Building Capacities: Policy, Advocacy:Kayvan Roayaie


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Global Partners in Anesthesia and Surgery: A model partnership between two academic institutions to build surgical and perioperative services in Uganda

Kayvan Roayaie, UCSF

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  • Building Capacities: Policy, Advocacy:Kayvan Roayaie

    1. 1. <ul><ul><li>Global Partners in Anesthesia and Surgery </li></ul></ul><ul><ul><li>A model partnership between two academic institutions to build surgical and perioperative services in Uganda </li></ul></ul><ul><ul><li>University of California San Francisco, USA </li></ul></ul><ul><ul><li>Mulago Hospital, Makerere University, Uganda </li></ul></ul>Kayvan Roayaie MD, PhD
    2. 2. Global Health in Surgical Education <ul><li>Traditional Model </li></ul><ul><li>Volunteerism (ACS - Operation Giving Back) </li></ul><ul><li>Select residencies - international electives </li></ul><ul><li>Initial UCSF Model </li></ul><ul><ul><li>Clinical electives for senior residents </li></ul></ul><ul><ul><ul><li>Reciprocity </li></ul></ul></ul><ul><ul><li>Long term </li></ul></ul><ul><ul><ul><li>Faculty collaboration </li></ul></ul></ul><ul><ul><ul><li>Teaching </li></ul></ul></ul><ul><ul><li>Structured joint research projects </li></ul></ul>
    3. 3. UCSF - Makerere U. Alliance <ul><li>Started in 2003, at Department of Surgery level </li></ul><ul><li>Evolved via resident interest, faculty commitment </li></ul><ul><li>Senior surgical faculty from each institution - set goals and specific objectives </li></ul><ul><ul><li>Clinical rotation for residents </li></ul></ul><ul><ul><li>Faculty exchange </li></ul></ul><ul><ul><li>Research collaborations </li></ul></ul><ul><ul><li>Seminars, educational resources </li></ul></ul>
    4. 4. Why Uganda? <ul><li>Developing country with extreme resource constraints </li></ul><ul><li>Pre-existing UCSF collaboration and infrastructure </li></ul><ul><li>Regional prominence of Makerere University and Mulago Hospital </li></ul><ul><li>English-speaking, politically stable </li></ul>
    5. 5. Uganda: Surgical Care <ul><li>MD : population ratio = 1 : 12-25,000 </li></ul><ul><li>Countrywide: 75 general surgeons, 10 anaesthesiologists </li></ul><ul><li>Most surgery is not performed by specialist surgeons </li></ul><ul><ul><li>Typical of low-income countries </li></ul></ul><ul><ul><li>No clear data on who is providing surgical services in rural areas </li></ul></ul>
    6. 6. Clinical Rotation <ul><li>1-2 month elective at Mulago Hospital, Uganda </li></ul><ul><li>At level of senior resident - research period </li></ul><ul><li>Self-funded, salary support maintained </li></ul><ul><li>Rotation preparation </li></ul><ul><ul><li>Personal safety / daily logistics manual </li></ul></ul><ul><ul><li>Surgical texts on care in developing world </li></ul></ul><ul><li>Formal evaluation and presentation upon return </li></ul>
    7. 7. Realizations <ul><li>Surgical care is limited in Uganda </li></ul><ul><li>Anesthesia and perioperative care was a scarcer commodity </li></ul><ul><li>Exact reciprocity is very difficult </li></ul><ul><li>Reciprocity is not necessary for mutual benefit </li></ul><ul><li>Interventions and projects would have to involve all stakeholders </li></ul>
    8. 8. Burden of Surgical Disease <ul><li>Quantifying Burden of </li></ul><ul><li>Disease: </li></ul><ul><ul><li>“ Disability-Adjusted Life Year” (DALY) = YLL (years of life lost) + YLD (years of life lived with disability) </li></ul></ul><ul><li>Surgical Conditions: </li></ul><ul><ul><li>11% of the World’s DALY’s, 27 per 1,000 population </li></ul></ul><ul><ul><li>Disease Control Priorities, 2 nd ed. World Bank, Chapter 67. </li></ul></ul>
    9. 9. Common Categories <ul><li>SIX conditions result in 81% of all surgical disease burden in SSA: </li></ul><ul><ul><li>Injuries – 38% </li></ul></ul><ul><ul><li>Malignancies – 19% </li></ul></ul><ul><ul><li>Congenital anomalies – 9% </li></ul></ul><ul><ul><li>Obstetrical complications – 6% </li></ul></ul><ul><ul><li>Cataracts and glaucoma – 5% </li></ul></ul><ul><ul><li>Perinatal conditions – 4% </li></ul></ul>
    10. 10. <ul><li>Improve perioperative and surgical care at Mulago Hospital </li></ul><ul><li>Emphasis on: </li></ul><ul><ul><li>Collaboration across disciplines </li></ul></ul><ul><ul><ul><li>Anesthesia, Nursing, other perioperative support </li></ul></ul></ul><ul><ul><ul><li>ER, OB/Gyn, orthopedics </li></ul></ul></ul><ul><ul><li>Sustainability </li></ul></ul><ul><ul><li>Building capacity </li></ul></ul><ul><ul><li>Appropriate and context dependent </li></ul></ul><ul><ul><ul><li>Defined by Ugandans </li></ul></ul></ul>
    11. 11. GPAS Strategies <ul><li>Increasing healthcare workforce </li></ul><ul><li>Training </li></ul><ul><li>Improving perioperative services </li></ul><ul><li>Research and mentoring </li></ul>
    12. 12. GPAS Scholars <ul><li>Train more surgeons and anesthesiologists </li></ul><ul><ul><li>Sponsor trainees in departments of surgery and anesthesia </li></ul></ul><ul><ul><li>Applications reviewed and recipients selected by faculty at Makerere </li></ul></ul><ul><ul><li>Number of surgical house officers in the entering class more than doubled </li></ul></ul>
    13. 13. GPAS Scholars “ I saw how hard it was to get an anesthetic technician to work on emergencies, so I felt the best I could do, would be to join the field. You never know I could help change the situation on [the] ground. “ “ While practicing [after internship] I noted many people dying of treatable surgical conditions simply because no surgical treatments were available in that area of Uganda. As a result … I chose to pursue a Masters in surgery.” Surgery Scholars Anesthesia Scholars
    14. 14. GPAS Strategies <ul><li>Increasing healthcare workforce </li></ul><ul><li>Training </li></ul><ul><li>Improving perioperative services </li></ul><ul><li>Research and mentoring </li></ul>
    15. 15. <ul><li>Uganda/Kampala statistics </li></ul><ul><ul><li>Injury is attributed to 24% of deaths (7% in US) </li></ul></ul><ul><li>Road traffic crashes were the most common mechanism in both countries </li></ul><ul><li>Modified ATLS course created and incorporated into surgical training </li></ul>TRAUMA: Uganda
    16. 16. FAST (Focused Abdominal Sonogram for Trauma) <ul><li>Portable </li></ul><ul><li>Quick assessment </li></ul><ul><li>No prohibitive costs </li></ul><ul><li>Relatively easy maintenance </li></ul><ul><li>Operator dependent </li></ul><ul><ul><li>>95% accuracy in trained hands </li></ul></ul>
    17. 18. November 2006 <ul><li>FAST Exam Course in Kampala </li></ul><ul><ul><li>ACS Instructors </li></ul></ul><ul><ul><li>Two Ultrasound Machines </li></ul></ul><ul><ul><li>19 participants </li></ul></ul><ul><ul><li>5 day course based on ACS model course </li></ul></ul><ul><ul><li>Multiple practical sessions </li></ul></ul><ul><ul><li>Added lectures in advanced trauma care </li></ul></ul>
    18. 19. Our Goal <ul><li>Implementation of FAST for assessment of injured patients in Kampala, Uganda </li></ul>
    19. 20. Stakeholders <ul><li>UCSF Faculty and Residents </li></ul><ul><li>Director of Casualty; Mulago Hospital </li></ul><ul><li>Deputy Director of Mulago Hospital </li></ul><ul><li>Registrars and House Officers at Mulago </li></ul><ul><li>Sonosite </li></ul><ul><li>COME Uganda </li></ul>
    20. 22. Challenges <ul><li>Real-time feedback in follow up </li></ul><ul><li>On the ground “champion” of the project </li></ul><ul><li>Machine security </li></ul><ul><li>Ongoing training of house officers </li></ul>
    21. 23. November 2008 <ul><li>Two-day refresher course </li></ul><ul><li>One-day Instructor course </li></ul><ul><li>Multiple practical sessions </li></ul><ul><li>Machine security </li></ul>
    22. 24. Plan for Sustainability <ul><li>Routine rounds with Instructors and the machine </li></ul><ul><li>Record exams in log book </li></ul><ul><li>Mulago Instructors to run a refresher course in July </li></ul><ul><li>Email communication with UCSF Faculty </li></ul><ul><li>Image transmission to check continued accuracy </li></ul>
    23. 25. Study to test Feasibility, Utility and Accuracy <ul><li>Mulago House Officer Thesis Project </li></ul><ul><ul><li>Analysis of log data for feasibility </li></ul></ul><ul><ul><ul><li>Is the machine incorporated into rounds? </li></ul></ul></ul><ul><ul><ul><li>Are House Officers recording exam results </li></ul></ul></ul><ul><ul><ul><li>Are the Instructors maintaining involvement? </li></ul></ul></ul><ul><ul><li>Analysis of data for utility and accuracy </li></ul></ul><ul><ul><ul><li>Incorporation of findings in decision-making </li></ul></ul></ul><ul><ul><ul><li>Verification of findings in the Operating Room (no CT) </li></ul></ul></ul><ul><ul><ul><li>Patient outcomes </li></ul></ul></ul>
    24. 26. GPAS Strategies <ul><li>Increasing healthcare workforce </li></ul><ul><li>Training </li></ul><ul><li>Improving perioperative services </li></ul><ul><li>Research and mentoring </li></ul>
    25. 27. Biomedical Support <ul><li>Collaborative efforts </li></ul><ul><ul><li>UCSF GPAS, Kaiser, Duke, UBC, MedShare International </li></ul></ul><ul><ul><li>Resources secured from UK/NHS </li></ul></ul><ul><ul><ul><li>Biomedical engineers to conduct training at Mulago </li></ul></ul></ul><ul><ul><ul><li>Funding to assess the equipment at Mulago </li></ul></ul></ul><ul><ul><ul><li>Funding for a mechanism to recognize and repair faulty equipment </li></ul></ul></ul><ul><li>Coordinated by Gerald Dubowitz, UCSF Anesthesia Faculty and GPAS representative </li></ul>
    26. 28. GPAS Strategies <ul><li>Increasing healthcare workforce </li></ul><ul><li>Training </li></ul><ul><li>Improving perioperative services </li></ul><ul><li>Research and mentoring </li></ul>
    27. 29. Research Collaborations <ul><li>Trauma </li></ul><ul><li>Breast Cancer </li></ul><ul><li>Colon Cancer </li></ul><ul><li>Critical Care </li></ul><ul><li>Pre-hospital Care </li></ul><ul><li>Goiter and Thyroid Cancer </li></ul><ul><li>Pediatric Surgery </li></ul>
    28. 30. Benefits of Research <ul><li>Identify problems and needs </li></ul><ul><ul><li>Assess magnitude </li></ul></ul><ul><ul><li>Choose intervention </li></ul></ul><ul><ul><li>Assess effectiveness of interventions </li></ul></ul><ul><li>Good data is evidence </li></ul><ul><ul><li>Evidence-based medicine </li></ul></ul><ul><ul><li>Evidence-based policy </li></ul></ul>
    29. 31. Study on Occupational Injury <ul><li>First grant EVER received by Mulago Hospital Dept of Surgery </li></ul><ul><li>$25,000 Grant: UCSF Center for AIDS Research </li></ul><ul><li>Modeled after US study at SFGH in the 1990s (Schecter/Gerberding) </li></ul><ul><li>An intra-op observational study to measure rates of exposure </li></ul>
    30. 32. 2003-2008 <ul><li>1998-2002 </li></ul><ul><li>4 faculty - overseas work (not in Uganda) </li></ul><ul><li>No organized resident clinical rotations abroad </li></ul>UCSF - Makerere U.
    31. 33. Pathways in Global Health at UCSF GHCSP Program GHCSP GH Project Clinical Experience Career with GH Emphasis Non-UCSF Formal GH training UCSF GHS MSc Medical Students Faculty TICR Residents with Interest in Global Health
    32. 34. GPAS Efforts <ul><li>Increasing healthcare workforce </li></ul><ul><ul><li>GPAS Scholars </li></ul></ul><ul><li>Training </li></ul><ul><ul><li>Advanced trauma training </li></ul></ul><ul><ul><li>Use of FAST for abdominal trauma </li></ul></ul><ul><li>Improving Peri-operative Services </li></ul><ul><ul><li>Biomedical Support </li></ul></ul>
    33. 35. GPAS Efforts <ul><li>Research collaboration </li></ul><ul><ul><li>FAST implementation results </li></ul></ul><ul><ul><li>Health worker Safety </li></ul></ul><ul><ul><ul><li>Operating room exposure risk </li></ul></ul></ul><ul><li>Mentoring </li></ul><ul><ul><li>Support in clinical and research activities </li></ul></ul><ul><ul><li>Creating a career in surgery and global health </li></ul></ul>
    34. 36. Acknowledgments UCSF William Schecter Gerald Dubowitz Rochelle Dicker Diana Farmer Jennifer Wang Other Institutions Doruk Ozgediz Laura Goetz Michael Lipnick Mulago Hospital, Uganda Dean Steven Kijjambu Prof. Sam Luboga Samuel Kaggwa Jackie Mabweijano Cephas Mijumbi Jane Fualal