK spoke on the the WHO safer surgery guidelines. The application of these guidelines and barriers to uptake of these guidelines in some countries, especially low income countries were discussed.  She defined safer surgery guidelines as determined by the who formulated in 2009. These guidelines were not limited to high income countries alone but are to serve as applicable guidelines in all countries irrespective of income. Available statistics indicate that 30% of disease requires surgical care worldwide with about 16.9 million deaths preventable if safe surgical and anaesthetic principles are applied. In developing countries, death rate from major surgery is about 10%. She highlighted the inequity in funding of surgery compared to other specialties such as infectious disease because surgical procedures were often considered luxuries which can wait, a view which she felt needed to change.

 

Barriers to Adoption and Utilization of Surgical Checklist among Countries

She proceeded to give an overview of the principles of safe surgery some of which include correct patient and surgical site identification, safe and effective anesthesia, etc. She proceeded to talk about the global uptake of the surgical checklist which was 30 vs 90% for low income and high income countries respectively, with none availability of checklists in indigenous language being an example of  key limitation to its use in some low income countries. Other limitations include cultural practices and beliefs abhorring practices such as body marking of individuals by others, difficulty implementing new practices, and limited devices such as pulse oximeters. In Africa, uptake ranged from 23% in East Africa and 74% in Madagascar. Nigeria was shown to

have an average uptake of 63% with key limitations identified to include lack of assertiveness, training or time.

She highlighted guidelines towards modification of the checklist to improve its applications, and concluded with questions about the possibility of modification, application, and evaluation of outcomes using surgical checklist in Nigeria.

 

Towards Safer Surgery In Nigeria

Dr. Adewale Adisa, a consultant surgeon and Reader at Obafemi Awolowo University Teaching Hospital the second speaker opened his speech with statistical summary of surgeries in 79 ICU facilitated hosp[ital in 34 of the 36 Nigerian states.  Extrapolation of the Nigerian component of the ASCUS study showed that 1425 elective surgical procedures were reported with 18.5% complications and 1.5% mortality. From his experience, there was gross under-utilization of surgical checklists up to just 10% in some emergency settings with haste and lack of time being the most frequent excuses. In his opinion, disasters are usually a cumulative effect of frequent and repeated failures which if unchecked, manifest as a major medical error with time. He also believed that some medical errors or complications such as diathermy burns might go unreported in some instances, hence under representing the true scale of the problem.

He reemphasized the significance of the checklist in preventing complications. He was of the opinion that the use of the checklist might be lower in non research settings than reported. He drew attention to the practice of surgical procedures under non optimal conditions such as done during some outreaches which is not considered a problem by those in authorities. Other factors he enumerated to include poorly motivated workforce, insufficient staffing, lack of adequate facilities necessary for monitoring such as pulse oximeters, and resistance to change from older superiors. He emphasized the need for physicians to be willing and ready to accept changed especially evidenced based findings to improve their practices as most physicians are not comfortable with upsetting the status quo. This he further emphasized by referencing a study by Divya et al about the physicians experience of changing clinical practices, which concluded that physician unlearning models be modified to reflect the consonantly changing nature of clinical practice.

He shared tips to implementing cultural organization changes which can be applied in the Nigeria setting. He enumerated institutional safety protocols which are adoptable and if followed will help guide the practice of surgery in Nigeria, these include regular training on safety, periodic audit systems and practices, investment and good maintenance culture etc.

 

Dr. Muktar Ahmad shared that there were initial resistance to implementation of the surgical checklist and that its use was still variable among surgeons, but the differences was that there are strong checks and balance systems to guide the practices of heal practitioners.

 

Summary:

The key points from the webinar include:

• Surgery accounts significantly for health tourism among the Nigerian population and it is therefore important to standardize surgical practice through adoption and implementation of available guidelines to ensure safe surgical practices in Nigeria. This would have far-reaching implication to inspire confidence and possibly reduce the need to seek care abroad.
• There are who approved safe surgical guidelines designed for implementation in all countries irrespective of income status. The aim of such is to avert complications and ensure safe surgical practices if strictly adhered to.
• The rate of adoption and implementation of checklists for safe surgery is lower among low income countries and higher among high income countries, with Nigeria being at about 63%. Some factors responsible for the low uptake include non availability of these checklists in local languages, lack of time and training on the use of such tools and also non assertiveness to ensure their utilization.
• Though safe surgical practise extends beyond the operating room, routine use of checklist and standard operating procedures would aid to eliminate gross errors such as wrong siting of procedures or operating on wrong patients.
• The Nigerian health system, though imperfect is still functional and would benefit from support from the government to improve health services delivery especially as regards surgical care for patients.

 

Discussion

The were no questions in the chart box as the participants considered the presentations concise and easy to follow.

Dr. Zainab Kartongo, a consultant plastic surgeon based in Nigeria, one who is  highly passionate about safe surgery improvement and patient safety initiative, highlighted the problem of sustainability as a barrier to implementation of safer surgery practices. This problem she said could be solved through establishment of sacrosanct or non negotiable grounds. She spoke on the need for adoption of performance based models to review complications and outcomes of individual surgeons, which she said should constitute part of the employment and remuneration criteria.

Mrs. Grace Yakubu, a Nigerian trained theater nurse who eventually emigrated to the UK shared her experiences to reiterate the need for continuous use of surgical checklists to improve organization of surgical and anesthetic procedures as she believed proper and continuous utilization of checklist  as part of standard operating procedure would  prevent complications such as wrong siting of procedures which may often go unreported when such errors occur.

Dr. Mutaleeb Shobode, acknowledged that though the Nigerian system was imperfect, it was functional and required more support from the government. His facility of practice serves as a regional referral center for various orthopedic cases, which have to be done irrespective of the imperfect system in place. His opinion was that safe surgical practice neither begins nor ends in the theater but involves other aspects of preoperative and post-operative patient care, and the need to ensure that the most qualified surgeon takes the case, as well as preparedness of the facility to manage complications which may occur during and after surgical procedures. He highlighted the stress that surgeons operate in Nigeria spanning from equipment problems to amendments of procedures due to financial constraints of patients.

 

Conclusion

The webinar was brought to a close by Dr. Femi F., who expressed appreciation to all participants of the webinar session, and again seized the opportunity to reiterate the interest of the group in partnering with various persons and organizations to achieve its long term objectives.