A major contributor to the surgical access and outcomes deficit experienced by vulnerable populations worldwide is the lack of trained anesthesia clinicians in low- and middle-income countries (LMICs). The World Federation of Societies of Anesthesiologists Global Anesthesia Workforce Survey revealed large gaps in both physician and non-physician anesthesia provider density, including 70 countries with a total anesthesia provider number <5 per 100,000 population (Anesth Analg 2017;125:981-90). Closing these gaps will require high-level investment, partnership, and innovation for education capacity in these settings.
The Improving Perioperative Anesthesia Care and Training (ImPACT) Africa program is making strides to close this anesthesia education gap in East Africa. Founded in 2014 by a team at Vanderbilt University Medical Center (VUMC) with a grant from the GE Foundation, the program has focused on four key areas of capacity-building: learning resource development, training educators, health care simulation, and data collection. ImPACT was initially launched in partnership with AIC Kijabe Hospital/Kijabe College of Health Sciences and the Kenya Medical Training College in western Kenya. With the assistance of Bahir Dar and Mekelle universities as well as the Ethiopian Society of Anesthesiologists Professional Association (ESAPA), it was expanded to training sites in Ethiopia in Addis Ababa and the Amhara and Tigray regions in 2018. ImPACT is currently in the process of launching at three major teaching hospitals in Tanzania. To date, over 600 learners have been reached across its programs, and ImPACT is positioned for continued growth.
High-quality learning resources are a cornerstone of any educational program. Accessing these materials, particularly those developed with the resource limitations and disease processes present in many LMICs in mind, can be challenging for fledgling programs. The first aim of the ImPACT program was to build an anesthesia curriculum, including a comprehensive repository of video-recorded lectures accompanied by case-based discussions and multiple-choice quizzes. The library of 174 modules was developed by faculty, anesthetists, fellows, and residents at VUMC and integrated into a learning management system (LMS) able to track each student's utilization and test results. At each site, the LMS was installed on a local wireless network to allow continuous access to students without using cellular data. As a new approach compared to traditional classroom lectures, initial uptake of the system was slow. However, after a series of virtual sessions led by Vanderbilt faculty demonstrating flipped classroom methodology, participation in the system by students improved.
Teaching resources are not useful without teachers, and a major challenge for educational programs in LMICs is the shortage of educators. Educators in these settings are often relatively young, hampered by clinical demands leaving minimal time to develop teaching experience and training in how to be an educator, and are usually expected to train a large number of students with very limited materials. Understanding this, ImPACT created an intensive two-week training-of-trainers course for anesthesia educators. This course introduces the concepts of team-based learning, problem-based learning, the flipped classroom model, teaching in the OR and incorporation of simulation training to existing curriculum. After undergoing this course, educators continue to receive long-distance mentorship by VUMC faculty to ensure they are successful in incorporating these concepts. To date, ImPACT has trained 18 nonphysician anesthesia educators in Kenya, and 33 nonphysician anesthesia educators in Ethiopia. Because of COVID-19 and the difficulties of traveling, the training was adapted to a virtual format, and starting in the last quarter of 2020 is being used to teach 15 anesthesiologists in Ethiopia. These educators are impacting both physician and nonphysician anesthesia training programs in Kenya and Ethiopia with nearly 200 anesthesia graduates in Kenya and 80 graduates in Ethiopia from ImPACT-affiliated programs to date. The most fulfilling aspect of this training is seeing the growth of these educators through the years. Some of the educators now help teach and run their own training-of-trainers courses.
An innovative feature of ImPACT has been the integration of high-fidelity simulation as an educational intervention to aid learners and educators alike. This training tool is ubiquitous in high-resource environments and valued as a way to create a standardized, high-stakes clinical setting without putting patients at risk. ImPACT made use of the simulation experience of VUMC faculty to introduce health care simulation at two sites in Kenya and two in Ethiopia and train local educators and technicians to run them. These sites are now actively being used for trainee education at multiples levels pre- and post-graduate training. As an extension of this paradigm, team members from VUMC and Kenya developed the Mobile Obstetrical Simulation Training (MOST) program. This course is directed toward anesthesia providers, obstetricians, medical officers, nurses, and nurse midwives involved in emergency obstetrical care. MOST incorporates didactics on obstetrical emergencies, teamwork concepts of crisis resource management, and simulation training for peripartum emergencies using a high-fidelity mannequin. It has been performed at two dozen sites in East Africa led primarily by local teams and has demonstrated measurable improvement in clinical performance. These simulation initiatives have advanced the clinical and educational skills of hundreds of learners and educators in these settings.
From the outset, the ImPACT Africa team and collaborators believed it was very important to monitor the effects of educational capacity-building efforts on clinical care and patient outcomes. To measure this, the program set out to implement a data collection tool granular enough to collect key anesthesia and surgical data points and outcomes but short enough that collection wasn't burdensome. The goal was to collect these data electronically, with an ability to collect data offline without the need for an internet connection. To accomplish this, the team partnered with REDCap to modify an existing online data collection tool to a mobile app that would enable offline data collection, with intermittent uploading of data when internet connection was available – a feature crucial for low-resource settings where an internet connection is not constant and readily available (Anesthesiology 2017;127:250-71). Data collection was started at Kijabe Hospital and expanded to 29 hospitals in Kenya over the next two years, managed by a team of eight data managers and research assistants. In five years of data collection, this team has collected data from over 50,000 surgical cases with over 130 unique data points. In Ethiopia, data on over 10,000 cases have been collected from two tertiary hospitals over the last two years. As an initiative that called for transparency and sharing of potentially poor outcomes in clinical cultures not accustomed to doing so, data collection and reporting required building relationships and trust, empowerment and vision-setting, constant follow up, and vigilance among all team members involved. As data have emerged detailing outcome disparities in these settings compared with high-resource environments – including a recent finding regarding an unacceptable high postoperative pediatric mortality in Kenya (Anesthesiology 2020;132:452-60) – the value of data to aid advocacy and to mark progress for anesthesia development has become clearly apparent.
Educational partners from the ESAPA, Bahir Dar University, and Mekelle University have confirmed the tangible results of these strategies on anesthesia capacity-building in Ethiopia, a country of 110 million people. Anesthesiology in Ethiopia is a relatively young field, and despite its large population, it has barely one-hundred anesthesiologists. Relationships fostered through ImPACT have paved the way to build much-needed anesthesiology residency programs by focusing on future educators, enrolling them in a series of lectures and workshops, and providing continuous support and mentorship. Nonphysician educators who were trained by ImPACT at Mekelle University have been able to equip anesthesia providers in the Tigray region via the MOST program and other in-person trainings at the simulation center. They estimate they have been able to train around 30% of the region's anesthesia providers and other health professionals and believe it is starting to have a significant role in decreasing the maternal and child mortality. Similarly, Bahir Dar University educators have trained a significant number of practitioners from the Amhara region, impacting the region beyond their university. This collaboration has also been essential in developing contextually appropriate basic and subspecialty anesthesia curricula now adopted as a standard for the country. These relationships have allowed VUMC to join forces with the ESAPA to create a vibrant, highly scientific and state-of-the-art annual conference that has been critical to enhancing recognition and networking for the specialty.
By aligning with individual, institutional, society, and national clinical and educational goals, the ability of team members from high-resource areas to partner with colleagues around the global to build anesthesia capacity through ImPACT has been immense. More importantly, investment in local leaders in pursuit of equity in anesthesia education will allow these programs to flourish for years to come.
Acknowledgement: Work described is supported by the GE Foundation and ELMA Foundation.