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BOSTON: Although there are many U.S.-based surgical organizations providing urgently needed care in low- and middle-income countries (LMICs), knowledge of whether these groups are adhering to a U.S. standard of care is noticeably lacking. In one of the first studies to investigate guideline-based practices that U.S. humanitarian surgical non-governmental organizations (NGOs) adhere to, or deviate from, researchers from Rutgers New Jersey Medical School, Newark, N.J., surveyed 83 U.S.-based NGOs and found that the majority of these groups adhere to U.S. protocols when providing care abroad. Results from the study were presented at the American College of Surgeons Clinical Congress 2018.
"We realized that there were a lot of NGOs out there doing work in different parts of the world, but very few of us were talking to each other," said lead study author Peter F. Johnston, MD, a surgical resident and global surgery fellow at Rutgers New Jersey Medical School. "Our goal was to try to get an idea of what different NGOs are doing and with that information, break down silos, share knowledge, and come together to form guidelines."
Findings from the survey indicated 67 percent of NGOs followed at least four protocol-based practices, but also that 20 percent of NGOs reported that deviation from standard U.S. practice occurred "often" or "very often," most commonly in the areas of pain management, preoperative workup, and operative technique. However, only 32 percent of the NGOs believe these deviations affect outcomes. The protocol-based practices most likely to be used by NGOs when providing care in LMICs included a standard operating room timeout checklist, collecting clinical information, and a perioperative antibiotic protocol.
"Realistically, you have to leave a little bit of space for deviation just based on resource limitations, so some things have to be flexible," Dr. Johnston said. "But we may be able to come up with certain things that should be universally followed, such as perioperative antibiotics."
The researchers found that the NGOs more likely to follow protocols are those that have been around longer, suggesting experience breeds structure, according to the researchers. Additionally, they found that more complicated procedures tended to be more protocol-driven. If consensus best practice guidelines for short-term surgical mission were to be developed, 85 percent of the NGOs surveyed showed interest in using such guidelines.
"Surgical teams who work with these organizations perform a wide range of procedures. We saw that some of the more advanced types of surgery are more protocol-driven, but for some of the more simple and safe procedures, surgical teams may take a bit more leeway because the procedure is less complicated," Dr. Johnston said.
Developing a baseline understanding of the clinical practices of U.S. humanitarian surgical NGOs in LMICs is just a first step, according to Dr. Johnston. He has his sights set on bringing together global surgeons and NGOs so that they can share knowledge and develop guidelines that will help improve surgical patient care.
"Participation in global surgery is only going to grow. This data is going to help set the path moving forward," Dr. Johnston predicted.
Dr. Johnston's study coauthors are Rijul Asri; Vennila Padmanaban, MD; Patricia M. Dalton, JD; and Ziad C. Sifri, MD, FACS.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
