This July, we received a $500,000 grant from GE Foundation to continue our support of safer surgery in Ethiopia.
Over the next 18 months we’ll be working with colleagues on the ground to understand more about the challenges they face – and how we can build systems and practices that work through these barriers, rather than break against them.
We’re focusing on the devastating impact of surgical site infection – painful and life-threatening for the patient, and demoralising and draining for the operating room team.
In August, our Surgical Site Infection lead, Lifebox trustee, Stanford surgeon and global surgery academic Tom Weiser visited our primary pilot site, Jimma Hospital, to begin.
Follow his progress below.
Pre-arrival and first impressions:
Jimma, the largest city in the south of Ethiopia, is located 6 hours by car from the capital city Addis Ababa – or a shorter flight. I met Nick, one of our Lifebox Fellows, at the airport in Addis and we flew together – to the town, to his apartment, and straight to Jimma University and its hospital for a quick tour.
We walked around the campus. The rooms were cavernous, with large windows and very high ceilings – but crowded with patients and their attendant families. They spill out into the hallways, metal cots stacked along dark orange walls scuffed from all the traffic and activity. There’s a new hospital being built in collaboration with Chinese construction – nearly finished after six years, but no activity on the worksite. There’s no power supply and the water hasn’t been connected. In order to obtain power, the hospital needs to procure a generator from abroad, import and install it, and connect it to the wiring – or wait for the building of a power station.
Nick has been incredibly accommodating. I am staying in his spare room, a simple house without running water in the faucets – but we have a large barrel outside the door from which we draw water into buckets that we store in the bathrooms.
We started the day by joining the surgeons for their morning hand off conference. There’s a Swiss orthopaedic traumatologist, Sonja, who briefly joined to hear about patients admitted the night before. One had a horrible fracture (pelvic and proximal femur, including a displaced fracture through the iliac wing and pubic rami). The fracture pattern is so complex that it would be hard to reduce at any hospital, much less one without fluoroscopy.
After sign out I met Dr Saifu, one of the staff surgeons here. We had tea together and he told me a bit about how the system runs. A laparotomy at the public hospital comes with a charge of 250 birr, about $12; a significant cost for some, but limited help to the hospital: it’s hardly enough to cover the cost of the suture.
Nick and I returned to the main lecture hall where I presented the WHO Surgical Safety Checklist work and science. The questions were familiar – what about emergency cases?
What about when things are not available?
Who is responsible for the checklist?
What about the legal and documenting issues?
I tried to use these opportunities to explain that the Checklist was not about ‘checking’ a box or about the paperwork, but really supposed to support and encourage team communication and an interdisciplinary discussion. They seemed satisfied with this response.
In truth, it was probably a bit premature to actually present; I would have liked to have had a few days in operating room to observe how surgery happens, and what the entire perioperative process looks like in Jimma. Without some insight into the overall workflow, structure, and processes currently in place, it’s difficult to know what is going to be applicable, or anticipate how and where the Checklist will struggle.
On top of that, I’m a new face here, and a successful Checklist has profound roots in culture and community. The professional bonds that develop between surgeons when dealing with surgical patients helps establish a sense of goodwill that strengthens the power of the presentation and helps with intellectual buy-in for the Checklist.
After the presentation I went on ward rounds with the surgical team to see some of the patients. The range of pathology is extraordinary – in addition to the typical trauma patients and wounds, we saw numerous laparotomies for bowel obstruction and perforation. Other than Sonja, the orthopaedic traumatologist from Switzerland, there are no specialist surgeons – everyone is a generalist, and they perform an incredible range of procedures including open prostatectomy, open retrieval of ureteral stones, enormous goiter resections, etc.
I finally got myself into some scrubs and plastic sandals courtesy of Nick, and went to the OR. All the staff work incredibly hard – the surgeons are quite talented technically, against a crush of work which is fairly overwhelming and essentially endless.
There are three rooms in the main complex: one for obstetrics and gynaecology with an older anaesthetic machine, one general room, and one trauma room. The trauma room is the exclusive domain of the Swiss volunteer team, GoStar. They do only traumatology and fracture repair. They have a dedicated anaesthesia provider – not an MD, as is largely the case across the hospital – but efficient and experienced. They perform a surgical pause prior to incision, but not before induction of anaesthesia, and use a whiteboard to guide this discussion. At the moment this is entirely instigated by Sonja.
The other rooms were much less structured. People circulated frequently, and it was hard to keep track of counts and antibiotics (apparently administered on the ward prior to transfer).The clean equipment room had the expected wrapping of surgical trays in cloth, and indicator tape sealed the folds. As a matter of necessity, almost everything potentially reusable is reused: diathermy, suction catheters, endotracheal tubes, IV tubing; they dispose of gloves and swabs.
As fundamental as teamwork is to the Checklist, there is a potential problem working across disciplines. It’s impossible to miss the disparity in both stature and training between the surgical staff and the anaesthetists and nurses. Issues of management, resources and support lead to delays and blame games.
At the end of the day we had a meeting with Mr Kora, the chairman of the board of the university. We introduced ourselves and then I explained about the Checklist: its origination and effect on clinical care, what the project was about and how we had identified Jimma as a pilot site. Jimma is the head of a four-hospital consortium in the southwest of the country, with aspirations to be the leader and demonstrate improvements in care, professionalism and best practices. The Checklist fits nicely with this, and allows for future implementation in other hospitals. Since they first have to get it to work themselves, Mr Kora committed to making it happen – and hoped this would also sit well with the health ministry…
I started today with coffee with Dr Saifu and quick rounds to see a few patients. There were two who were particularly sick.
One young guy who had a sigmoidectomy and colostomy for gangrenous volvulous. Colostomies are devastating here as there are almost no stoma supplies.
We were directed to another patient, an older tribesman who had been hit by a car about four days prior and had a very complex tibial plateau fracture. He was lying in a bed in a hallway flanked by a few family members, and the driver who had struck him was by the foot of the bed. The fracture would have been difficult to manage at the best hospital, and here in Jimma, with no fluoroscopy or specialized fixation equipment, it was going to be exceedingly problematic.
His relatives had kidnapped the wife and child of the driver, threatening violence if he did not facilitate all the appropriate treatment. The driver translated for Dr Saifu as the patient did not speak Amharic; he looked like he was about to faint or cry. He was pale, his cheeks drawn into his face and his eyes sunken deep into his head, but still wide and dilated, in a semi-permanent state of panic, devastating to behold. We went to find Sonja and showed her the X-ray. She confirmed the difficulty of fixation, and left towards the hall to discuss things with the patient and driver.
Dr Saifu and I met with Dr Fekadou, the hospital CEO, to discuss implementation. Dr Fekadou proposed a number of potential studies involving baseline assessments of knowledge, a situational analysis, an educational session, baseline data collection, and a formal plan for implementation. But this information is really available right now, if we ask the experts about what the processes and procedures look like: Dr Saifu and his colleagues. Dr Fekadou agreed to convene a small group of selected surgeons, anaesthetists, and OR nurses to work work together on a modified Checklist, that could begin addressing issues immediately.
We started the day with Intensive Treatment Unit rounds. From there we held a meeting in the office of Dr Diriba, the hospital medical director. Today is Eid al Adha, so things were fairly slow at the hospital, and many people were off for the holiday; Jimma has a large Muslim population, including the majority of residents. This freed up a number of staff for a meeting, with a brilliantly multi-disciplinary team: Dr Saifu (surgeon), Dr Girma (anesthesia), Admasu and Gugsa (nursing directors), Hunduma and Gezahasu (anesthetic nurses), Menbere (head theatre sister), and Tamin (theatre nurse).
We started with a quick round of introductions, and then I briefly provided an overview for those who were new and showed the Checklist video we made at the Brigham and Women’s Hospital. I then asked what they thought of the process.
Initially no one said anything.
Then the first statement: we should adopt this Checklist for patient safety!
Yes, but is this Checklist the right one for you? Could you make some changes that would make things easier?
Now people started looking at it more closely. Dr Diriba printed out a bunch of copies. I remarked that in the video there was no surgeon during the pre-anaesthetic pause, but here at Jimma it seems that the surgeon, or at least a resident, is always present at induction. So I asked if there were things they could move from one column to another.
They quickly made suggestions, starting with something they don’t routinely do: site marking the patient. In fact this is not usually an issue as most sites are obvious from the wounds or the condition (pregnancy, for example). But they did want to make sure the correct site had been confirmed in some way, even verbally – so we changed the language from “marked” to “identified”.
On we went, making changes and shifting some of the items around. Hunduma wanted to ensure that for all difficult airways a surgeon was present; since they do not have any advanced airway equipment, this was quickly agreed upon. We changed the language to include the presence of a surgeon at a difficult airway. Dr Saifu wanted the surgical issues and concerns moved to the pre-anesthesia time out as well.
Then we integrated the blood loss discussion. They wanted spaces to write things down. They wanted it included in the medical record. They discussed whether to include the entire ward pre-procedure check in this document, but opted instead to check if it had been completed. They added a check at the end regarding whether all equipment had been available, in part to document opportunities for improvement in availability of materials.
We also discussed the very different ways the Checklist is integrated into practice at Stanford and Guy’s and St Thomas’ Hospitals. I explained that as Stanford we had a poster that we used to guide the dialogue; Nick described the paper form that actually follows patients from the preoperative area to surgery and recovery, and includes the pre-OR checklist similar to what they had discussed.
Gugsa asked how difficult it was to implement. Very, I answered.
The conversations were detailed, occasionally conflicted, and overall incredibly helpful. We made a plan for next steps – a draft version to circulate and pilot in surgery. Then the inevitable killer questions: how do we study this?
How do we do a pre-assessment and see how much improvement is made?
And how is the GE Foundation going to help us in this program?
I pushed back against the idea of a formal study. We already know the data – a New England Journal of Medicine article demonstrating the effects of such a Checklist – and now we need to refine the product for the local market. This is, I explained, science, but not the science that we clinicians are used to.
The academic lessons learned are incredibly valuable, I explained, but my descriptions of the difficulties, challenges, and ultimately of the solutions for implementation are more important for convincing them than the data. We know that testimony is often the most important tool to persuade people of its effect.
I explained that the Checklist implementation program would help the entire staff at Jimma understand where and why failures happen and provide important baseline data and evidence for how things could be improved. Once the GE Foundation has a more concrete vision for this entire enterprise, they can together determine how processes can be strengthened and where resources and expertise can best be leveraged.
The meeting concluded on a very positive note. From there, coffee with Gugsa and Drs Saifu and Diriba to discuss in more depth some of the nuances of implementation – and how this could be a first step towards improved perioperative care. Jimma has a very large manual of protocols for perioperative care, and we talked about Checklists and worksheets as useful tools for translating protocol into clinical care.
We discussed strategies for improving OT nursing, including the idea of a special training program (currently none exist) with Menbera and Tamin, excellent scrub nurses. They have all the local expertise they need, but they noted a huge barrier to launching new programmes was the lack of a foreign partner. They need higher-profile partnerships to convince administration that these kind of programmes are worthwhile and important. Thus the perverse effect of foreign aid…
Tomorrow, first day of testing!
Hand off rounds was at 8, which took a bit of time as there were several cases to review from the holidays. I then met the nurses and gave a presentation to them about the Checklist. Following yesterday’s conversation, I focused more on stories and anecdotes, rather than data, showing both the instructional video as well as the episode in ER of Benson using the Checklist. (Unfortunately none of the audience was familiar with the TV series, so that was kind of a bust.)
As mentioned, there is no formal training system for either the circulating or scrub nurses – a source of frustration for everyone, as it’s hard to develop routine practices or good habits and strategies for managing tables and instruments.
Heading to the OR, the first cases of the day were just finishing, so I stuck around – and when Dr Saifu prepared for his next case, I led the Jimma version of the Checklist. We did it smoothly, without too much fanfare or production, and didn’t dwell on some of the inconsistencies. It actually promoted a bit of communication, although some of it happened after the Checklist was done. But in many ways I felt like the experience might have “activated” people in the room to talk about the case.
We started with the correct patient and consent. This is fairly problematic, as there really isn’t a formal process for obtaining consent and it’s unclear how much the patients really know about what is going to happen. There are some generic forms that don’t include a description of the procedure, but are sometimes signed in the OR by having patients’ thumbprint the document – fairly common, since many cannot read.
Preoperative preparations were completed on the ward, though it was unclear what they were. Anaesthesia safety check and monitors – all completed appropriately. No allergies, no concerns for the airway. I asked Dr Saifu about the surgical site, position, and procedure, and that all went fine: open cholecystectomy, one hour case, 100 ml expected blood loss.
Any specific concerns?
I asked the scrub nurse, do you have all the equipment you need? Yes. Pre-anesthetic check done. There were draping and equipment issues noted during the skin prep and draping process, but it was sorted – and the surgical team got in position.
I started the pre-incision Checklist. Team introductions went smoothly and without any snickering; they seemed a bit surprised, but did it without hesitation.
Antibiotic given in last 60 minutes?
Check. But actually there was no way to know this, with no documentation to identify.
No, but after the case maybe if they placed an NG tube. Fine.
Specific concerns from the team? Routine open chole; unless there was something unusual all should be smooth.
Instrument sterility confirmed? Yes. And I did notice the sterility indicator tape around the instrument trays and drapes.
Equipment issues or concerns?
The diathermy does not work, has not worked well for months; but they have not been able to procure a new one. (I’m working on this now in Addis, if I find one I’m going to buy it and send it to Saifu).
I watched over Saifu’s shoulder as he took the resident through a tough open cholecystectomy. All went well, gall bladder out in an hour without much blood loss, and now they’re closing fascia.
The first, posterior layer closed – but wait, there seems to be an incorrect towel count. Saifu asked for the count again, we located the towel in the drapes.
As they started closing the anterior layers I asked if I could do the final part of the Checklist. What procedure?
Open chole, check.
Sponge, instrument, and needle counts complete? Check, though I didn’t see any instruments counted, and there were no sheets to record the numbers and types of instruments, sponges, or needles.
Were all instruments available during surgery? Yes.
Were there equipment problems? Yes – diathermy still not working well, and the long Meztenbaum scissors were so dull they couldn’t cut. But they were placed back in the tray with the rest of them, and Saifu sighed as he was sure to get them handed to him in an upcoming case.
Any concerns for recovery and management? None.
I asked about antibiotics – Saifu wanted 2 days worth. I asked about feeding – as tolerated, he said.
And with that, we were done.
I suppose I could be accused of fudging the Checklist, or of not being true to its purpose. There were many process issues to address, and it was going to be extremely difficult to bring the hospital into compliance with this single piece of paper, with the standards laid out in the WHO guidelines. Together we have our work cut out for us. But I also wanted the team to know that it doesn’t have to be difficult, even if it’s certainly awkward at first. When it’s done well and everything is in place, it takes no time at all.
Checklists can make us uncomfortable, but that passes. My main goal, to be honest, was to get them talking to one another, and we certainly did this.
My plane was leaving soon, I said my goodbyes to the staff and to Sonja (from GoStar) and to Nick, found a badjadj (the local name for a three-wheeled tuk-tuk), and headed to the airport. Now if I can just locate a diathermy pencil and a few cautery tips…
I had an uneventful flight back to Addis Ababa yesterday afternoon. After checking in to my hotel I called Dawit Moges, the CEO of Sister Aklesia Hospital in Adama. We had originally been connected through Dr Gitahi from Smile Train (following introduction’s from Priya Desai). Smile Train works at the hospital, and Dr Gitahi was confident that this would be a good place to trial the Checklist – supportive of their work and complimentary of staff and management.
Dawit spends most of the week running a private diagnostic lab in Addis; the first (and perhaps only) ISO certified laboratory in Ethiopia. He’s a stickler for detail and for strong protocols and procedures – indeed that’s how they were able to get certified to international standards, and they’re working on the same certification at Sister Aklesia.
I then told him about the program, the background, how the Checklist came about, what I was doing in Ethiopia, and about Lifebox Foundation. After showing him the data, he was quite enthusiastic.
“We must use this Checklist!” he proclaimed, but then hesitated.
The doctors have to have an incentive to do such work. I provided my three standard answers. In addition to improved patients safety, the Checklist:
- makes life easier because the communication it fosters helps reduce the numerous little frustrations clinicians experience while doing their job because it helps identify issues before they even arise
- actually saves time. It takes only 45 seconds or a minute to complete if everything runs smoothly, and at Stanford it cut the average operating day by 45 minutes so everyone gets to go home a bit earlier
- is currently best practice, and everyone wants to claim to perform to best practice standards.
But what about recognition? Is there a certification, or some sort of pin, or treat, or something that we can offer the staff? I agreed and told him of our ongoing discussions about developing a piece of equipment to accompany the project, and that one reason we believe we have been so successful with our safe anaesthesia work was the fact that we had an invaluable piece of kit to accompany our training.
He stood, picked up the phone, and dialled; a few minutes of Amharic followed, and then we set things up for me to Arrive in Adama the following morning at 9am. Demrew, his chief administrator, would have the operating room staff ready for a meeting the Saturday morning of a holiday weekend. Thus signalled my entry into the private sector.
I hired a car to Adama, and arrived in the morning. Entering the hospital I met Mekonen, head of the lab and the person in charge of hospital documentation, who showed me around the small but organized facility. As we approached the OR, he introduced me to Dr Tesfaye, the principle staff surgeon and medical director for the hospital. He noted that I was going to introduce a new program for surgery to the hospital and hoped to talk to all the theatre staff.
As it happens, we had the chance to introduce it in real time first.
He introduced me to Gemechu, the nurse anesthetist, and Emenesh and Aberu, the two theatre sisters. The patient was on the table but not yet under anaesthesia. I didn’t want to disturb their routine so I did not interrupt, but I did notice the Lifebox pulse oximeter beeping away on the anaesthesia stand!
Anaesthesia commenced without difficultly, and Dr Tesfaye put on rubber aprons, washed his hands, and returned to the theatre while Sister Emenesh prepped the skin. He gowned and gloved while Sister Aberu draped the patient. We were ready. He held his hand out for the knife, and with his permission, I spoke up.
“You know,” I said, “at Stanford we do a pause here to make sure everyone is prepared and everything is ready. In fact, this is the thing I’m going to present to you after we are done.” Tesfaye smiled through his mask.
“I start by asking everyone to introduce themselves. Since I’m new, I don’t know everyone – and even though I just met you I would like to hear you say your names once more. I’m Tom Weiser, a surgeon from Stanford.”
“I am Dr Tesfaye.”
“I am Gemechu, anesthetist.”
“I am sister Aberu.”
“I am sister Emenesh.”
“So, we’ll be doing an open cholecystectomy,” I said. “It will take about one hour total, probably less. We don’t expect more than 100 ml of blood loss, do we Dr Tesfaye?”
“And do we need any antibiotics?”
“They have been given.”
“Is there anything unusual about this patient or procedure, or things we should know?”
Turning to Gemechu I asked, “do you have any anesthesia concerns?”
“No,” he replied.
“Is all our equipment ready? Is there anything special we need for this?”
“It seems that we are all set then.” I thanked them all.
Dr Tesfaye performed an open cholecystectomy smoothly and efficiently, and was done in 30 minutes. Once the peritoneum closed, I indicated that I’d like to speak again.
“We also do a quick debriefing at the end of surgery to make sure there is nothing missed. So, to confirm, we did an open cholecystectomy. Are all the counts correct?”
“And will you send this gall bladder as a specimen?”
“Were there any other equipment problems?”
I turned to Tesfaye. “Any other concerns?”
There were not, he replied.
“Would you keep giving antibiotics?”
This was a very straightforward surgery, no spillage, and no indication – so no more antibiotics.
And we were done. We all changed and met in one of the conference rooms, and I gave them the formal presentation with all the data, details, stories, etc. I reiterated the importance of creating their own Sister Aklesia Checklist, and passed around a few copies of the one Jimma had created. The entire staff, particularly Dr Tesfaye, was enthusiastic.
I kept repeating that they should start small – make a personalized Checklist, try it for a day, see how it worked, and keep trying to make it better until everyone was comfortable with it. Dr Tesfaye was keen to make it a standard practice at the hospital, since it serves as the facility for a number of other surgeons doing private cases. But he was also keen to get the system right in his own theatre, and said he would hold off on spreading it until he was comfortable using it.
Tesfaye and Mekonen took me out for lunch at Yilma’s, a well-known restaurant that serves raw meat cut straight off the carcass. And I ate it, and it was delicious.