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Pre-Operative Screening


Synopsis

Elective surgery in resource-limited countries is often performed by mobile surgical teams, either as an outreach within the country itself, or as a volunteer group from another country. These teams provide a needed service; however, they are often operating in unfamiliar settings and with limited ancillary support. Careful screening of the patients with respect to overall health and post-operative requirements is necessary to ensure maximum benefit from the surgery, with minimum risk to the patient. This chapter offers guidelines for pre-operative screening, including a targeted medical history, the medical examination, and appropriate laboratory testing. Specific concerns are outlined. Sample medical history checklist and an immediate pre-operative checklist are included.

Introduction

You are planning to do surgery in a resource-limited country. The need is great. The surgical team is willing. Your goal is to help as many people as possible. In this setting, how can you ensure the maximum benefit for your patients with the least risk? Appropriate evaluation of the site and careful screening of the prospective patients are vital to ensure patient safety and to produce good outcomes. Site requirements and patient selection will vary according to area, team expertise, and the types of surgeries planned. The following are some general guidelines and considerations to aid in the process.

Screening of the Site

When planning surgery in a new and unfamiliar venue, the site should be evaluated. The more complex the surgery and the longer the recovery, the more important are the physical environment and the services available. Guidelines for the operating room (OR) and post-anesthesia care unit (PACU) needs are discussed in their respective chapters. The following are considerations for optimal post-operative care.

Ward Needs

  • Adequate number of beds for anticipated patient days (number of patients × length of stay per patient).

  • Hygiene: adequate bathroom and handwashing facilities.

  • Ability to keep surgical sites clean post-operatively.

  • Ability to ensure patient comfort (which in turn facilitates pain control). This includes temperature conditioning (AC units, fans, heaters) and positioning.

  • Reasonable proximity to OR and PACU to allow monitoring and ease of transport. Ramps or elevators to move between levels may be needed.

Nursing Support

  • Adequate trained nurses to carry out any patient care and medication administration that exceed the family's capabilities (e.g., IV medications).

  • Staff comfortable with monitoring patients for post-operative complications (bleeding, poor circulation, poor intake, uncontrolled pain).

Ancillary Support

  • Availability of an intensive care unit (ICU) and arrangements for transfer of care, if needed.

  • A laboratory able to perform blood counts, routine chemistries and, when appropriate, HIV tests, sickle cell anemia screens, and malaria screens.

  • Access to a blood bank with the ability to obtain screened blood and to perform a type and cross-match in a reasonable length of time (1–2 hours).

  • A pharmacy in-house or within a reasonable distance that can supply medications that are needed and that were not brought into the country by the team.

Follow-Up Care

  • A designated, willing, and available practitioner is needed for the care needs during the time period when the team is no longer present (dressing changes, graft monitoring, pins, catheters, etc.). This individual should be identified before surgery and must realistically have time available. Optimally this person will be able to work with the operating surgeons while they are on-site and communicate with them after they leave, to discuss care concerns and to provide follow-up information.

  • Physical/occupational therapy may be needed to monitor patients and provide splinting and exercises to preserve surgical improvements. Speech therapy is ideal after the correction of a cleft palate.

These follow-up care requirements are ideal. If certain requirements cannot be met, it does not necessarily mean that surgery is not possible. It does, however, limit the types of surgery that can be safely performed at the targeted venue and in the time allotted.

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