The prevention of postoperative adverse events requires trained individuals. Many LICs and some middle income countries (MICs), have an extraordinary lack thereof, the magnitude of which is not well understood due to lack of data on numbers of providers within many LICs [1, 5, 15]. In Uganda, one of the few LICs from which data has been collected, reports in 2008 noted that there were only 14 anesthesiologists for a population of 30 million, giving a ratio of 1 provider per 2.1 million population [1, 20, 21]. In neighboring Kenya there are only 13 anesthesiologists that work in public hospitals serving a population of 32 million [15]. While joint education projects between facilities within a LIC and outside education organizations are ongoing in some areas to improve the lack of trained providers [22], the high cost of training relative to per capita income means many training positions in LICs go unfilled [15]. Moreover, reports on the training providers receive for postoperative care are unknown. Long standing programs created by the World Federation of Societies of Anaesthesiologists (WSFA) and the Committee for European Education in Anaesthesiology (CEEA) are initiatives that can serve as models for increased training in perioperative care by agencies external to a country [23]; however, their overall impact in improving anesthesia and postoperative quality has not been determined [15]. Given the scarcity of providers and the unknown extent of training in postoperative care, there is always a role for visiting practitioners in teaching postoperative care. As part of a 2 year development of a process road map for the improvement of women’s care in a health care facility by the Kybele organization and Ridge Hospital in Ghana (Fig. 13.2) [24, 25], post-cesarean section care was identified as a process for improvement and the visiting team developed a program of education for post-cesarean care.

In many MICs resources exist to support training of an adequate number of providers, but standards to insure the quality of the training are often lacking. One focus for short term visit teams to MICs should be not only to provide education, but to partner with interested host facility personnel in creating training standards. During a recent Kybele team visit to Serbia by two of the authors (CB and IV), the local host was engaged in outlining a strategy for education of practitioners outside of the host facility. A curriculum that could be standardized for wide spread use is being created.

In addition to production of trained individuals, the retention of trained practitioners is difficult because the rate of pay for health care practitioners is very low. Once trained in their home country, many anesthesia providers have the qualifications to work elsewhere and thus migrate to better paid positions outside their home country. A “brain-drain” is thus created [15, 20] and the scarce resources used to train in-country providers are exported to more developed nations when those persons leave. The detrimental effect on postoperative care is probably significant, but currently not quantified. As a process improvement, visiting teams could use morale improving measures to encourage and bolster local practitioners; examples are noted below in the section entitled “Workforce Morale.”

The prevention of adverse events requires adequate infrastructure and supplies. The lack of transportation for supplies and inadequate support staffing compound the inability to provide essential materials for safe anesthesia care of reasonable quality. Hodges et al., in their report of anesthesia services in Uganda in 2007 using a standardized survey tool, noted that only 23 % of hospitals surveyed could provide a safe general anesthetic for an adult, 13 % could so do so for a child, 28 % could do spinal anesthesia safely, and that resources to provide safe anesthesia for cesarean delivery were available in only 6 % of facilities [3]. Equally dismal percentages for adequate equipment maintenance and drug availability were noted. Although adequate resources do not translate into quality anesthesia provision, provision of necessary resources is required. Donated equipment can be a useful means of improving physical resources, but it must meet the need of the host facility otherwise it will be discarded and can then become a significant environmental hazard to an individual facility as waste disposal is almost non-existent in most LICs. The troubleshooting and subsequent disposal of inappropriate equipment further drains scarce resources and degrades quality care [26]. The WHO has published guidelines that charitable organizations could use for equipment donations [27].

In contrast to surgical facilities in most wealthy western countries, virtually all facilities in LICs and most in MICs do not have a post-anesthesia care unit (PACU) attached to the operating room. Patients are most often returned to the regular wards or sent to areas little different from them following an operative procedure. Recently reported evidence from France reinforces that establishment of PACUs significantly reduce postoperative adverse events [28]. Unfortunately, resources in most LMICs will likely not be available to provide such a specialized area in facilities in which it currently does not exist. Resources in LICs would probably be better spent on higher priorities. In MICs, extensive facilities were often constructed with operating areas near patient rooms dispersed throughout a facility without dedicated PACUs. The creation of centralized PACUs is unlikely in these settings as the cost of changing this infrastructure would be substantial. Quality improvement could focus on more extensive preanesthetic assessment and preparation and alterations of intraoperative anesthetic techniques to reduce the possibility of anesthesia related post-anesthesia complications. Since airway obstruction and respiratory complications are among the most frequent causes of postoperative morbidity [29], the use of regional anesthesia as a strategy to reduce adverse events could be encouraged as a measure to improve quality. For example, in a recent report of a Kybele sponsored trip to Georgia, Ninidze et al. reported an increase in the use of regional anesthesia for cesarean delivery [30]. While specific effects on postoperative adverse events were not noted, the report was done in the context of improving total perioperative care in which increased use of regional anesthesia was thought to improve maternal outcomes.

Although the only randomized controlled trial examining the effects of pulse oximetry introduction failed to show a reduction in adverse effects postoperatively [29], its widespread use to improve patient outcomes during the immediate operative period is now part of the International standards for a safe practice of anaesthesia [31]. Best practice guidelines vary considerably among organizations in all health systems, but virtually all guidelines demand use of pulse oximetry and compliance among practitioners for its use is nearly 100 % when made available [31]. Currently The Global Oximetry project promotes the widespread adoption of pulse oximetry during the operative period [32]. As an initiative, visiting teams could promote pulse oximetry use into the postoperative period regardless of patient location and, with their host facility, adopt processes to implement immediate care when hypoxemia is detected.

Improving process to prevent of adverse events requires good workforce morale. The poor infrastructure and lack of medical supplies noted above are commonly found in LICs and some MICs and lead to poor workforce morale [15]. Provider psychological reaction to the organizational structure in which the provider works has an almost equal effect. A recent systematic review of studies examining factors contributing to poor health care worker morale in LICs, noted that while financial constraints and poor resource availability ranked near the top of factors associated with poor morale (90 % and 80 % respectively), lack of career development and lack of recognition by the organization for worker contributions ranked nearly as high (85 % and 70 %, respectively) [33]. In contrast, poor infrastructure was reported by only 45 % of workers as contributing to low morale. As part of their ongoing improvement, the above mentioned Kybele–Ghana partnership began a program recognizing individual nurse suggestions, implemented a monthly nurse recognition award, and sponsored an out of country educational trip to the United States for those nurses who were recognized as team leaders. Although the effects on overall morale were not measured, other improvements in work performance measures (decreased work tardiness for example) were noted.

The prevention of adverse events is likely to be incentivized by changes in behavior and culture. As an example, the attitudes and practice habits of anesthesiologists and other anesthesia providers in LMICs regarding vigilance have not been evaluated or studied. However, the behavior of local anesthesia providers has been anecdotally noted by humanitarians, visiting physicians, and surgical teams providing care through nonprofit organizations. Often anesthesia providers will leave a patient under anesthesia for a variety of reasons, including caring for another patient, being called to an emergency, and in the most shocking of situations, for a lunch break leaving no one else in attendance. The process of providing a thorough hand-off of care to persons who will care for a patient in the postoperative period is not often performed. These practices were common place in developed countries prior to 1950, but a culture of vigilance and the availability of safety monitors which demand continuous assessment has forever changed the standard of care for an anesthesia provider in the immediate and postsurgical period. However, for providers who have rendered pre- and post-anesthetic and surgical care for years and decades without monitors, and often with minimal resources, an emphasis on vigilance may have waned. Vigilance in many LICs needs to be reintroduced, and postoperative hand offs to other health personnel need to be mandatory.

Vigilance may be enhanced by the simple measure of identifying the sicker vs. the healthiest postoperative patient. The good success in reducing maternal mortality reported by the Kybele-Ghana experience may lie in separating the sick from the less sick by screening for preeclampsia and post-delivery hemorrhage. This action allowed scarce and overworked care givers to focus their attention on those patients who needed it most. Similarly an index of patient risk for postoperative difficulty could be generated using a combination of unstable intraoperative hemodynamics, excessive surgical blood loss, and complexity of preoperative medical conditions. Postoperative care givers could identify those patients with increased risk vs. those with less and thus focus their scarce time preferentially.

Team building will help change workplace behavior. Team building encourages participation by all stakeholders in perioperative care. Regular meetings ensure all persons have a say in the change process that affects them. Ensuring that everyone can speak during meetings and using power elevating techniques allow individuals, including those who are low in the organizational structure to feel that that they have input [7]. Shortly after The Kybele-Ghana project began, both the visiting team and the facility hosts agreed that monthly morbidity and mortality conferences and monthly service meetings would occur. All stakeholders at the host facility participated, and everyone were encouraged to have input.

Prevention of adverse events requires change to the processes and ways of doing work; “all change will not result in improvement, but any improvement will need to result in change” [7]. Although the application of implementation science to LIMC health care systems is in its infancy, Ramaswamy and Barker [7] and Berwick [10] (based on his review of successful project implementation in an LIC [Peru] and an MIC [Russia]) suggest common factors that can lead to successful implementation and maintenance of quality improvement (Tables 13.1 and 13.2). These authors state that successful implantation will often lead to higher quality with consumption of fewer resources and better quality care that often costs less compared to the provision of defective care [7, 10]. The challenge of improving postoperative care relies upon consuming fewer resources. Implementation of better processes needs to be the focus in LICs in particular that often waste many of the scarce resources that they can ill afford to lose [7].