Global Capnography Project (GCAP): implementation of capnography in Malawi – an international anaesthesia quality improvement project

Abstract

Summary The Lancet Commission on Global Surgery emphasised the importance of access to safe anaesthesia care. Capnography is an essential monitor for safe anaesthesia, but is rarely available in low‐income countries. The aim of this study was twofold: to measure the prevalence of capnography in the operating theatres and in intensive care units; and to determine whether its introduction was feasible and could improve the early recognition of critical airway incidents in a low‐income country. This is the first project to do this. Forty capnographs were donated to eight hospitals in Malawi. Thirty‐two anaesthesia providers received a 1‐day capnography training course with pre‐ and post‐course knowledge testing. Providers kept logbooks of capnography use and recorded their responses to abnormal readings. On follow‐up at 6 months, providers completed questionnaires on any significant patient safety incidents identified using capnography. In January 2017, at the commencement of the project, only one operating theatre had a capnograph. Overall, 97% and 100% ‘capnography gaps’ were identified in the theatres and intensive care units, respectively. The mean (SD) scores of our capnography multiple choice questionnaires improved after training from 15.00 (3.16) to 18.70 (0.99), p = < 0.001. The capnography equipment was appropriately robust and performed well. Six months following implementation, 24 (77%) anaesthesia providers reported recognising 44 oesophageal intubations and 28 (90%) believed that capnography had saved lives. This study has shown it is feasible to introduce capnography in a low‐income country, resulting in early recognition of critical airway incidents and ultimately helping to save lives. Building on the experience of the first trial of pulse oximetry implementation in low‐income countries in 2007, we believe this is one of the most important projects in anaesthesia safety in the last decade.

The global capnography gap: a call to action

“…The study by Jooste et al. published in this issue of Anaesthesia not only highlights the capnography gap by assessing the prevalence of capnography in a low‐income country (Malawi) but also is the first to report the feasibility of implementing capnography among anaesthesia providers and the potential for averting significant morbidity and mortality by increasing access to capnography in operating theatres, ICUs and emergency departments worldwide . The authors are to be congratulated on this achievement.…”

“…General anaesthesia in low‐ and middle‐income countries is frequently administered by providers with very limited training. Respiratory complications are a relatively common adverse event . The study by Jooste et al.…”

“…The study by Jooste et al. estimates a rate of 11.7 oesophageal intubations per million population per year (44 oesophageal intubations for a population of 7.5 million during the 6‐month study period) in Southern Malawi . When extrapolated to the entire African continent this equates to over 11,000 oesophageal intubations per year.…”

“…One of the merits of the Jooste et al. study is that they used a simple tool for interpreting the capnography curves which allowed for rapid training of anaesthesia providers with various levels of knowledge . However, it is unclear if the 6‐month follow‐up questionnaire used in this study assessed knowledge retention, as this would be key for ongoing, accurate incident recognition and reporting.…”

Global capnography and airway teaching. A reply

“…We thank Basler et al. for their interest in the Global Capnography Project (GCAP) and also congratulate them on their airway training work in the plastic surgical unit across Ghana. The data they give including seven deaths from failed ventilation or aspiration, confirm the serious airway issues that exist in low‐income countries.…”