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How to deliver

Lifebox training

in the field

October 2012

Clockwise from top left: National oximetry distribution in Eritrea – Kossamak Hospital, Cambodia –– national workshop and distribution in

Sierra Leone – neonatal monitoring in Rwanda - colleagues at Vanimo General Hospital, Papua New Guinea– oximetry training in Uganda

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Contents

Purpose of this manual 4

Intended audience 4

What will users of this guide gain? 4

1. How to be a good instructor

1.1 Introduction 5

1.2 Principles of adult learning 5

2. How to teach

2.1 Giving a lecture 6

2.2 Teaching a scenario 7

2.3 Leading a discussion 7

2.4 Mentoring 7

2.5 Feedback 8

3. Pulse oximetry

3.1 Background 8

3.2 The setting 8

3.3 Situational analysis and needs assessment 8

3.4 Workshop outline 9

3.4.1 Suggested timetable 10

3.4.2 Objectives 10

3.4.3 Instructions for tutorials 1 and 2 10

3.4.4 Instructions for clinical scenarios 11

4. The WHO Surgical Safety Checklist

4.1 Background: WHO Guidelines for Safe Surgery 13

4.2 Discuss ‘human factors’ in healthcare 14

4.3 The WHO Surgical Safety Checklist 15

4.4 Introducing the WHO Checklist into routine practice 15

5. Monitoring and evaluation

5.1 Principles 17

5.2 Evaluation of the workshop 17

5.3 Evaluation of impact 17

6. Scale up of surgical safety and pulse oximetry

6.1 Review of targets and goals 18

6.2 Barriers to scale up 18

6.3 How you can help 19

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Appendices

Appendix 1 Additional resources 20

Appendix 2 Specifications of the Lifebox oximeter 23

Appendix 3 Lifebox needs survey 24

Appendix 4 Clinical scenarios 26

Appendix 5 Pre and post workshop tests for pulse oximetry 31

Appendix 6 Course feedback sheet 33

Appendix 7 Oximetry logbook 34

Appendix 8 WHO Surgical Safety Checklist 37

Appendix 9 WHO Checklist Implementation Manual 38

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Purpose of this manual

For many of you, delivering a Lifebox oximetry workshop will be your first foray into

international medicine. It will be exciting but can also be daunting, and this manual aims to

provide you with background and guidance on how to make a Lifebox training workshop a

success. There are many resources available that provide important advice, and we therefore

recommend looking at the links and resources listed in Appendix 1.

Intended audience

An oximetry workshop is usually led by a senior anesthesiologist who has had some previous

experience as an educator.

This manual is also aimed at anesthesiologists who are novice educators and other

practitioners who are experienced in anesthesiology.

Section 1 (How to be a good instructor) will be particularly useful for novice educators, but

we recommend all users read it as it captures some valuable lessons.

What will users of this guide gain?

- Users will understand the principles of being a good educator and understand the different

teaching modalities applicable for adult learning

- Users will understand the background to the pulse oximetry project and appreciate the

need for this essential equipment

- Users will have a basic understanding of how to do a systematic and rapid situational

analysis to identify gaps in pulse oximetry and be able to identify key stakeholders

- Users will understand how to deliver the pulse oximetry education programme, be able to

identify the target audience and will be familiar with the materials and methods required

for a workshop.

- Users will appreciate the need for ensuring surgical safety and will be comfortable

introducing the WHO Surgical Safety Checklist

- Users will have a basic understanding on how to monitor and evaluate the process of

implementation and outcomes of a pulse oximetry workshop.

- Users will have a basic understanding of the complexities of scale up and sustainability of

the pulse oximetry programme.

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1. How to be a good instructor

1.1 Introduction

Being a trainer or facilitator is about making sure that those you are teaching learn what is

intended. If they do not learn, you have not done your job properly. Valuable time and money

is spent on attending and delivering courses and it is our duty to ensure that the learners get

the best they can out of it. Make a commitment to this. Prepare well. Strive constantly to

improve your abilities as a trainer.

For the participants on Lifebox training courses, you are seen as a professional and clinical

role model. Many participants will never have been to a course such as this one and may be

unfamiliar with this type of teaching.

Just as the learners, you too may require support. Prior to embarking on a Lifebox pulse

oximetry workshop, we recommend contacting Lifebox headquarters in London who can put

you in touch with previous course facilitators for some informal advice.

Course participants in Mbarara, Uganda, July 2011

1.2 Principles of adult learning To be able to teach effectively you need to understand something of the principles of

adult learning:

Adults are generally in a learning situation because they want to be. Children are in a learning

situation because they have to be. This is a good start but it means that if adults do not want

to be in the learning situation they will not participate.

Therefore:

adults must enjoy what they are doing: they will not enjoy threats, humiliation and fear

adults must understand what they are doing

adults must see a reason for what they are doing and their reasons are very varied

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learning must be interesting, relevant, applicable, achievable and learners must be able

to say they have achieved something

adults must be able to see how what they learn can be applied

adults learn in many different ways; therefore, different methods of teaching must be

used, including:

o listening

o watching

o reading

o talking

o doing

o interacting

It is interesting to consider through which methods you find it easiest to learn.

2. How to teach

Any teaching activity should have a defined beginning (sometimes known as a ‘set’), a

middle and a defined end (sometimes known as ‘closure’).

The beginning (set) is about emphasising the importance of the teaching and stating which

important points will be covered, explaining how this will be done and setting the mood. The

end is about emphasising the main points that have been covered.

This model applies to all teaching methods such as lectures, scenarios, skills, workshops and

demonstrations.

2.1 Giving a lecture

The Lifebox course has a set of generic lectures. All lectures are part of the course ‘package’.

You do not have to write the lecture: it is already written, but you do have to practise it. A

guide is that the practice time should be ten times the length of the lecture, so spend about

two and a half hours practising a 15-minute lecture. You must be very familiar with the

lecture and also very familiar with the subject, as you might get asked questions about things

which have not been covered in the lecture.

Make sure your lecture is loaded on to the laptop and that it runs and projects. Shortly before

you give your lecture, go through the slides on the screen to which they are projected to

check that they look OK. Make sure that you know how to move slides forward. Make sure

that you know where your lecture is on the laptop and that you are able to get it up on the

screen quickly in presentation form once you go up to lecture.

Begin by greeting the audience and introduce yourself. Then start with the beginning

(the ‘set’). This is covered on a summary slide at the beginning of every lecture. If

necessary, add to this the arrangements for questions such as ‘I will take questions at the

end’ and set the mood.

Do not read from the slides. Know them well and say in a natural way what the message

on the slides is. You can add in comments or examples if you have time, although this

will mostly be covered in the breakout sessions.

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Stand to the right of the screen and half way between the screen and the audience,

making sure that you can reach the laptop to change the slides.

Hold your head up and throw your voice, as if you are talking to somebody at the back

of the room.

Please note that, for many people attending Lifebox training, English is not their first

language. Speak clearly, avoid colloquial language, slang, jokes, and so on. Use simple

English.

You can put out questions to all participants or to individuals. Be careful not to

‘humiliate’ participants. Be sensitive to cultural practice and be aware that some

healthcare providers will have many years of experience (although practice may be

different from that to which you are used). When the answer comes, repeat it so that

everyone in the audience hears it.

When you take questions, make sure that the audience has heard the question and, if

necessary, repeat it.

If a question is not easily answered in the group, you can ask for the help of the

facilitators or ask if anyone has any ideas or relevant experience. If the question

develops into a discussion, keep the discussion brief by saying that there is time to

elaborate in the scenario session and during break times.

2.2 Teaching a scenario

A scenario is a method of teaching which aims to be as near to real life as possible. If you are

delivering the course with a colleague, one of you will act as the patient – otherwise you can

choose a trainee to do this. One trainer presents the clinical situation (see Appendix 4) and

asks the group to repeat back and then show what they would do. Make the ‘set’ (beginning)

by introducing yourself, saying what this session is about and describing how it will be run.

At the end, ask if there are any questions and then make the ‘closure’ by describing the main

points which have been covered.

2.3 Leading a discussion

There are two sorts of discussion: open and closed. An open discussion is where comments

are made from individual to individual without going through the discussion leader. A closed

discussion is one where the leader is at the centre of the discussion and comments are all

passed though the leader. A closed discussion allows the leader to control the direction and

content of the discussion. It is recommended for more junior (or new) learners.

2.4 Mentoring

Mentoring can be an extremely valuable part of learners’ experience of any training course. It

helps them to learn and achieve on the course, and makes them feel comfortable and valued.

When delivering Lifebox training you may want to set aside time to meet with trainees on a

one-to-one basis to check whether there are any problems and whether they need any more

help or support of any sort. If you are organizing a larger course with a number of trainers or

faculty, you may also want to set up a more formal mentoring programme.

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2.5 Giving feedback

Although this course is not a pass/fail course, feedback can be useful. It must be given

sensitively. A useful method is to ask the participant how they think that they performed,

encouraging them to highlight the positives and then consider points for improvement. If the

facilitator chooses not to ask the participant but just give feedback directly, he or she should

also give positive points first and then points for improvement.

3. Pulse oximetry

3.1 Background

Pulse oximetry is recognised as forming an essential part of the minimum standards of patient

monitoring and is now mandatory in western operating rooms. However, a recent study has

revealed that up to 77,000 operating rooms globally do not have access to this essential

equipment, therefore putting lives at risk.1 Lifebox Foundation, a UK-registered non-profit

set up by international experts in surgery and anesthesia, is working to close this gap.

Through a competitive international tender, Lifebox has been able to procure the ideal pulse

oximeter for a low-resource setting which also exceeds WHO specifications (see Appendix

2). In addition to providing this essential equipment, Lifebox has developed a thorough

education programme that can be delivered in a one-day workshop.

3.2 The setting

It is important to note that the target countries of operation for Lifebox are low and middle-

income countries as defined by the World Bank. The environment and culture in these

settings are often very different to those that you are used to, and we recommend preparing

thoroughly for the “culture shock” you may experience. In many countries, the individuals

providing anesthesia are not physicians, but can be nurse anesthetists or technicians. These

may have limited experience and exposure, and this is an important consideration when

planning your workshop and teaching methods.

3.3 Situational analysis and needs assessment

It is important to secure the right relationships and have accurate information before planning

your workshop. Some of you will already have long standing links between your own

anesthetic department and that of a low or middle-income country, and we would suggest

focusing your efforts initially in those places where you have good contacts. Before

delivering a workshop, Lifebox needs to have some minimum information in order to plan

the delivery of equipment and organise the teaching materials. The mission of Lifebox is to

ensure that every operating room has access to a functioning pulse oximeter. Therefore, we

recommend performing a survey (or equivalent alternative) to gauge the need for oximeters

and we have developed a survey for this purpose that can be found in Appendix 3. We also

need to know what the intended target audience is for your workshop so that we can arrange

the necessary teaching materials and give advice on which approaches have worked well in

the past.

1 Global operating theatre distribution and pulse oximetry supply: an estimation from reported data

Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, Wilson IH, Dziekan G, Gawande AA.

Lancet. 2010 Sep 25;376(9746):1055-61.

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In the following section, we give a detailed structure on how to deliver the oximetry

workshop. The tutorials (basic and advanced) can be found in the educational DVD and at

http://www.lifebox.org/education/po-training. Please email us at info@lifebox.org to get

copies of the PowerPoint materials needed for the course.

3.4 Workshop outline

Learning Modality Workshop

Equipment List Laptop and projector

Blackboard and chalk or flip chart with pens

Pulse oximeter, charged and ready to use

Key Teaching Points Safe practice of anesthesia is enhanced by monitoring

Monitoring should be carried out pre-operatively and

postoperatively

Monitoring is only of benefit if we respond to abnormalities

that are detected

Key Learning

Objectives

Understand why monitoring is important

Identify minimum standards of monitoring and prioritise

them

Understand how to use and interpret pulse oximetry

Lifebox training run by ANZCA in Papua New Guinea, September 2012

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3.4.1 Suggested timetable

1. Introduction (20mins)

2. Pulse oximetry tutorial 1 Small group/lecture (45mins)

3. Pulse oximetry tutorial 2 Small group/lecture (45mins)

4. Clinical scenario workshop Case based discussions (90mins)

5. Discussion (30mins)

3.4.2 Objectives

Pulse oximetry tutorial 1

At the end of this teaching session, participants should:

- Understand the function of a pulse oximeter

- Know how oxygen is transported to the tissues

- Understand how a pulse oximeter can help them in anesthesia

Pulse oximetry tutorial 2

At the end of this teaching session, participants should:

- Understand how to use an oximeter correctly

- Know what can interfere with the functions of an oximeter

- Know how to maintain a pulse oximeter

- Understand how to manage a falling SpO2 during anesthesia

Clinical scenario workshop

At the end of this teaching session, participants should understand how to apply the action

plan for managing SpO2 < 94% using the nine scenarios provided (see Appendix 4).

Discussion

This final session allows for further discussion and feedback

3.4.3 Instructions for tutorials 1 and 2

These tutorials are designed to stimulate thought and discussion, which will promote learning

more effectively than a lecture. These tutorials contain a large amount of information. You

may not have time to discuss each slide in great detail; therefore it is important that you

consider the prior knowledge of the workshop participants when preparing for each tutorial.

The presentations may be projected on to a wall or displayed on a monitor. The fine detail of

the action plan (Tutorial 2) may not be visible when projected. This is not critical because the

Clinical Scenario Workshop is aimed at teaching the action plan.

Consider the seating arrangement for your participants. Try and avoid a lecture theatre

setting. Ideally, seat the participants in a circle. This encourages active involvement by the

whole group.

There are a number of question slides. Allow the group time to respond to these.

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3.4.4 Instructions for clinical scenarios

Scenario teaching or case-based teaching can be defined as any situation where real or

simulated case histories are used for teaching and learning. The format ranges from simple

case discussions of written cases to simulations using manikins.

The advantages of scenario teaching are: it encourages active involvement by students; it is

patient centred and can be used to teach knowledge, clinical decision making,

professionalism and team work.

For Lifebox training, scenario teaching aims to teach participants the basics of clinical use of

pulse oximeters and problem solving by the use of the ABCDE action plan.

Selection of Cases and Preparation

It is important that the selected case scenarios are appropriate for the target audience. This

requires some knowledge of the level of training of the participants, the types of anaesthesia

they administer, the scope of surgery and the medical problems of their patients. The way a

scenario is used will vary from one hospital and one country to another.

A number of scenarios have been provided for you as teaching tools (Appendix 4). You are

most welcome to adapt these scenarios to suit the participants on your course. You are also

encouraged to develop your own scenarios, especially if it is felt that the scenarios provided

are not suitable.

It is not essential to use all scenarios in the workshop. Try and choose scenarios that identify

different ABCDE problems, remembering that airway problems are probably the most

common cause of desaturation.

Consider the seating arrangement for the teaching session. Try to avoid creating the

atmosphere of a lecture. Seating in a circle, or semi-circle, if using a black/white board works

well and encourages active involvement by participants. If using written scenarios, provide

each participant with a copy of the scenario, but not the expected discussion points per case,

which should be given to the participants, by the instructor, as needed.

Simulated oximeter

The simulated oximeter is a very useful computer programme that is easily installed on a

laptop or desktop. You will find this on the CD Rom which comes with each of the Lifebox

pulse oximeters.

This can be easily programmed to provide a pulse rate and saturation with an audible tone

that varies its pitch with saturation change. The simulated oximeter is very useful for scenario

teaching.

Teaching Format

The simplest form of scenario teaching is to use a written scenario and for the participants to

discuss the management of the case. Instructors with clinical skills-laboratory simulation

experience may use more sophisticated forms of teaching using role play or manikins. The

simulated pulse oximeter, if available, may be useful for all forms of teaching.

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In scenario teaching the instructor introduces the scenario and encourages participants to

manage the case as they would in a real clinical situation. The instructor should act as a

facilitator for the process only.

It is important that the participants understand the format of the scenario teaching sessions

and the role of the instructor.

Participants should be encouraged to work through each case using the ABCDE action plan.

It is important that participants identify and treat serious problems before moving onto the

next step. A number of discussion points are included as expected discussion points for each

case. These discussion points contain the causes, or potential causes, of the oximetry problem

for each case.

The simulated oximeter can be quickly programmed to provide the saturation and pulse rate

described in the written scenario. The instructor can adjust these values as the scenario

evolves. This will add realism to the teaching session.

Try to get all participants involved in the discussion as with all small group teaching.

Remember that the main focus of the teaching is the appropriate use of the oximeter and

recognition and correction of hypoxia, rather than choices of anaesthesia technique.

Allow enough time for discussion at the end of each scenario. It may take up to thirty minutes

to complete a scenario and discussion. Some of the provided scenarios are more complex

than others.

At the end of each discussion ask for questions and summarise the key findings and reinforce

the use of the action plan.

Summary / Closure

Monitoring is important for safe perioperative and intraoperative care

We should know how to care for, use and interpret the monitoring we use.

We must respond to abnormalities if the monitoring is to be effective

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4. The WHO Surgical Safety Checklist Learning Modality Discussion

Equipment List Flip chart and pens or blackboard and chalk

Copies of the WHO Surgical Safety Checklist

Copies of the WHO Checklist Implementation Manual

Members of team to role-play (surgeon, anesthesia provider,

scrub nurse)

Simulated operating table or role play in theatre

Key Teaching Points This is a discussion with the facilitator as the focus, and will

finish with role-play to practice the points described. It is

important to recognise that adverse events in surgery are

common and that many can be avoided by a structured approach

to OR procedures. At the end of the session the candidates will

have acquired knowledge of the WHO Guidelines for Safe

Surgery, the ten objectives for safe surgery and the importance of

‘human factors’ in patient safety. The WHO Surgical Safety

Checklist should be discussed and the three elements of the

checklist considered in detail. The candidates should then use

role-play to practice the use of the checklist for an emergency

under GA. The workshop should finish with a discussion on how

best to integrate the WHO Surgical Safety Checklist into their

daily practice.

Key Learning

Objectives

To be aware of the WHO ‘ten objectives for safe surgery’

To be aware of the contribution of ‘human factors’ to

adverse events

To describe the elements of the WHO Checklist – Sign in,

Time out, Sign out.

To be able to role-play the use of the Checklist

4.1 Background: WHO Guidelines for Safe Surgery

It has been estimated that 234M patients undergo surgery every year, there are an estimated

7M patients who suffer complications from surgery, and 1M patients die.2 It is likely that

50% of complications are avoidable. A team of experts at the WHO have considered the

evidence as to why patients suffer complications during surgery, and have realised that

avoidable errors fall into a predictable number of categories. The WHO has identified ten

objectives for safe surgery, published in the WHO Guidelines for Safe Surgery and

summarised below. The surgical team shall:

1. Operate on the correct site on the correct patient.

2 A surgical safety checklist to reduce morbidity and mortality in a global population. Haynes AB, Weiser TG,

Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF,

Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. N Engl J Med. 2009

Jan 29;360(5):491-9.

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2. Avoid anesthesia complications, prevent pain.

3. Recognize and prepare for airway or respiratory complications

4. Recognize and prepare for high blood loss

5. Avoid known allergies

6. Minimize surgical site infection

7. Avoid retained swabs/needles/instruments

8. Correctly handle/label surgical specimens

9. Improve teamwork/communication

10. Collect data about surgical activity and outcomes

Ask the candidates to describe adverse events that they have experienced in their practice.

List these examples on the flip chart. Relate these to the ten objectives for safe surgery.

Discuss how the adverse events could have been prevented.

4.2 Discuss ‘human factors’ in healthcare

Ask the candidates to consider the situations in which they make a list to remind themselves

to do something – for instance shopping, travelling, at work. What are the consequences of

forgetting to check the list?

‘Human factors’ considers the relationship between humans and the systems in which we

work. It has been defined as: ‘the study of all the factors that make it easier to do the work in

the right way’. The science of human factors relates to the way in which we interact with our

environment (including equipment), and the ways in which we interact with each other, for

instance, communication and teamwork.

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Humans are not machines and we will inevitably make mistakes. Factors that make us more

likely to make mistakes are fatigue, stress, boredom, when we are distracted or interrupted

during a task, or when we have inadequate knowledge or skills. Our mind may play ‘tricks’

on us, and we may misread a situation; others in the team may see things differently and be

able to help us.

Ask the candidates to reconsider the adverse events that they described previously – what

were the human factors that were involved?

4.3 The WHO Surgical Safety Checklist

Surgery is a complex process involving interactions between the patient and many different

healthcare workers. A way to lessen the effect of human factors is to standardise the way that

we do things, work as a team, and reduce the reliance on memory. This is why the WHO

Surgical Safety Checklist has been developed.

The WHO Checklist should be used at critical points in the patient’s journey through theatre

to make sure that the team has done the right thing. By doing the checks routinely as a team,

communication and teamwork are improved. The WHO Checklist has been shown to reduce

complications due to surgery in all income settings.

Hand out copies of the WHO Checklist and WHO Checklist Implementation Manual to

all candidates. (You can find links to the WHO website where you can download these in

Appendix 8 and 9.)

4.3.1 The Sign in

Run through the components of the ‘sign in’ with the candidates. Consider any local

problems – how may these be addressed? (for example; language difficulty, how patient

identity and consent are confirmed, no oximeter, no blood available, additional requirements)

4.3.2 The Time out

Run through the components of the ‘time out’. Consider any local problems – how may these

be addressed? (for example; raising awareness of the checklist before introduction,

emergency cases)

4.3.3 The Sign out

Run through the components of the ‘sign out’. Consider any local problems – how may these

be addressed?

Show the candidates a video of the checklist in action – ‘How to’

Ask the candidates to role-play the use of the checklist for an emergency under GA.

4.4 Introducing the WHO Surgical Safety Checklist into routine practice

Ask the candidates to consider how they will introduce/use the WHO Checklist in their

practice.

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Factors that have been shown to be useful include:

Multidisciplinary education to explain the background to the Checklist. Resources are

available from WHO http://www.who.int/patientsafety/safesurgery/en/index.html

Consider modifying the Checklist to suit local practice – but do not overly complicate

it, e.g. start small in one theatre with one team.

Consider the barriers to introduction – what is making it difficult?

Roll out the Checklist to other theatres when it is being successfully used in one

theatre

Measure the impact of the Checklist – for instance, the number of incidents avoided,

or a staff questionnaire to assess the impact - Does the Checklist improve

communication? Does the Checklist improve patient safety? Would you feel happy to

speak up if there was a problem? Would you like the Checklist to be used if you were

a patient? Feed back this information to the theatre team. Consider critical incidents –

how could the Checklist have been used to avoid these?

Summary / Closure

Recap main points

Colleagues from World Orthopaedic Concern and Kossamak Hospital, Cambodia, summer 2012

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5. Monitoring and evaluation

5.1 Monitoring and evaluation principles

Monitoring and evaluation (M&E) are important for a number of reasons and it is imperative

that this is planned from the start of the programme, whether you are planning a standalone

oximetry workshop or a wider programme of capacity building that includes pulse oximetry.

Monitoring is a continuous process to measure progress of projects against pre-defined

objectives, and planned outputs and outcomes.

Evaluation is a thorough review of a project or programme which may consider issues such

as process, relevance, effectiveness, efficiency, impact and sustainability.

Some reasons why M&E are important:

• For personal accountability and job satisfaction

• To inform the planning of future activities

• To strengthen accountability to stakeholders

• To inform policy makers of the value of your programme

• To demonstrate achievements in order to secure funding

5.2 Evaluation of the workshop It is best to plan the evaluation of the workshop at the start. A basic method of evaluating the

knowledge transfer during your workshop is to perform a pre and post-workshop test of the

workshop topics with the caveat that this will only be a short-term assessment. You can see a

test example in Appendix 5. However, a repeat test with the same candidates at a later date

(if possible) can provide evidence of a longer-term knowledge transfer.

The workshop consists of a number of individual sections and it is useful to evaluate each

section separately. We recommend that feedback forms are collected from students after all

the sessions. It is also useful to gather information about which teaching style and methods

are most suitable for this audience as Western-style approaches are not always the most

effective. A template feedback sheet is included in Appendix 6.

5.3 Evaluation of impact Above we have discussed the M&E for outputs (what your project achieves) and outcomes

(what your project changes). Impact refers to the ultimate consequence of your intervention.

In our example, nurse anaesthetists given an oximeter and provided with oximetry training

(output) may result in improved monitoring of patients (outcome), which may lead to a

reduction in perioperative mortality (impact).

The impact of distributing oximeters and educating this group of anaesthesia provider is

unquestionable but needs some careful thought on how it can be reliably measured. Previous

groups have used the oximetry logbook (in Appendix 7) to demonstrate a reduction in the

length of time patients remain hypoxic after the training and distribution of oximeters, which

can enable us to conclude that patient care has been improved.

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We strongly suggest that logbooks are used as these help trainees to reflect on practice, why

and when the patient becomes hypoxic, and appropriate measure to take to avoid this. The

logbook would ideally be used for 100 patients.

We would welcome you contacting the Lifebox office to discuss some methods of assessing

the impact of your workshop.

Participants at Lifebox training course in Togo, spring 2012

6. Scale-up of surgical safety and pulse oximetry

6.1 Review of targets and goals Recent figures estimated the global need for oximeters to be in excess of 77,000. The mission

of Lifebox is to ensure that no patient dies because a pulse oximeter and basic safety checks

were not used during surgery. To date, Lifebox have distributed close to 4,000 oximeters in

over 70 countries and we are continually striving to close this global oximetry gap. We are

also working to implement the WHO surgical safety checklist in a number of countries. We

need on-going support, both financial and programmatic, to enable us to reach this aim.

6.2 Barriers to scale-up There are numerous barriers to scaling up the efforts of Lifebox, none of which are

insurmountable. Providing oximeters to those who need them most (and where the gap is

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greatest) requires ongoing financial support. This can be achieved by targeted fundraising and

also increased advocacy among the end user group so they know that this equipment has been

made available for them to purchase at a reduced cost. Crucially, getting the oximeters to

where there is greatest need also depends on the existence of sound networks of anesthetic

practitioners and the ability to accurately estimate the oximetry gap. Utilising north-south

partnerships between anesthetic departments is also an effective way to deliver the education

programme and save lives.

6.3 How you can help

Here are some ideas about how you can make a difference:

- Host departmental fundraising events (e.g. cycle ride) to benefit Lifebox Foundation’s

work

- Suggest that each member of your anesthetic society donates an oximeter to an anesthetic

colleague in a low or middle income country

- Apply for a grant to enable you to travel to a target country and deliver the Lifebox

education programme

- Encourage the development of networks between your department and counterparts in a

low or middle income country to provide a sound platform upon which you can deliver a

training workshop

- Give a talk about your experiences to national or international academic conferences

- Write an abstract or an article for a well-read journal

There are many other ways to help – please contact Lifebox Foundation with your

suggestions, comments and queries info@lifebox.org

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Appendix 1 Additional resources

Advice on planning a visit

Tips for travelling abroad

http://travel.state.gov/travel/tips/tips_1232.html

British Association of Urological Surgeons

http://www.baus.org.uk/urolink/working-abroad/making-a-visit/organising-a-visit

Leow J, Groen R, et al. A preparation guide for surgical resident and student rotations to

underserved regions. Surgery Volume 151, Issue 6 , Pages 770-778, June

http://www.surgjournal.com/article/S0039-6060(12)00098-0/abstract

General links to global health

Global Surgical Consortium

http://globalsurgicalconsortium.org/about

Alliance for Surgery and Anesthesia Presence

http://asaptoday.org/blog/

Global Health Delivery Online

http://www.ghdonline.org

Global Health Education Consortium

http://globalhealthedu.org/SitePages/Home.aspx

Global Partners in Anesthesia and Surgery

http://www.globalpas.org/?status=home

International Surgical Mission Support (ISMS)

http://ismission.org

World Health Organization (surgery)

http://www.who.int/topics/surgery/en/

Royal Society of Medicine (RSM) Global Health

http://www.rsm.ac.uk/globalhealth/news.php

Tropical Health and Education Trust (THET) (UK)

www.thet.org

The Society of International Humanitarian Surgeons

http://www.humanitariansurgery.org

Global Health Delivery Online

http://www.ghdonline.org

21

Centers for Disease Control and Prevention

http://www.cdc.gov/globalhealth/

University of British Colombia Branch for International Surgery

http://www.internationalsurgery.ubc.ca/resources_links.html

United Nations Humanitarian Affairs

http://www.un.org/en/humanitarian/

Government agencies

UK – Department for International Development

http://www.dfid.gov.uk

USA – US Agency for International Development

http://www.usaid.gov

Canada – Canadian International Development Agency

http://www.acdi-cida.gc.ca/home

National anesthesia and anesthesiology societies

American Society of Anesthesiologists – Global Humanitarian Outreach

http://www.asahq.org/GHO

American Association of Nurse Anesthetists

http://www.aana.com/Pages/default.aspx

Association of Anaesthetists of Great Britain and Ireland (AAGBI)

http://www.aagbi.org

Canadian Anesthesiologists’ Society – International Education Foundation

http://www.cas.ca/English/CASIEF

The World Federation of Societies of Anaesthesiologists

http://www.anaesthesiologists.org

University departments (global health)

Harvard Global Health Institute

http://globalhealth.harvard.edu

Harvard Humanitarian Initiative

http://hhi.harvard.edu/events/upcoming-events

University of Utah Center for Global surgery

http://medicine.utah.edu/globalsurgery/

22

Duke Global Surgery

http://surgery.duke.edu/about-department/divisions-and-programs/duke-global-surgery

University of Toronto Office for International Surgery

http://www.utoronto.ca/ois/

University of Florida Environmental and Global Health

http://egh.phhp.ufl.edu

Emory University School of Medicine

http://www.surgery.emory.edu/training/general-surgery

residency/global_surgery_program.html

Stanford University Global Anesthesia

https://www.stanford.edu/group/globalanesthesia/cgi-

bin/mediawiki/index.php/Main_Page

Yale Global Health Initiative

http://ghi.yale.edu

McMaster University

http://fhs.mcmaster.ca/surgery/ISD.html

University of Washington Department of Global Health

http://globalhealth.washington.edu

Oregon Health and Science University

http://www.ohsu.edu/ohsuedu/academic/som/surgery/divisions/Global-health-surgery/

Johns Hopkins Bloomberg School of Public Health

http://www.jhsph.edu/departments/international-health/about/mission.html

George Institute for Global Health

http://www.georgeinstitute.org/global-health-landscape

Surgical colleges and networks

American College of Surgeons – Operation Giving Back

http://www.operationgivingback.facs.org

International College of Surgeons

https://www.icsglobal.org

College of Surgeons of East, Central and Southern Africa

http://www.cosecsa.org

Canadian Network for International Surgery

http://www.cnis.ca

23

Appendix 2 Specifications for the Lifebox pulse oximeter

The Lifebox pulse oximeter is a robust hand held device suitable for use in the operating

room, recovery unit and ward areas. It has a clear display and is available with a variety of

probes to make it suitable for all ages. It is both battery and mains powered. The Lifebox

oximeter was selected for by a panel of experts from WHO and the WFSA, and is available at

a low price for distribution to medical facilities and hospitals in low and middle income

countries.

Features

- Light and compact handheld design

- High resolution, 2.4” color display

- Rotating screen for maximum clarity

- Visual & sound alarms

- IPX1 level protection against liquids

- Uses AA size alkaline or rechargeable batteries

- Supplied with clip and case to attach to pillow

Technical Specifications

Patient Range

Adult, Pediatrics and neonatal patients

Digital SpO2

Range 0 100%

Resolution 1%

Accuracy 70% to 100%: ±2%

Refreshing rate < 13 seconds

Pitch Tone Yes

Pulse Rate

Range 25 250 bpm

Resolution 1 bpm

Accuracy ±2% or ±1 bpm, whichever is the greater

Refreshing rate < 13 seconds

Display

Type 2.4” color display 320 x 240 pixels

Parameter

Digital SpO2, Pulse Rate, Pleth bar & SpO2

waveform

Alarm

Audible alarm, audible button tone

Supports Pitch Tone and multilevel volume

Alarm tones meet the requirement of IEC 6060118

Appearance

Dimension 123mm (H) x 58.5mm (W) x 28mm (D)

Weight < 200g

Data Storage

Display: Trend table

Trend interval: 2 seconds to 30 minutes

Trend parameter: PR, SpO2

Trend data spot-check mode: ID from 1 to 99, 300

records for each ID

Battery

Type 3 AA Alkaline batteries or NIMH

rechargeable battery (optional) or Lithium ion

rechargeable battery (option)

Runtime 14 hours standard use

Nellcor SpO2 probe compatible

Safety Standards

CE classification: IIb

Type of protection against electric shock: II, with

internal power device

Degree of protection against electric shock: CF

Degree of protection against ingress of liquid: IPX1

Acare Technology Co., Ltd.

info@acaretech.com www.acaretech.com

24

Appendix 3 Lifebox needs survey

25

26

Appendix 4 Clinical scenarios

Case 1

A 12-year-old child is scheduled for elective anaesthesia for foot surgery. The patient is ASA

1. Anaesthesia is induced with thiopentone followed by halothane in air and oxygen via a face

mask. During the induction the patient starts to cough and gets laryngospasm. The SpO2,

which started at 98%, falls to 88% during coughing and then to 74% when laryngospasm

occurs. Discuss why the saturation has fallen and what would be the most appropriate

actions?

Expected discussion points:

• Give 100% oxygen, assess ABCDE

• A – Is there airway obstruction due to laryngospasm? Apply positive pressure to the

reservoir bag, deepen anaesthesia. If the situation does not resolve, a small dose of

suxamethonium (0.5mg/kg) should be given.

• B – The breathing improves after resolution of laryngospasm.

• C – Assess pulse rate - bradycardia may occur due to hypoxia or secondary to

suxamethonium. Consider atropine after treating hypoxia.

• D – Check the halothane has not run out. Light anaesthesia can cause laryngospasm.

• E – Check that the anaesthesia equipment is functioning and connected appropriately.

• After treating the laryngospasm, the patient improved and the SpO2 returned to

normal.

Case 2

A 56-year-old obese patient is undergoing a laparotomy for bowel obstruction.

Preoperatively he is reasonably fit and his SpO2 is 95%. After rapid sequence induction and

intubation, the patient is ventilated and anaesthesia maintained using halothane in air with

30% oxygen. Over the next 10 minutes the patient’s SpO2 falls to 85%. What are the most

likely causes and what action would you take?

Expected discussion points:

• Give 100% oxygen, check ABCDE

• A – Check the airway and position of the tracheal tube. Check there is equal air entry

to both sides of the chest and that the tube is not kinked. Check that there is no vomit

in the mouth to suggest that the patient may have aspirated.

• B – Check that there are no added breath sounds to suggest aspiration, lung collapse

or bronchospasm. Give large tidal volumes by hand and listen to the chest. Is

ventilation easy?

• C – Assess whether the circulation is normal.

• D – Assess whether the patient is fully relaxed. Check that there are no signs to

suggest drug reaction (particularly wheeze + hypotension + rash, which are signs of

anaphylaxis)

• E – Check that the anaesthesia equipment is functioning and connected appropriately.

27

• After ventilating the patient with some large tidal volumes and increasing the inspired

oxygen the patient improved. The problem was lung collapse (atelectasis).

Case 3

During a Caesarean section under spinal anaesthesia, a fit 23-year-old primigravida

complains of tingling in the fingers and difficulty breathing. The SpO2 falls from 97% to

88%. What are the most likely causes and what action would you take?

Expected discussion points:

• Give 100% oxygen. Check ABCDE

• A – Check that the airway is clear

• B - Assess breathing. A high spinal may paralyse the muscles of respiration. If

breathing is inadequate, ventilate the patient and induce anaesthesia and intubate after

rapid sequence induction. Ventilate until the block wears off.

• C – Check the blood pressure – hypotension is likely. Treat with left lateral tilt, IV

fluids and vasopressors.

• D – Check the height of the block. Look for signs of a very high block - difficulty

breathing, whispering rather than talking, weak arms and numbness on the shoulders.

All indicate the nerves to the diaphragm are becoming blocked. This will make it

impossible for the patient to breathe. If the block is not this high, the patient can talk

in a normal voice and move their arms normally, but breathing may feel difficult due

to the paralysis of the intercostals muscles.

• E – Always ensure that equipment is ready in case this complication occurs

• After giving oxygen, the anaesthetist determined the block was not too high and the

patient settled with reassurance, left lateral tilt and IV fluids. The SpO2 improved

with oxygen. Any hypoxia in a pregnant patient is dangerous for the baby.

Case 4

A 7 year old boy is undergoing an open reduction of a fractured radius and ulna. Anaesthesia

is induced with thiopentone and suxamethonium. After intubation you are unable to ventilate

the patient. His saturation starts to fall. What is your management?

Expected discussion points:

• High flow oxygen is given.

• You are unable to ventilate the patient – this could be a patient problem or an

equipment problem

• Replace the patient breathing circuit with self-inflating bag to exclude possible

equipment problems. Don’t forget to replace the angle piece as this may be where the

obstruction is.

• Investigate possible patient problems, including a problem with the tracheal tube -

Check ABCDE

28

• This case emphasises the importance of excluding an obvious equipment problem

prior to assessing the patient using ABCDE

Case 5

Your colleague asks you to take over an anaesthetic for him as he has to get away to a family

event. The patient is a 19 yr old man who suffered major burns 2 weeks ago in a house fire.

The patient is breathing spontaneously via an LMA. The mixture is air, oxygen and

halothane. The surgery has been going on for over an hour. There is an IV of NS in the right

arm which also has a BP cuff and a pulse oximeter in place. The left arm and both legs and

part of the left abdomen are involved in the burn debridement. Things continue for another

hour and you notice the pulse rate going up to 110/min and the BP dropping to 80-90 systolic.

The pulse oximeter seems to only work intermittently. When it does read, the saturation

seems to be steadily decreasing. Your colleague documented the SpO2 at the start as 97%. It

is now reading 92%. What issues are you thinking about as this case proceeds?

Expected discussion points:

• A – The airway is clear.

• B – Respiratory depression from Halothane; atelectasis from long procedure; pre-

existing lung damage from fire

• C – Volume loss due to burns; blood loss due to debridement.

• D – Consider hypoventilation secondary to opioids.

• E – Use of oximeter on same limb as BP cuff; hypothermia from wide exposure and

debridement and inadequate signal due to shivering.

Case 6

In the Recovery Room, following a laparotomy under relaxant anaesthesia, a 43-year-old

patient is reported to have a SpO2 of 77% and is making twitching, jerky movements. What

are the most likely causes and what action would you take?

Expected discussion points:

• A – Open the airway and give 100% oxygen.

• B – If chest expansion is inadequate assist ventilation with a bag and mask.

• C – Check pulse and ensure intravenous access.

• D – Give anticholinesterase as relaxant reversal.

• E – Check position of pulse oximetry probe.

• Inadequate reversal is a common cause of breathing problems and hypoxia in

recovery.

Case 7

A 6 month old child is booked for general anaesthesia for an emergency laparotomy. She has

been unwell for five days and required large amounts of fluid for resuscitation. Just prior to

induction her pulse rate is 130 and SpO2 is 95% on high flow oxygen. Anaesthesia is induced

29

with thiopentone and suxamethonium. Just after intubation her saturations drop to 80%. What

is your management?

Expected discussion points:

• A – The tracheal tube is a new size 4.0. It does not seem to be blocked. Whilst

preparing to listen to the chest, saturations have fallen to 60%.Capnometry is not

available.

• B – Her abdomen is swollen and chest expansion is difficult to assess. You are unable

to hear breath sounds. Saturations are now 45% and heart rate is 60.

• It is not certain that the TT is in the trachea. Participants should be prompted to return

to A to check the position of the TT.

• A – Repeat laryngoscopy shows the TT is not in the larynx. The SpO2 falls to 30%

before the patient is reintubated.

• B – Chest expansion is now obvious and the saturations quickly return to 96%.

• This scenario highlights the importance of correcting a problem before moving to the

next step of the algorithm.

Case 8

You are giving an anaesthetic to a 75 yr old woman for an ORIF of a fractured hip. She fell 1

week ago and has been waiting for surgery since then. She has dementia and cannot give you

any proper history. You hear a grade 3 systolic murmur at the right sternal border radiating to

the right carotid. Air entry at the lung bases is very poor and you think you can hear some

coarse crackles over both lung fields. You proceed with a general anaesthetic consisting of

fentanyl, thiopentone and atracurium. Following intubation, you connect the TT to the

ventilator and give oxygen and halothane. The patient is moved onto the operating table.

Following positioning, you replace the pulse oximeter and cannot get a trace. You check the

blood pressure but find it hard to hear the sounds. You try a couple more times but no luck.

You feel for a carotid pulse and think you can feel it. What is your management?

Expected discussion points:

• A – The TT appears to be correctly positioned

• B – Listen to the chest. Does she have atelectasis or pneumonia or both? Has she

aspirated?

• C – Does she have congestive heart failure? Does she have aortic stenosis? Is low BP

a problem in aortic stenosis? Is there evidence of low blood volume?

• D – Is her blood pressure low from thiopentone and/or halothane? What is the

treatment for this?

• This is a complex case and there may be a number of contributing causes.

• E – What is the problem with the pulse oximeter? Does it work if the peripheral pulse

is absent or weak? Is the patient cold? Is the oximeter working at all?

30

Case 9

You are giving an anaesthetic for a laparoscopic cholecystectomy in a 45 yr old woman.

Preoperatively you notice that she has prominent upper incisors. You induce anaesthesia with

fentanyl, thiopentone and suxamethonium and then oxygenate the patient via a face mask.

When relaxed, you proceed to intubate the patient. With laryngoscopy, all you can see is the

tip of the epiglottis. You try to intubate but are unable to. You can hear the pitch of the pulse

oximeter getting lower. You look and it is reading 90%. You ventilate the patient and get the

saturation up to 96%. You try intubating again using a different blade and with a stylette in

the tube. You are unsuccessful. You call a colleague who tries a blind nasal intubation and

causes a nose bleed. By now the oxygen saturation is 80%. It is becoming increasingly

difficult to ventilate the patient. What is your management?

Expected discussion points:

• A – Management of unanticipated difficult intubation. Discuss management of a

“can’t intubate, can’t ventilate” situation

• B – Aspiration

• C – Severe bradycardia secondary to hypoxia. Treating A + B should treat the

bradycardia. Commence CPR if there is a cardiac arrest.

• D – Should anaesthesia drugs be continued or stopped?

• E – What is your backup plan for an unexpected difficult airway? What equipment

would you have nearby?

31

Appendix 5 Pre and post-workshop tests for pulse oximetry

Can be used pre and post-workshop to gauge level of knowledge

1. What two things does a pulse oximeter measure?

2. What is the normal oxygen saturation in arterial blood in an adult?

Quiz

Each question has 5 parts. Please answer each part TRUE or FALSE.

1. The pulse oximeter measures:

a. The patient’s haemoglobin level TRUE FALSE

b. The respiratory rate TRUE FALSE

c. Percentage of haemoglobin saturated with oxygen TRUE FALSE

d. Pulse rate TRUE FALSE

e. Blood pressure TRUE FALSE

2. Which of the following statements are true about oximeter probes?

a. Probes should be very tight TRUE FALSE

b. A red light on the probe is normal TRUE FALSE

c. The probe can be cleaned gently with soapy water TRUE FALSE

d. If I cannot get a good reading there must be something wrong with the probe

TRUE FALSE

e. Nail varnish does not affect probe function TRUE FALSE

3. Which of the following can cause false readings on a pulse oximeter?

a. Dark skinned patients TRUE FALSE

b. Shivering TRUE FALSE

c. Overhead lights shining on probes TRUE FALSE

d. Hypovolaemia TRUE FALSE

e. Oxygen treatment TRUE FALSE

4. Which of the following statements are true:

a. Saturation should always be 100% during anaesthesia TRUE FALSE

b. Saturation of 95% is OK a healthy 2-year-old TRUE FALSE

c. Saturation is normally less than 93% in a 70-year-old TRUE FALSE

d. Saturation only becomes seriously low when less than 75% TRUE FALSE

e. Saturation is not worth measuring during spinal anaesthesia for Caesarean section

TRUE FALSE

5. The following may reduce the chance of a successful oximeter reading:

a. Movement by the patient TRUE FALSE

b. Hypertension TRUE FALSE

c. Sickle cell disease TRUE FALSE

d. Arrhythmia TRUE FALSE

e. Hypovolaemia TRUE FALSE

32

6. When using an oximeter:

a. It must be kept plugged into the electricity supply at all times TRUE FALSE

b. Wipe the probe after each patient TRUE FALSE

c. Do not leave on the patient for more than one hour TRUE FALSE

d. Turn the sound to silent to avoid distracting the surgeon TRUE FALSE

e. The unit can be tested by placing it on your own finger TRUE FALSE

7. The battery in a Lifebox oximeter

a. Will last 24 hours TRUE FALSE

b. Should be charged when electricity is available TRUE FALSE

c. Can be replaced by 3 AA cells (batteries) TRUE FALSE

d. Will last around 5 years TRUE FALSE

e. When the battery level is very low the oximeter may become less accurate

TRUE FALSE

8. If the saturation is 85% in a healthy patient:

a. Turn off the alarm and watch what happens next TRUE FALSE

b. Check ABCD TRUE FALSE

c. There must be a problem with the oxygen supply TRUE FALSE

d. Stop the surgery TRUE FALSE

e. Start an IV infusion immediately TRUE FALSE

9. About the probe:

a. The probe can only be used on the fingers in adults TRUE FALSE

b. The probe can never be used in babies as it is too big TRUE FALSE

c. Probes become less accurate after 1-2 years TRUE FALSE

d. If the probe becomes faulty it should be taken to pieces and checked

TRUE FALSE

e. The lead should be tightly coiled when not in use TRUE FALSE

10. About age

a. Babies always need to breathe 100% oxygen during anaesthesia TRUE FALSE

b. The normal heart rate in a 5 year old child is around 140/min TRUE FALSE

c. An 80 year old normally has a saturation of around 88% TRUE FALSE

d. With children it is best to turn off the alarms to avoid annoying the surgeon

TRUE FALSE

e. In recovery children always have a low saturation TRUE FALSE

33

Appendix 6 Course feedback sheet

What did you like most about the workshop?

Which sessions were most useful and why were they useful?

What did you not like about the workshop?

How could the workshop be improved?

34

Appendix 7 Oximetry logbook

After working through the manual and learning about the pulse oximeter, it is recommended that you use the pulse oximeter on all your patients

and that you record details of their anesthetics in the logbook. The logbook takes only a few seconds to fill out and will help you identify areas

in which you can improve your anaesthesia care.

The logbook records the type of surgery performed, the kind of anaesthesia and the lowest saturation that was recorded. As you get more used to

the oximeter and responding appropriately to the readings, you should see the number of patients who become desaturated decrease. Share your

experience with your colleagues.

In order to understand how to complete the logbook, try filling in the logbook for the following cases:

1. A 6-year-old child under ketamine anaesthesia for reduction of a dislocated elbow. Saturations remained above 95% at all times.

2. A 23-year-old adult induced with thiopentone and then maintained on halothane anaesthesia under face mask for incision and drainage of a

thigh abscess. At incision he developed laryngospasm and his saturations fell to 77%. He improved with airway management and additional

oxygen.

3. In recovery, a normally fit 45-year-old patient developed a saturation of 82% lying on his back following an elective laparotomy.

Anaesthesia was with tracheal intubation following thiopentone and suxamethonium. Maintenance was with ether. He improved when

turned on his side and his airway was opened.

4. A 22-year-old patient undergoing emergency Caesarean section under spinal anaesthesia developed a saturation of 92% with mild difficulty

in breathing. Her airway and breathing were satisfactory. BP was 75 mmHg systolic. She responded to left lateral tilt, oxygen and fluid.

35

OXIMETRY LOGBOOK: Name: ________________________ Hospital: _____________________________

Date Patient initials

Age ASA Score

Operation Anaesthesia Lowest SpO2 during case

If the SpO2 fell below 90%, why did this happen and what did you do to correct it?

Patient Outcome

If LSCS, outcome for baby

1/2/09 AA 6 1E MUA elbow K, O2 95% N/A

G

1/2/09

BB 23 1E I&D Hal, O2, STP 77% Laryngospasm – anaesthesia deepened and 100% oxygen given

G

1/2/09

CC 45 1 Laparotomy TT, hal, O2, STP, sux

82% In recovery obstructed airway – turned on side and given O2. Nurse to watch carefully

G

1/2/09

DD 22 1E CS Sp 92% High spinal with hypotension – BP 75/40. Breathing OK, extra O2 and ephedrine

G G

36

The American Society of Anesthesiologists’ Classification of Physical State:

This is used worldwide as a simple way for anaesthetists to describe the physical state of their patients before surgery. Allocate your patient an ASA

grade when you assess them preoperatively.

ASA Grade 1 A fit healthy patient

ASA Grade 2 A patient with minor disease, such as mild hypertension, mild anaemia or mild asthma.

ASA Grade 3 A patient with severe disease that limits their activity, such as untreated diabetes, breathlessness or heart disease.

ASA Grade 4 A patient with disease that is a constant threat to life, such as eclamptic fits or malignant hypertension.

ASA Grade 5 A moribund patient not expected to survive with or without an operation, such as a patient with septic shock in whom the

blood pressure is unrecordable.

Addition of E’ indicates that this was an emergency operation, for instance a patient with a ruptured uterus in whom the blood pressure is

unrecordable is designated as ASA 5E.

During anaesthesia for these 10 patients, were there any problems with the oximeter or the probe? YES/NO

If yes, please describe what the problems were:

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

Did any of these patients die in theatre or within the first 24 hours? YES/NO.

If yes, please indicate which patient and describe what happened:

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

37

Appendix 8 WHO Surgical Safety Checklist

Can be downloaded from the World Health Organization website at

http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf

38

Appendix 9 WHO Checklist Implementation Manual

Can be downloaded directly from the World Health Organization website at

http://whqlibdoc.who.int/publications/2009/9789241598590_eng.pdf