Anaesthesia
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The World Health Organization (WHO) Surgical Safety Checklist is a cost-effective tool that has been shown to improve patient safety. We explored the applicability and effectiveness of quality improvement methodology to implement the WHO checklist and surgical counts at Mbarara Regional Referral Hospital in Uganda between October 2012 and September 2013. Compliance rates were evaluated prospectively and monthly structured feedback sessions were held. ⋯ Use of the checklist was associated with performance of surgical counts (p value < 0.001; r(2) = 0.91). Pareto analysis showed that understaffing, malfunctioning and lack of equipment were the main challenges. A carefully designed quality improvement project, including stepwise incremental change and standardisation of practice, can be an effective way of improving clinical practice in low-income settings.
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The aim of this study was to create and evaluate the validity, reliability and feasibility of the Regional Anaesthesia Procedural Skills tool, designed for the assessment of all peripheral and neuraxial blocks using all nerve localisation techniques. The first phase was construction of a 25-item checklist by five regional anaesthesia experts using a Delphi process. This checklist was combined with a global rating scale to create the tool. ⋯ In the third phase, 70 clinical videos of trainees were scored by three blinded international assessors. The RAPS tool exhibited face validity (p < 0.026), construct validity (p < 0.001), feasibility (mean time to score < 3.9 min), and overall reliability (intraclass correlation coefficient 0.80 (95% CI 0.67-0.88)). The Regional Anaesthesia Procedural Skills tool used in this study is a valid and reliable assessment tool to score the performance of trainees for regional anaesthesia.
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Observational Study
An observational study of the 'isolated forearm technique' in unparalysed, spontaneously breathing patients.
The isolated forearm technique enables a patient, otherwise paralysed by neuromuscular blockade, to communicate by movement if wakeful during surgery. The positive response rate to verbal command is high (~32%). The 5th National Audit Project recommended that this monitoring technique should become more widely taught and considered, so this study was designed to assess its utility as a standard of care in unparalysed patients. ⋯ Even at extubation, when patients moved to expel the airway, there was no response to command until after wakening. These results suggest that in contrast to its use in paralysed patients, the isolated forearm technique does not yield useful information about the patient's state of wakefulness in the unparalysed. Another interpretation is that unparalysed patients are less prone to wakefulness than the paralysed.