Hello and welcome back to the Anesthesia Patient Safety Podcast.

I'm your host, Ellie Bechtel.

Thank you for joining us for another show.

And we have an exciting episode today.

An expert on anesthesia patient safety in low and middle resource settings will be joining us for a discussion.

Thank you so much to Dr.

Kelly McQueen for joining us for this episode.

Dr.

McQueen is a professor of anesthesiology and the chair of the Department of Anesthesiology at the University of Wisconsin School of Medicine and Public Health.

Dr.

McQueen provides compassionate, patient-centered anesthesia care for adults and pediatric patients.

She also works to improve anesthesia care around the world with her patient safety research as well as research on health outcomes and access to anesthesia care in low and middle-income countries.

Dr.

McQueen is a strong proponent for global health equity, and she believes that the equity principles are contributors to patient safety and best outcomes in all settings, especially in low and middle-income countries.

Before we dive into today's episode, we'd like to recognize Vertex, a major corporate supporter of APSF.

Vertex has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care.

Thank you, Vertex.

We wouldn't be able to do all that we do without you.

And now my conversation with Dr.

Kelly McQueen.

Thank you so much and welcome to the show.

To get us started, can you just introduce yourself briefly and then tell us a little bit about your anesthesia training career and your current role?

Well, thank you so much.

I'm Kelly McQueen.

I'm an anesthesiologist, and my current role is chair of the Department of Anesthesiology at the University of Wisconsin.

I've been practicing for a long time and at one time was in private practice, but now have served most of my career in academic practice.

And I have a tremendous interest in global health, where I conduct most of my research in low and middle-income countries.

So just to get us started as well, what got you first interested in patient safety and quality improvement and broadening that out to global health?

When I came into anesthesiology in the 1990s, I would say that patient safety and quality improvement was really already baked into our daily lives and into the practice of anesthesiology.

And so I was always interested as new technology got added, including pulse oximetry and capnography.

Pulse oximetry had been around for a while, but capnography was introduced during the early years of my practice.

And as I learned more about those technologies, I became increasingly interested in patient safety and then also how we could use quality improvement to really further leverage patient safety for patients in all settings.

Can you tell us a little bit more about your work on anesthesia in low and middle-income countries?

What first got you interested in this area of research?

Yes, I've had a long-term interest in the disparities of anesthesia care in low and middle-income countries.

This first became obvious to me in my overseas work related to humanitarian aid and outreach.

And I noticed that patient outcomes were poorer in those settings than, for instance, in the US.

And so as I learned more about anesthesia capacity and also investment in anesthesia infrastructure in low and middle-income countries, I became very committed to making a difference.

And so I started researching the barriers to anesthesia care in low and middle-income countries, and then later made a commitment to really improving infrastructure, improving patient safety, and eventually introducing quality initiatives in these countries.

There are quite a few threats to anesthesia patient safety in some of these low resource settings.

Can you tell us more about the impact of a limited available workforce and how this has a big impact on patient safety?

Yes, I absolutely agree.

There are many threats to patient safety in these settings.

And first and foremost, workforce is a contributor because there are very few anesthesia providers trained and credentialed in these settings.

And perhaps more alarming is the reality that there are even fewer anesthesiologists, physicians working in these settings, and overseeing the education of new non-physician providers for anesthesiology.

This history goes back quite a long ways, and um, and the lack of available workforce relates to many variables, including those that are trained in these countries may seek employment in other countries nearby to improve their quality of life or improve their outcome.

Andor because anesthesiology has not been well compensated, not at all similarly to surgery, for instance, in low resource settings, there's less interest among physicians and other professional providers to seek a career in anesthesiology.

And this reality in total has resulted in compromises being made about who is providing care in these settings.

Historically, many times there were individuals who were trained on the job by the surgeon to put in a spinal and watch the patient, or to give some ketamine and watch the patient.

And this lack of training and expertise and generalized knowledge very much contributed to poor patient outcomes over time and was a definite threat to patient safety throughout the years.

But even today, uh, the lack of trained workforce is a threat to patient safety in low resource settings.

You kind of mentioned this already, but it seems like if we look even like closer at the workforce that is available, um, it seems like there might be a couple of areas for improvement when it comes to credentialing as well as education and training for the anesthesia professionals and the non-physician anesthesia providers in these areas.

Can you tell us more about these challenges?

Absolutely.

Um, and these are also two areas of strong interest for me to really support anesthesia education and training in these um settings and to find practical solutions to ensure that over time patient safety and quality is increasing.

And so, first and foremost, I like to say that because there are a limited number of current professionals in low resource settings, we shouldn't be pushing anyone out of the job market.

But rather, we should really be investing in uplifting their training and improving their education on the ground so that they have the best ability to practice in their setting.

And at the same time, we must really encourage ministries of health and health systems to invest and support credentialing because oftentimes in low resource settings, credentialing isn't prioritized, nor is continuing medical education.

And I think those two components together will really help countries embrace improving their own workforce specific to anesthesiology.

And that's inclusive of both physician providers as well as non-physician providers.

What do you hope to see going forward when it comes to the anesthesia workforce globally?

I definitely hope to see a broader investment from ministries of health in anesthesiology, generally speaking, and also an investment by medical schools in low resource settings for encouraging uh young medical students to understand anesthesiology and to experience it firsthand so that they have an opportunity to become interested in the field and potentially follow that career path for the benefit of their own hospital systems and patients.

I think there's a lot of trends right now that should encourage us that things are changing within anesthesiology in these countries, including a greater investment in infrastructure for anesthesiology and surgery more generally.

Now, keeping patients safe during anesthesia care relies on access to monitors such as the pulse oximeter and capnography and access to oxygen and rescue medications.

These are things we probably take completely for granted in our hospital settings.

But can you tell us more about this lack of access to monitors and medications in many low and middle-income countries?

And how can people providing anesthesia care work to keep patients safe with these limited resources?

Yeah, thank you for this question.

This goes back quite a long way historically, and I won't tell you the whole story, but a piece of the story I think is relevant for your listeners to understand that up until the early 1990s, most of the diseases that were prevalent and really impacting patients in low and middle-income countries were infectious diseases.

And so for decades, there was little or no investment in surgery and anesthesia.

And the only thing that ministries of health really prioritized was emergency surgery for things like C-sections and trauma.

But as the disease burden changed and the need for more surgery became apparent due to chronic disease, there was a lag in that investment in the infrastructure that was necessary for safe anesthesia and for surgery.

And so, as you mentioned, in many hospitals across low and middle-income countries, you would be very surprised to find that there are very limited monitoring systems available, including pulse oximetry sometimes being available, capnography generally only being available in the most developed hospitals, and even EKGs and blood pressure cuffs not being routinely available.

My colleagues have always been surprised to find out as well that oxygen is not ubiquitously available.

And uh, all of these things really limit our ability to care for patients effectively and to keep them safe during surgery.

Our colleagues overseas have found creative ways to work around this, but I think what what we know from comparing outcomes is that patients aren't as safe in situations that don't have standard monitoring and essential medicines, including oxygen.

And therefore these workarounds haven't been entirely um effective for their patients.

But those things have included continuously listening to the heart and lungs during surgery with a stethoscope, keeping a finger on the pulse during the entire surgery as well, um, watching for other physical signs of decrease in oxygen, such as cyanosis and blanching of the gums and lips.

But as your listeners will know, this really sounds like anesthesiology between before the 1950s.

And that's really what it was and is in many of these countries.

And so efforts are underway to improve monitoring and safety equipment in these settings, and also to improve access to essential medicines, including oxygen.

We've talked about checklists before on this podcast as a tool to improve patient safety.

Is there a role for checklists to help improve patient safety in these settings?

There absolutely is.

And I would like to strongly endorse the surgical safety checklist, uh, which has been endorsed by the World Health Organization and other important initiatives like Lifebox.

Um, I think that we know in our own practices the power of a checklist.

Um, and I think overseas in low-income countries, especially many hospitals, have endorsed using a checklist to improve the quality of care and also patient safety.

I think somewhat unfortunately, they haven't been um adopted 100% of the time.

And as you know from other discussions on your podcast, um, a checklist is only as effective as how often it is routinely used.

And so there is room for improvement in these settings, such that uh providers understand that it will really make a difference for the care of their patients if they're used every single time.

Checklists often need to be modified for local settings, though.

Um, and I think the World Health Organization has acknowledged that modifications in the surgical safety checklist for local constraints is acceptable and should be considered to make sure that the checklist is feasible and will be widely adopted.

I could see an important part of the checklist.

If you have like limited monitors or limited resources, would be to state something to the extent of we will be using a pulse oximeter for the case today, but we do not have technography, or I will be listening with my stethoscope during the case today.

So we'll need to keep it quiet in the operating theater today, or just keeping that communication lines open, I could see being very important and necessary in these areas.

I absolutely agree with that.

I think communication in the operating room is essential no matter where you are in the world.

What do you hope to see going forward when it comes to safe anesthesia care in low and middle-income countries?

And what steps need to be taken immediately?

And what are some longer-term plans that could be initiated now to improve access to safe anesthesia care around the world over the next 10 to 20 years?

Yeah, I think that the things that I am most encouraged by and would most like to see carried out to a greater degree is the engagement of government and ministries of health in supporting the advancement of anesthesiology and more broadly, patient safety in low and middle-income countries.

Without the endorsement and investment of ministries of health, it's very, very difficult for hospitals to make changes and improvements on their own.

And so impactful change to anesthesiology really has to start from that level with additional investment.

Along with that, I think the other thing that we should think about as anesthesiologists within a high-income country is our support for national anesthesiology societies across the world.

Because the other area of potential impact is to really empower anesthesiologists to also advocate for the things that they need for safe patient care, to advocate for pulse oximetry, to advocate for the addition of capnography and the continuous availability of oxygen and other rescue medicines would make a huge difference to their patients.

And in many of these settings, anesthesiologists do not feel as empowered as other physicians, such as surgeons, to really speak up on behalf of our of their patients.

And so I think that's an important role that we can play from a distance.

We have talked about anesthesiologists as leaders on the perioperative team.

It's a frequent theme in the APSF newsletter articles and something that we've talked about on the podcast.

And so it's so interesting to hear how that really is something that needs to be worked on in these settings to help improve patient safety.

Because I think we've seen it in kind of high resource settings where we say anesthesiologists need a seat at the table.

And I think in areas where just having an anesthesia professional available is tough.

And then the next step is okay, we need to have, you know, anesthesiologists who can do the anesthesia, but who are also able to be advocates for patient safety and in their healthcare systems.

Absolutely.

I think the reason that it's so challenging in low-income countries, especially, is because there are so few anesthesiologists.

In many of these settings, there's only one anesthesiologist per million people.

And so when we look at advocady and leadership, there are so few people that would be available to advocate to health ministers and to hospital systems.

And therefore, the intraoperative provider is also is often at a disadvantage because they're they don't have the same degree of training and they don't have the education, nor have they been empowered to speak out.

Wow, that number is absolutely staggering.

It is.

It is, yeah.

And I imagine you could feel very isolated in that situation too.

And I it probably speaks to the importance of teamwork in the perioperative space for patient safety and working together with the surgeons and the nurses and the anesthesia provider.

Because if we're all on the same page to improve patient safety, that has to be the best thing for the patients.

But it makes sense that we still have some way to go to get there.

Absolutely.

And I guess the other thing that I'd like to, you know, make your listeners aware of is that there are hospital systems that are regional or tertiary care centers in low and middle-income countries that are practicing at a very high level and where their providers are well educated and where they have the necessary equipment.

But that's a very small percentage of hospitals in low and middle-income countries.

And so many new, newly trained physicians or non-physician providers are sent to these remote hospitals where they're all alone and where they are doing the best that they can with what they have, but they often don't have what they need and aren't necessarily empowered to speak up about it.

That sounds really tough, but it's so good that there is work being done right now to improve the workforce, access to important monitors and vital medications, and education and training.

And so it seems like we have this outline for what we know needs to happen.

And now we just need that work done to get there.

I couldn't agree more.

And there have been some international efforts to make sure that this agenda moves forward.

The Lancet Commission on Global Surgery was published in 2015, and it really promoted the global surgery agenda and endorsed the availability of surgery and safe anesthesia at all hospitals in all countries around the world.

And this has really moved the needle forward, both for access to safe anesthesia and surgery, but also to improving the circumstances, including the things you and I have already mentioned with access to monitoring, essential medicines, and the things to really improve patient safety.

Can you tell us what's next for your research or projects?

So the work that I'm engaged in now is really uh following outcomes in low and middle-income countries related to surgery and anesthesia.

And the reason that I think that this is so important, like for all of us, we use data as a feedback mechanism to help us improve quality and then eventually to improve safety, of course, as well.

But this data is often absent in low and middle-income countries, primarily because the providers there are already clinically overworked and overcommitted.

And so they they have very few resources to really collect their own data to analyze it and then reflect on it.

And so several of my current projects have been looking at perioperative mortality rates in Rwanda and in Zambia, and then allowing their providers to really reflect on what happened in these case scenarios where patients died and what could have been done differently.

And of course, this is the work that we do all the time during our morbidity and mortality conferences and um and our reflection on um quality projects that can help us provide continuous improvement within our systems of care.

That is very interesting.

We will have to stay tuned for how that research continues to go and progress.

Thank you.

Is there anything else that you want to share with us that we haven't already talked about today?

The other way that I think we can really um improve the situation for patients globally when it comes to anesthesia and patient safety is to engage in bilateral partnerships with countries and organizations that will really help them do their own work and move the needle forward.

You've noticed that I haven't suggested that we send money or equipment or things like that to improve patient safety or outcomes, but rather that we engage in relationship building and support of our professional colleagues so that they can find solutions that will work for them in a sustainable way over time.

Thank you so much to Dr.

McQueen for joining us on the show today.

We hope that you will check out the show notes to links to all the resources that we talked about today, as well as article citations and more.

If you are interested in anesthesia patient safety in low and middle resource settings, we hope that you will check out the upcoming APSF article, Perioperative Safety and Quality in Low and Middle Income Countries, Progress and Remaining Challenges by Eva Lou Becher and Kelly McQueen.

Check out the show notes for more information.

If you have any questions or comments from today's show, please email us at podcast atapsf.org.

Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice.

We hope that you will visit apsf.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.