Nov 5, 2018, 21:43 PM by Mark A. Brouillette, MD; Swetha Pakala, MD; Patrick Laughlin, MD

In 2018, Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, and Hospital for Special Surgery (HSS) in New York joined forces to pilot a global regional anesthesia curricular engagement (GRACE) at KATH. In limited-resource settings (LRS) like KATH, oxygen supply failures are common, ventilators are often faulty, postanesthesia care units are under-resourced, vital signs monitors are frequently unavailable, and opioid medications can be difficult to obtain. Because of those constraints, regional anesthesia may have a significant role in facilitating patient safety and well-being in LRS. GRACE would create a standardized platform to design, implement, and measure changes associated with a regional anesthesia training program that can be used in any LRS.

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In hospitals with limited access to ultrasound, the GRACE expert panel suggested using paresthesia-seeking interscalene and transarterial approaches to the brachial plexus block for upper-extremity surgery and nerve localization guided by peripheral nerve stimulator and surface anatomy for select lower-extremity blocks.

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KATH is one of two teaching hospitals in Ghana where physician anesthesiologists are trained. Orthopedics makes up 16% of KATH’s surgical volume, and more than 1,600 orthopedic operations are performed annually.¹ Of those cases, 95% are done for trauma, and 99% are performed on the upper and lower limbs.² KATH has two modern ultrasound machines, peripheral nerve stimulators, a consistent supply of local anesthetic medication (lidocaine and bupivacaine), and most other basic supplies necessary to perform regional anesthesia. Prior to GRACE, however, less than half of upper-limb surgeries received a peripheral nerve block as the primary anesthetic; lower-limb cases were typically done under subarachnoid blocks, but long-acting peripheral nerve blocks for postoperative analgesia were never done.¹ The KATH-HSS partnership was formed to increase use of peripheral nerve blocks for those cases.

 At HSS, the department of anesthesiology, critical care, and pain management’s Global Health Initiative was founded by Swetha R. Pakala, MD, to support global health ventures such as GRACE. HSS is a high-volume orthopedic center in New York where physician anesthesiologists are versed in the use of regional anesthesia techniques for orthopedic surgery. The Global Health Initiative leads a global health track in which regional anesthesiology and acute pain medicine fellows take part each year. In 2018, Fellows Mark A. Brouillette, MD, and Patrick Laughlin, MD, joined Dr. Pakala on two HSS-sponsored trips to KATH in West Africa.

To design a curriculum specifically tailored for KATH, the GRACE team conducted a needs assessment to define local conditions and trainer expertise. The results of the needs assessment were reviewed by an expert panel of five physicians from HSS and University of Kansas Medical Center considered to be experts in regional anesthesia and with experience applying those skillsets in LRS. The panel provided recommendations for curriculum teaching modalities, lecture content, and specific blocks to introduce.

From the expert recommendations, the GRACE team put together a final curriculum of didactic lectures, simulation training with ultrasound volunteers and gel block mannequins, and hands-on teaching during patient care. They taught interscalene, supraclavicular, and infraclavicular approaches to the brachial plexus block for use as the primary anesthetic for upper-extremity surgeries. Trans- and subgluteal sciatic nerve, femoral nerve, and fascia iliaca plane blocks were taught for hip and femur analgesia. They taught sciatic nerve in the popliteal fossa and saphenous nerve in the adductor canal blocks for surgical anesthesia and postoperative analgesia for patients undergoing knee and leg operations. Nerve colocalization with both ultrasound and peripheral nerve stimulator was taught as an option for sciatic and femoral nerve blocks in patients with challenging anatomy.

Fourteen of 16 anesthesia physicians, both trainees and attendings, at KATH enrolled in and completed the course. They rapidly acquired clinical skills and translated them into meaningful patient care. Interest in GRACE was strong during the two three-week training sessions held in 2018. Anecdotally, patient and surgeon satisfaction with GRACE was high. Surgeons reported better surgical conditions and improved postoperative mobilization and pain control in patients who received blocks. Surgeons’ only complaint was that the GRACE team did not block more patients.

Using the Kirkpatrick four-part method for training program evaluation, the team attempted to objectively measure changes associated with GRACE.³ The Kirkpatrick method was originally developed for use with industrial training programs, and it was recently used to evaluate a point-of-care ultrasound course for anesthesia residents.⁴ According to the four-level model, GRACE measured trainee satisfaction (Level 1), changes in knowledge (Level 2), clinical skill (Level 3), and peripheral nerve block utilization (Level 4) at KATH.

Responses to a satisfaction survey were all affirmative when trainees were asked to rate agreement with statements such as “the program was applicable to my practice” and “the program should be continued at KATH.” A novel multiple-choice knowledge exam and an observed structured clinical skills exam⁵ were administered before and after GRACE. The percentage of questions answered correctly on the knowledge exam improved from 65% to 88%, and the pass rate on the clinical skills exam increased from 29% to 86%. KATH residents had the highest participation rates in curriculum activities. Residents’ knowledge exam scores increased from 60% to 90%, and their pass rate on the clinical skills exam improved from 0% to 100%. Collection of before-and-after data on block utilization is ongoing and is to be completed in October 2018.

Although the GRACE experience demonstrates it is possible to effectively introduce a basic regional anesthesia curriculum in LRS in a short period of time, important considerations for the model should be noted. First, ultrasound machines are expensive and many surgical centers in LRS do not have them. Peripheral nerve blocks can still be taught, however, if trainers are facile in non–ultrasound-based nerve localization techniques. In hospitals with limited access to ultrasound, the GRACE expert panel suggested using paresthesia-seeking interscalene and transarterial approaches to the brachial plexus block for upper-extremity surgery and nerve localization guided by peripheral nerve stimulator and surface anatomy for select lower-extremity blocks.

A second consideration is that patients at major trauma centers such as KATH may have injuries that put them at increased risk for acute compartment syndrome (ACS). Whether a peripheral nerve block can mask the presenting pain of compartment syndrome or delay its diagnoses is controversial. Case reports and expert recommendations have conflicting findings, and quality evidence is lacking.⁶ At KATH, patients at high risk for ACS regularly receive blocks because the safety of general anesthesia is compromised by limited resources and because opioids are often unavailable. It is recommended, though, that the decision to block patients at high risk for ACS be made in close consultation with the patient and surgical team. Use of dilute concentrations of local anesthetic is an option that may theoretically reduce the likelihood of masking the ischemic pain of ACS. Close follow-up of inpatients and delaying discharge of outpatients until blocks have resolved are additional measures that can safeguard this population.

Looking forward, the GRACE team is enthusiastic to continuing teaching at KATH. KATH has now been designated as an official regional anesthesia training site for the World Federation of Societies of Anesthesiologists (WFSA), and two WFSA fellows participated in GRACE training in 2018. Feedback from the trainee satisfaction surveys is being used to update the curriculum for the coming year. Additional sites are also being considered for implementation of the GRACE program. 

References

1. Brouillette MA, Aidoo AJ, Hondras MA, et al. Anesthesia capacity in Ghana: a teaching hospital's resources, and the national workforce and education. Anesth Analg. 2017;125(6):2063–2071. https://doi.org/10.1213/ANE.0000000000002487
2. Brouillette MA, Kaiser SP, Konadu P, Kumah-Ametepey RA, Aidoo AJ, Coughlin RC. Orthopedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United States. World J Surg. 2014;38(4):849–857. https://doi.org/10.1007/s00268-013-2314-0
3. Kirkpatrick JD, Kirkpatrick WK. Kirkpatrick's four levels of training evaluation. Alexandria, VA: ATD Press; 2016.
4. Ramsingh D, Rinehart J, Kain Z, et al. Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents. Anesthesiology. 2015;123(3):670–682. https://doi.org/10.1097/ALN.0000000000000776
5. Chuan A, Graham PL, Wong DM, et al. Design and validation of the Regional Anaesthesia Procedural Skills Assessment Tool. Anaesthesia. 2015;70(12):1401–1411. https://doi.org/10.1111/anae.13266
6. Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth. 2015;8:45–55. https://dx.doi.org/10.2147%2FLRA.S55322