Anaesthetic practices at Gulu Regional Referral Hospital in Northern Uganda, who does what and where? A retrospective study.

Abstract

Background: Hospitals such as the Gulu Regional Referral Hospital (GRRH) in northern Uganda, like many other regions of sub-Saharan Africa, lack the anaesthetists needed to provide adequate analgesia during surgical procedures. The GRRH has not employed any anaesthesiologist for many years. Instead, anaesthesia is carried out by non-physician anaesthetic officers (AO) and other healthcare workers (HWs). In this setting, peripheral regional anaesthesia (pRA) is a safe and resource-efficient alternative that HWs and AOs could use. The study aimed to evaluate surgical procedures, anaesthetic practices, and staffing at Gulu Regional Referral Hospital in Northern Uganda. The objective was to identify the appropriate audience for pRA training and the corresponding training content.

Methods: A retrospective review was conducted on surgical procedures and their anaesthetic management in three departments of GRRH during 2019. The possibility of performing pRA was determined based on the surgical site, infection status, and the type of surgical procedure being performed. A pRA was considered adequate when conditions for pRA were met and pRA was carried out. Chi-square test was used to compare categorical data. A bivariable logistic regression analysis was performed to identify the factors associated with the administration of peripheral regional anaesthesia and the qualifications of medical staff.

Results: A total of 804 procedures were recorded [67% in accident and emergency (A&E), 31% in operating room (OR), and 2% on the surgical ward]. Anaesthesia was recorded in 82% of cases. Of these, 86% were documented in regional and local anaesthesia. Anaesthetic officers carried out anaesthesia in 20% of all cases and in all cases in the operating room. HWs with more than 2 years of training performed adequate pRA more frequently than HWs with less than 1 year of experience [Odds ratio (OR) = 2.586; 95% CI 1.336-5.005; p = 0.005]. The last group, however, performed significantly more procedures in A&E than in other departments (89%, p < 0.001). Of the 209 procedures that could have been performed with pRA, 85 were found to be inadequately anaesthetised. 79% (67) of these were performed in the emergency department. In 45% of cases with inadequate anaesthesia, patients received local anaesthesia instead of appropriate pRA. Pain control was absent in 18% of cases, and 20% of cases received presumably unnecessary general anaesthesia or sedation. In 17% of cases, additional administration of ketamine and/or midazolam was required due to insufficient pRA.

Conclusions: The data show that pRA procedures are already used at GRRH, especially by HWs with high level of training in the OR. In A&E, which is primarily staffed by doctors with less than 1-year training, there is a potential to increase the administration of adequate pain relief by implementing simple nerve blocks into routine clinical practice. Therefore, doctors and staff in A&E would benefit from needs-based training in pRA.