Global Surgery

Capacity Building and Systems Innovation

Global Surgery

Problem

According to The Lancet’s Global Surgery 2030 report, more than five billion people lack access to safe, affordable surgical and anesthesia care when needed. Meeting the actual global surgical disease burden would require adding a minimum of 143 million operations every year, primarily in the poorest regions of the world where there is a severe deficit in healthcare workforce and infrastructure. Moreover, of those who can access surgical care, 33 million individuals face catastrophic health expenditure each year as a result of costs incurred.

Approach

Build capacity across multiple sectors of professional development of the surgical workforce, accompanying the next generation of global surgery leaders across every point in their journey, developing skill sets in surgical care delivery, medical education, and research.

Impact

From the program’s early days working on the World Health Organization Surgical Safety Checklist, which helped to reduce surgery-related deaths and complications around the globe, Brigham and Women’s Hospital has been a leader in advocating for the indispensable role surgery plays in global health.

Affiliate Faculty

Staff

Senior Project Manger – Wendy Williams, JD

Fellows

Rachel Koch, MD

Supporting the Next Generation | Education and Innovation

Contextualizing continuing medical education and engaging in parallel professional development of future leaders/champions of increased access to quality surgical care for vulnerable populations.

Rwanda HRH Program

Brigham and Women’s Hospital serves as the coordinating partner for surgery for the Rwanda Human Resources for Health (HRH) Program. Going into it’s seventh year, the institutional twinning program, facilitating the training of physicians, nurses, health managers, and dentists, has introduced competency-based training and pedagogic innovation into the medical education system. A dozen general surgeons, surgical specialists, radiologists, and anesthesiologists travel to Rwanda to serve as faculty, lowering the ratio of faculty to residents and supporting the professional development of junior faculty. With 300 new SAOs (surgeons, anesthesiologists, and obstetricians) trained by 2023, the Rwandan surgical workforce has nearly quadrupled since the Program’s inception.

NOTSS-VRC

First rolled out at the University of Rwanda for a multidisciplinary cohort of surgeons, obstetricians, and anesthesiologists, Non-technical Skills for Surgeons: Variable Resource Contexts (NOTSS-VRC) is a contextually-adjusted course designed to improve operating room behaviors that impact patient safety. The course was developed and implemented by a team of CSPH and Rwandan faculty and trainees, utilizing text and video content created in Rwanda. It has been taught twice at the University of Rwanda (October 2017 and March 2018) and is currently being integrated into the University of Rwanda curriculum.

The NOTSS team recently received a grant to support the implementation and evaluation of a NOTSS course for surgical providers in Rwandan district hospitals (e.g., general practitioners, nurse anesthetists, perioperative nurses), where over 80% of surgical procedures in Rwanda currently performed. This course is set to be implemented in 2019.

STARTLE

Surgical Techniques and Repairs in Trauma for the Low-Resource Environment (STARTLE), is a cadaver-based operative trauma course designed to teach surgical management. First taught in Mbarara, Uganda, this course was designed by a team led by Dr. Deepika Nehra for mid-level surgical residents. It has been replicated in Haiti and soon Rwanda (2019) as a way to improve trauma surgery capacity.

SURGICAL SITE INFECTIONS

Surgical site infections (SSI) are a rising cause of concern for countries wishing to expand surgical capacity and serve as a warning for the risks of expanding access to surgical care without a concerted effort to ensure quality and appropriate, context-relevant guidelines for care. We have focused our work around the care of and outcomes among women undergoing cesarean delivery at a district hospital in rural Rwanda. In our most recent study at a Rwandan district hospital, we have found that an estimated 11% of women develop a surgical site infection at 10-days post-cesarean delivery. In view of the rising rate of cesarean deliveries provided at the district hospital level and the challenges the women face in seeking postoperative care, these findings sound an alarm for an impending maternal health and surgical care delivery crisis. Our research, funded through the NIH, has included the development of an algorithm to help community health workers identify SSI, improved understanding of predictors for cesarean delivery, cataloging the range of antibiotic prescribing practices at a district hospital following cesarean section surgery, a randomized control trial assessing different modalities for improved follow-up for SSI, and determining barriers to access to return to care. Pending studies will explore the utility of technology in aiding SSI identification.

Implementation | Policy and Practice

Partnering with ministries of health, professional societies, and NGOs to incorporate evidence-based policy and practice into global health agendas.

Recent Publications

General Thoracic Surgery in Rwanda: An Assessment of Surgical Volume and of Workforce and Material Resource Deficits.

Evaluating the impact of the national health insurance scheme of Ghana on out of pocket expenditures: a systematic review.

Disparate outcomes of global emergency surgery – A matched comparison of patients in developed and under-developed healthcare settings.

Identification of the Critical Nontechnical Skills for Surgeons Needed for High Performance in a Variable-resource Context (NOTSS-VRC).

Using mobile health technology and community health workers to identify and refer caesarean-related surgical site infections in rural Rwanda: a randomised controlled trial protocol.

Critical Care Management of Peritonitis in a Low-Resource Setting.

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum, management, and patient outcomes.

Improving Surgical Safety and Nontechnical Skills in Variable-Resource Contexts: A Novel Educational Curriculum.

Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District.

Assessment of hemodynamic response to fluid resuscitation of patients with intra-abdominal sepsis in low- and middle-income countries.

Patient Navigation by Community Health Workers Increases Access to Surgical Care in Rural Haiti.

Improving prehospital trauma care in Rwanda through continuous quality improvement: an interrupted time series analysis.

Building Workforce Capacity Abroad While Strengthening Global Health Programs at Home: Participation of Seven Harvard-Affiliated Institutions in a Health Professional Training Initiative in Rwanda.

Contextual Challenges to Safe Surgery in a Resource-limited Setting: A Multicenter, Multiprofessional Qualitative Study.

Epidemiologic Characteristics of Pediatric Trauma Patients Receiving Prehospital Care in Kigali, Rwanda.