Rural generalist anaesthesia (RGA) training: Rural & remote practice

Introduction: Rural generalist anaesthetists (RGAs) are central to the delivery of health care in much of rural and remote Australia. This article details a systematic review of the literature specifically asking the question, 'What is the current evidence of the 'safety' of anaesthesia delivered by RGAs?'

Methods: Six databases were searched using terms including 'safety', 'rural', 'anaesthetics', 'general practitioners', and associated search terms. Relevant articles were assessed for rigour, and information was summarised using qualitative grid analysis that included information on the study setting, participants, methods, limitations and key result areas. The primary author developed key themes from the data, which were refined in discussion with other authors.

Results: The safety of RGAs was described using five concepts: appropriate training and leadership, rates of complications, volume or scope of practice, access to equipment, and case selection.

Conclusion: RGAs are pivotal in the delivery of health care in rural and remote communities. The sparse literature available on RGA safety is broadly grouped into five areas. There is a need to characterise and describe the role of RGAs, review and revise training and education, recognise RGA scope of practice and understand how RGAs lead the management of safety and risk in their practice.

Aim: Rural hospitals in New Zealand provide broad generalist clinical services, including procedural sedation and analgesia (PSA). This study was designed to explore patterns of procedural sedation use including indications, equipment, medications, logistical and medical staff support available by rural hospitals, and whether current professional guidelines support rural sedation practice.

Methods: Through the New Zealand Rural Hospital Research Network, 17 rural hospitals were enrolled in an online survey during February 2018. The electronic survey consisted of 31 questions, regarding general information, staffing level and procedural sedation practice. Further questions sought information on clinical documentation and training guidelines.

Results: Most participating sites represented larger rural hospitals and were distributed equally throughout New Zealand. All performed procedural sedation. The distance of rural hospitals to their referral hospitals varied, with the closest being 65 km and the furthest at 326 km away. This study found that staffing and equipment available for rural procedural sedation varied, with the majority of rural hospitals having access to only one doctor out of hours, and only half having access to two doctors within daytime hours. A majority of the respondents felt that a minimum safe level for procedural sedation in their rural hospital required only a single doctor. Procedural sedation is frequently performed in rural hospitals in New Zealand, with the majority of respondents performing PSA at least once a week or more. Ketamine is the preferred PSA agent. A wide variety of procedures are undertaken including orthopaedic and injury treatments, abscess incision and drainage, and cardioversions. Patient transfer to another centre for the purpose of PSA is infrequent, occurring a few times a month or less for all hospitals.

Conclusion: This exploratory survey of rural hospital PSA practice demonstrated that PSA is a commonly performed procedure for a variety of indications. Staffing, equipment and techniques available for rural PSA vary according to institution. There is no current professional framework that suitably defines minimum standards for rural PSA practice, and specific training resources are limited. Providing procedural sedation and analgesia is an essential rural hospital service which is patient and whānau (Māori-language word for extended family) centred, saves patient transfers, and should be supported by a safe, pragmatic and realistic framework of tools, recommendations and training for rural practitioners.

Abstract
The safety of anesthesia characteristic of high-income countries today is not matched in low-resource settings with poor infrastructure, shortages of anesthesia providers, essential drugs, equipment, and supplies. Health care is delivered through complex systems. Achieving sustainable widespread improvement globally will require an understanding of how to influence such systems. Health outcomes depend not only on a country's income, but also on how resources are allocated, and both vary substantially, between and within countries. Safety is particularly important in anesthesia because anesthesia is intrinsically hazardous and not intrinsically therapeutic. Nevertheless, other elements of the quality of health care, notably access, must also be considered. More generally, there are certain prerequisites within society for health, captured in the Jakarta declaration. It is necessary to have adequate infrastructure (notably for transport and primary health care) and hospitals capable of safely carrying out the "Bellwether Procedures" (cesarean delivery, laparotomy, and the treatment of compound fractures). Surgery, supported by safe anesthesia, is critical to the health of populations, but avoidable harm from health care (including very high mortality rates from anesthesia in many parts of the world) is a major global problem. Thus, surgical and anesthesia services must not only be provided, they must be safe. The global anesthesia workforce crisis is a major barrier to achieving this. Many anesthetics today are administered by nonphysicians with limited training and little access to supervision or support, often working in very challenging circumstances. Many organizations, notably the World Health Organization and the World Federation of Societies of Anaesthesiologists, are working to improve access to and safety of anesthesia and surgery around the world. Challenges include collaboration with local stakeholders, coordination of effort between agencies, and the need to influence national health policy makers to achieve sustainable improvement. It is conceivable that safe anesthesia and perioperative care could be provided for essential surgical services today by clinicians with moderate levels of training using relatively simple (but appropriately designed and maintained) equipment and a limited number of inexpensive generic medications. However, there is a minimum standard for these resources, below which reasonable safety cannot be assured. This minimum (at least) should be available to all. Not only more resources, but also more equitable distribution of existing resources is required. Thus, the starting point for global access to safe anesthesia is acceptance that access to health care in general should be a basic human right everywhere.