The World Health Organization (WHO) Surgical Safety Checklist is a cost-effective tool that has been shown to improve patient safety. We explored the applicability and effectiveness of quality improvement methodology to implement the WHO checklist and surgical counts at Mbarara Regional Referral Hospital in Uganda between October 2012 and September 2013. Compliance rates were evaluated prospectively and monthly structured feedback sessions were held. Checklist and surgical count compliance rates increased from a baseline median (IQR [range]) of 29.5% (0-63.5 [0-67.0]) to 85.0% (82.8-87.5 [79.0-93.0]) and from 25.5% (0-52.5 [0-60.0]) to 83.0% (80.8-85.5 [69.0-89.0]), respectively. The mean all-or-none completion rate of the checklist was 69.3% (SD 7.7, 95% CI [64.8-73.9]). Use of the checklist was associated with performance of surgical counts (p value < 0.001; r(2) = 0.91). Pareto analysis showed that understaffing, malfunctioning and lack of equipment were the main challenges. A carefully designed quality improvement project, including stepwise incremental change and standardisation of practice, can be an effective way of improving clinical practice in low-income settings.
Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, sideeffects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.
(Anaesthesia. 2019;74:167–173)
Worldwide, cesarean section is the most frequently performed major surgery. However, most research regarding anesthesia and postoperative analgesia for cesarean section has been performed in high-income countries that have extensive health care resources. In comparison, low-income and middle-income countries have markedly fewer resources for health care in general and postoperative nursing care specifically. This study was performed to compare analgesic outcomes after cesarean section. At a hospital in Southwestern Uganda where this study was undertaken, most of the basic postoperative nursing care after cesarean section is provided by family or friends of the patient. The current study was performed to compare outcomes when intrathecal morphine or transversus abdominis plane (TAP) block was used to provide postcesarean pain control in a resource-limited setting.
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