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Open Access 01-03-2019 | Care | Global Health Anesthesia (MJ Harris, Section Editor)

A Review of Anesthesia Simulation in Low-Income Countries

Authors: Oleg Turkot, Michael C. Banks, Seung Woo Lee, Adam Dodson, Shirley Duarte, Mwemezi Kaino, Howard Nelson-Williams, Serkan Toy, John Sampson

Published in: Current Anesthesiology Reports | Issue 1/2019

Abstract

Purpose of Review

Anesthesia workforce gaps in low- and middle-income countries (LMICs) can hinder safe surgical care. Several countries have fewer than one anesthesiologist per million population and some have fewer than two anesthesiologists nationally. Limited apprenticeship opportunities and inadequate supervision present serious challenges in these locations. Although simulation training could help disseminate expert guidance, the high cost, technical challenges, and varied approaches limit application. We reviewed the literature on cost-efficient and effective simulation training programs for anesthesia workforces in LMICs.

Recent Findings

Publications relevant to anesthesia simulation in these countries are limited but include anesthesia skill gap identification, technical skill training, and scenario management.

Summary

High-cost, high-technology simulation available in high-resource countries is often impractical in LMICs. We identified low-cost approaches that are typically used to assess skill deficiencies and develop nontechnical and technical skills. Future studies should evaluate optimal modalities and equipment for greatest impact.

Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624. https://doi.org/10.1016/S0140-6736(15)60160-X.CrossRef

The World Bank. New country classifications by income level: 2016-2017. 2016. Available from https://blogs.worldbank.org/opendata/new-country-classifications-2016. Accessed 13 Sept 2018.

Taché S, Mbembati N, Marshall N, Tendick F, Mkony C, O’Sullivan P. Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania. Hum Resour Health. 2009;7:64. https://doi.org/10.1186/1478-4491-7-64.CrossRefPubMedPubMedCentral

Holmer H, Shrime MG, Riesel JN, Meara JG, Hagander L. Towards closing the gap of the global surgeon, anaesthesiologist, and obstetrician workforce: thresholds and projections towards 2030. Lancet. 2015;385(Suppl 2):S40. https://doi.org/10.1016/S0140-6736(15)60835-2.CrossRefPubMed

Holmer H, Lantz A, Kunjumen T, Finlayson S, Hoyler M, Siyam A, et al. Global distribution of surgeons, anaesthesiologists, and obstetricians. Lancet Glob Health. 2015;3(Suppl 2):S9–11. https://doi.org/10.1016/S2214-109X(14)70349-3.CrossRefPubMed

Livingston P, Bailey J, Ntakiyiruta G, Mukwesi C, Whynot S, Brindley P. Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership. Pan Afr Med J. 2014;17:315. https://doi.org/10.11604/pamj.2014.17.315.4211.CrossRefPubMedPubMedCentral

Derbew M. COSECSA collaborates to address surgical shortages in sub-Saharan Africa. 2018. Available from http://bulletin.facs.org/2018/05/cosecsa-collaborates-to-address-surgical-shortages-in-sub-saharan-africa/. Accessed 31 Aug 2018.

•• Chima AM, Koka R, Lee B, Tran T, Ogbuagu OU, Nelson-Williams H, et al. Medical simulation as a vital adjunct to identifying clinical life-threatening gaps in austere environments. J Natl Med Assoc. 2018;110:117–23. https://doi.org/10.1016/j.jnma.2017.12.003The only article using simulation scenarios to assess knowledge and skills gaps in Africa and other low-income countries. Describes using spontaneous breathing simulation model which is the most common airway management technique in low-resource countries. CrossRefPubMed

McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003–2009. Med Educ. 2010;44:50–63. https://doi.org/10.1111/j.1365-2923.2009.03547.x.CrossRefPubMed

10.

Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, Bradshaw JH, Diener-West M, Perretta JS, et al. Pediatric resident resuscitation skills improve after “rapid cycle deliberate practice” training. Resuscitation. 2014;85:945–51. https://doi.org/10.1016/j.resuscitation.2014.02.025.CrossRefPubMed

11.

Magee MJ, Farkouh-Karoleski C, Rosen TS. Improvement of immediate performance in neonatal resuscitation through rapid cycle deliberate practice training. J Grad Med Educ. 2018;10:192–7. https://doi.org/10.4300/JGME-D-17-00467.1.CrossRefPubMedPubMedCentral

12.

Taras J, Everett T. Rapid cycle deliberate practice in medical education - a systematic review. Cureus. 2017;9:e1180. https://doi.org/10.7759/cureus.1180.CrossRefPubMedPubMedCentral

13.

Knowles MS, Holton EF, Swanson RA. A theory of adult learning: andragogy. The adult learner: the definitive classic in adult education and human resource development. London: Elsevier; 2005. p. 35–72.

14.

Zigmont JJ, Kappus LJ, Sudikoff SN. Theoretical foundations of learning through simulation. Semin Perinatol. 2011;35:47–51. https://doi.org/10.1053/j.semperi.2011.01.002.CrossRefPubMed

15.

Mezirow J. Learning as transformation: critical perspectives on a theory in progress. 2000. Available from https://eric.ed.gov/?id=ED448301. Accessed 23 Sept 2018.

16.

Clapper TC. Beyond Knowles: what those conducting simulation need to know about adult learning theory. Clin Simul Nurs. 2010;6:e7–e14.CrossRef

17.

Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. J Med Educ. 1969;44:515–9.PubMed

18.

Lane JL, Slavin S, Ziv A. Simulation in medical education: a review. Simul Gaming. 2001;32:297–314.CrossRef

19.

Engum SA. Do you know your students’ basic clinical skills exposure? Am J Surg. 2003;186:175–81.CrossRef

20.

Okuda Y, Bryson EO, DeMaria S, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 2009;76:330–43.CrossRef

21.

Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011;306(9):987–8.CrossRef

22.

Cook DA, Brydges R, Hamstra SJ, Zendejas B, Szostek JH, Wang AT. Comparative effectiveness of technology-enhanced simulation versus other instructional methods- a systematic review and meta-analysis. Sim Healthcare. 2012;7:308–20.CrossRef

23.

• Artyomenko VV, Nosenko VM. Anaesthesiologists’ simulation training during emergencies in obstetrics. Rom J Anaesth Intensive Care. 2017;24:37–40. https://doi.org/10.21454/rjaic.7518.241.dymThe only recent article on simulation training in a low middle income country in Europe. CrossRefPubMedPubMedCentral

24.

Core competencies for interprofessional collaborative practice. 2011. Available from https://www.aacom.org/docs/default-source/insideome/ccrpt05-10-11.pdf?sfvrsn=77937f97_2. Accessed 9 Oct 2018.

25.

Scavone BM, Toledo P, Higgins N, Wojciechowski K, McCarthy RJ. A randomized controlled trial of the impact of simulation-based training on resident performance during a simulated obstetric anesthesia emergency. Simul Healthc. 2010;5:320–4. https://doi.org/10.1097/SIH.0b013e3181e602b3.CrossRefPubMed

26.

Bhagwat M. Simulation and anaesthesia. Indian J Anaesth. 2012;56:14–20. https://doi.org/10.4103/0019-5049.93338.CrossRefPubMedPubMedCentral

27.

Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ non-technical skills. Br J Anaesth. 2010;105:38–44. https://doi.org/10.1093/bja/aeq134.CrossRefPubMed

28.

Lopreiato JO, Downing D, Gammon W, Lioce L, Sittner B, Slot V, et al. Healthcare simulation dictionary. Rockville: Agency for Healthcare Research and Quality; 2016.

29.

Yee B, Naik VN, Joo HS, Savoldelli GL, Chung DY, Houston PL, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology. 2005;103:241–8.CrossRef

30.

Gu Y, Witter T, Livingston P, Rao P, Varshney T, Kuca T, et al. The effect of simulator fidelity on acquiring non-technical skills: a randomized non-inferiority trial. Can J Anaesth. 2017;64:1182–93. https://doi.org/10.1007/s12630-017-0973-2.CrossRefPubMed

31.

• Skelton T, Nshimyumuremyi I, Mukwesi C, Whynot S, Zolpys L, Livingston P. Low-cost simulation to teach anesthetists’ non-technical skills in Rwanda. Anesth Analg. 2016;123:474–80. https://doi.org/10.1213/ANE.0000000000001434An excellent resource on implementation of nontechnical skills in sub-Saharan Africa. CrossRefPubMed

32.

Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. 1978. Qual Saf Health Care 2002; 11: 277–282.

33.

Williamson JA, Webb RK, Sellen A, Runciman WB, Van der Walt JH. The Australian Incident Monitoring Study. Human failure: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:678–83.CrossRef

34.

Perry MF, Seto TL, Vasquez JC, Josyula S, Rule ARL, Rule DW, et al. The influence of culture on teamwork and communication in a simulation-based resuscitation training at a community hospital in Honduras. Simul Healthc. 2018;13:363–70. https://doi.org/10.1097/SIH.0000000000000323.CrossRefPubMed

35.

Chung HS, Dieckmann P, Issenberg SB. It is time to consider cultural differences in debriefing. Simul Healthc. 2013;8:166–70. https://doi.org/10.1097/SIH.0b013e318291d9ef.CrossRefPubMed

36.

Pratt SD. Focused review: simulation in obstetric anesthesia. Anesth Analg. 2012;114:186–90. https://doi.org/10.1213/ANE.0b013e3182377bbc.CrossRefPubMed

37.

Alinier G, Dodson A. International perspectives on the role of the simulation operations specialist. In: Gantt LT, Young HM, editors. Healthcare simulation: a guide for operations specialists. Hoboken: Wiley; 2015.

38.

Grimes CE, Bowman KG, Dodgion CM, Lavy CB. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg. 2011;35:941–50. https://doi.org/10.1007/s00268-011-1010-1.CrossRefPubMed

39.

Lorello GR, Cook DA, Johnson RL, Brydges R. Simulation-based training in anaesthesiology: a systematic review and meta-analysis. Br J Anaesth. 2014;112:231–45. https://doi.org/10.1093/bja/aet414.CrossRefPubMed

40.

Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011;306:978–88. https://doi.org/10.1001/jama.2011.1234.CrossRefPubMed

41.

Morriss WW, Milenovic MS, Evans FM. Education: the heart of the matter. Anesth Analg. 2018;126:1298–304. https://doi.org/10.1213/ANE.0000000000002653.CrossRefPubMed

42.

Dubowitz G, Detlefs S, McQueen KA. Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices. World J Surg. 2010;34:438–44. https://doi.org/10.1007/s00268-009-0229-6.CrossRefPubMed

43.

Kneebone RL, Nestel D, Vincent C, Darzi A. Complexity, risk and simulation in learning procedural skills. Med Educ. 2007;41:808–14. https://doi.org/10.1111/j.1365-2923.2007.02799.x.CrossRefPubMed

44.

Okrainec A, Henao O, Azzie G. Telesimulation: an effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc. 2010;24:417–22. https://doi.org/10.1007/s00464-009-0572-6.CrossRefPubMed

45.

Mikrogianakis A, Kam A, Silver S, Bakanisi B, Henao O, Okrainec A, et al. Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries. Acad Emerg Med. 2011;18:420–7. https://doi.org/10.1111/j.1553-2712.2011.01038.x.CrossRefPubMed

46.

Shaikh FM, Hseino H, Hill AD, Kavanagh E, Traynor O. Mobile surgical skills education unit: a new concept in surgical training. Simul Healthc. 2011;6:226–30. https://doi.org/10.1097/SIH.0b013e318215da5e.CrossRefPubMed

47.

Glenshaw M, Madzimbamuto FD. Anaesthesia associated mortality in a district hospital in Zimbabwe: 1994 to 2001. Cent Afr J Med. 2005;51:39–44.PubMed

48.

Linden AF, Sekidde FS, Galukande M, Knowlton LM, Chackungal S, McQueen KA. Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda’s public hospitals. World J Surg. 2012;36:1056–65. https://doi.org/10.1007/s00268-012-1482-7.CrossRefPubMed

49.

Lim G, Krohner RG, Metro DG, Rosario BL, Jeong JH, Sakai T. Low-fidelity haptic simulation versus mental imagery training for epidural anesthesia technical achievement in novice anesthesiology residents: a randomized comparative study. Anesth Analg. 2016;122:1516–23. https://doi.org/10.1213/ANE.0000000000001260.CrossRefPubMedPubMedCentral

50.

Issenberg SB, McGaghie WC, Petrusa ER, Lee GD, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27:10–28. https://doi.org/10.1080/01421590500046924.CrossRefPubMed

51.

Rudolph JW, Simon R, Raemer DB, Eppich WJ. Debriefing as formative assessment: closing performance gaps in medical education. Acad Emerg Med. 2008;15:1010–6. https://doi.org/10.1111/j.1553-2712.2008.00248.x.CrossRefPubMed

52.

Brett-Fleegler M, Rudolph J, Eppich W, Monuteaux M, Fleegler E, Cheng A, et al. Debriefing assessment for simulation in healthcare: development and psychometric properties. Simul Healthc. 2012;7:288–94. https://doi.org/10.1097/SIH.0b013e3182620228.CrossRefPubMed

53.

Dubowitz G, Evans FM. Developing a curriculum for anaesthesia training in low- and middle-income countries. Best Pract Res Clin Anaesthesiol. 2012;26:17–21. https://doi.org/10.1016/j.bpa.2012.02.004.CrossRefPubMed

54.

Lundeg G, Baric A, Pescod DC, Pescod K. Anesthesia development in Mongolia: strengthening anesthesia practice in Mongolia through education and continuing professional development. Anesth Analg. 2018;126:1287–90. https://doi.org/10.1213/ANE.0000000000002566.CrossRefPubMed

55.

Khan FA, Merry AF. Improving anesthesia safety in low-resource settings. Anesth Analg. 2018;126:1312–20. https://doi.org/10.1213/ANE.0000000000002728.CrossRefPubMed

56.

Bergman S, Deckelbaum D, Lett R, Haas B, Demyttenaere S, Munthali V, et al. Assessing the impact of the trauma team training program in Tanzania. J Trauma. 2008;65:879–83. https://doi.org/10.1097/TA.0b013e318184a9fe.CrossRefPubMed

57.

Livingston P, Evans F, Nsereko E, Nyirigira G, Ruhato P, Sargeant J, et al. Safer obstetric anesthesia through education and mentorship: a model for knowledge translation in Rwanda. Can J Anaesth. 2014;61:1028–39. https://doi.org/10.1007/s12630-014-0224-8.CrossRefPubMed

58.

Taira BR, Orue A, Stapleton E, Lovato L, Vangala S, Tinoco LS, et al. Impact of a novel, resource appropriate resuscitation curriculum on Nicaraguan resident physician’s management of cardiac arrest. J Educ Eval Health Prof. 2016:13–25. https://doi.org/10.3352/jeehp.2016.13.25.

59.

Urbano J, Matamoros MM, Lopez-Herce J, Carrillo AP, Ordonez F, Moral R, et al. A paediatric cardiopulmonary resuscitation training project in Honduras. Resuscitation. 2010;81:472–6. https://doi.org/10.1016/j.resuscitation.2010.01.007.CrossRefPubMed

60.

Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-Booth J. The WFSA global anesthesia workforce survey. Anesth Analg. 2017;125(3):981–990. https://doi.org/10.1213/ANE.0000000000002258

Title: A Review of Anesthesia Simulation in Low-Income Countries
Authors: Oleg Turkot
Michael C. Banks
Seung Woo Lee
Adam Dodson
Shirley Duarte
Mwemezi Kaino
Howard Nelson-Williams
Serkan Toy
John Sampson
Publication date: 01-03-2019
Publisher: Springer US
Keyword: Care
Published in: Current Anesthesiology Reports / Issue 1/2019
Electronic ISSN: 2167-6275
DOI: https://doi.org/10.1007/s40140-019-00305-4

At a glance: The STEP trials

Springer Medicine

A Review of Anesthesia Simulation in Low-Income Countries

Abstract

Purpose of Review

Recent Findings

Summary

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

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