Lifebox pulse oximeter implementation in Malawi: evaluation of educational outcomes and impact on oxygen desaturation episodes during anaesthesia

Abstract

Pulse oximetry is an essential monitor for safe anaesthesia but is often not available in low-income countries. The aim of this study was to determine whether the introduction of pulse oximetry with training was feasible and could reduce the incidence of oxygen desaturation during anaesthesia in a low-income country. Pulse oximeters were donated, with training, to 83 non-physician anaesthetists in Malawi. Knowledge was tested immediately before and after training and at follow-up. Providers were asked to record the lowest peripheral oxygen saturation (SpO 2 ) for the first 100 cases anaesthetised after training. The primary clinical outcome was the proportion of cases with an oxygen desaturation event (SpO 2 < 90%). Seventy-seven of 83 (93%) participants completed all pre-and post-training tests. Pulse oximetry knowledge improved after training from a median (IQR [range]) score of 39 (37-42 [28-48]) to 44 (42-46 [35-50]) and this knowledge was maintained for 8 months (p < 0.001). Oxygen saturation data and provider responses were recorded for 4772 cases. The proportion of oxygen desaturation episodes decreased from 17.2% to 6.5%, representing a 36% reduction in the odds of an oxygen desaturation event in the second 50 cases compared with the first 50 (OR 0.64, 95% CI 0.50-0.82, p < 0.001). We conclude that donation of pulse oximeters, with training, in Malawi was feasible, improved knowledge and reduced the incidence of oxygen desaturation events.

The effective introduction of Lifebox pulse oximetry to Malawi

“…In the article by Albert et al [6], a 'preventable anaesthesia mortality' in Malawi of approximately 1 in 500 is described, which is orders of magnitude higher than those published for high income countries, which are typically 1 in 50,000 or lower (the 'preventability' at this extreme is of course an ongoing discussion) [13]. This highlights the potential benefits of what is taken for granted and difficult to 'test' in better resourced environments.…”

“…Programmes such as Lifebox are an important part of this upscaling of safe surgical activity. The retention of the equipment and knowledge in Malawi, despite many challenges and recent major floods [6], reflects the relevance and robustness of the Lifebox program.…”

What is the real oximeter gap?

“…So I examined the incidence of opening quotations in 150 consecutive Anaesthesia editorials up to September 2017. I discovered musings from Voltaire [1] and Tolstoy [2], William Osler [3], Atul Gawande [4], and even Michael Jordan [5], The Beatles [6] and Spiderman's uncle [1]! Henry Ford put in a particularly strong showing, supplying three quotations to three editorials over the time period [7][8][9].…”

“…Using three rabbits weighing between 2.7 kg and 4 kg to simulate neonatal respiratory system [1], and a bronchial blocker to create reproducible airway obstruction, we provided oxygenation using manual jet ventilation (MJV) first and then the oxygen flowmeter (OFM), or vice versa. One transtracheal cannula was used to deliver oxygen while another was used for measuring iPEEP.…”

“…Over the past 5 years, Lifebox has distributed over 15,000 oximeters (with training), in an attempt to address this gap. Some of these have been donated to institutions based on their number of operating rooms, whereas others have been provided to individual anaesthetists [1,2,8]. The current Lifebox pulse oximeter costs £189 (€213, $250), and comes with a 5-year guarantee.…”