Building safe surgery knowledge and capacity in Cambodia: a mixed-methods evaluation of an innovative training and mentorship intervention

Figures & data

Table 1. Facility characteristics¹

Facility Type	Average # of monthly surgical procedures	# of surgical, anesthetic, and obstetric providers	# of facility staff attending SS2020 trainings^2
NationalHospitals	1161	84	49
	993	85	28
	283	47	31
Provincial Hospitals	96	21	25
	302	25	19
	62	21	13
	159	32	18
	113	17	14

¹Characteristics were self-reported by facilities at end of program implementation in late 2019/early 2020

²Some SS2020 trainees served in administrative or leadership positions and were not staffed on respective facilities’ surgical teams

Figure 1. Safe Surgery 2020 flow of service and knowledge through Center of Excellence with link to trainings

Table 2. Completion rates (%) of performance indicators for surgical procedures observed at baseline and endline in 8 hospitals

Key Outcome Indicators	Baseline		Endline		Percent Change(Baseline-Endline)	Odds Ratio*	95 % CI	p-value
	N = 202		N = 231
	n	%	n	%	%
Safety Items
1. Patient Identity, Consent, and Procedure Confirmation Rate	85	42.3	110	47.6	5.3	1.24	[1.11, 1.38]	< .001
2. Appropriate Prophylactic Antibiotic Administration Rate	124	61.7	206	89.2	27.5	5.12	[4.57, 5.73]	< .001
3. Pulse Oximetry Usage Rate	191	94.6	228	98.7	4.1	4.38	[3.41, 5.62]	< .001
4. Rate of Surgical Instruments Free of Visible Soil	120	59.4	172	74.5	15.1	1.99	[1.79, 2.22]	< .001
5. Rate of Observed Chemical Sterilization Tape	104	52	138	59.7	7.7	1.37	[1.23, 1.53]	< .001
6. Rate of Appropriate Operative Site Cleansing	192	95	229	99.1	4.1	5.96	[4.54, 7.83]	< .001
7. Rate of Vaginal Cleansing with Povidone-Iodine (for caesarean sections only)	20	21.3	25	43.1	21.8	2.80	[2.02, 3.90]	< .001
8. Instrument, Sponge, and Needle Count Verifications	98	48.5	155	67.7	19.2	2.22	[2.01, 2.46]	< .001
9. Rate of Post-op Decontamination of All (used and unused) Instruments	145	72.1	225	97.4	25.3	14.48	[12.58, 16.67]	< .001
Communication Items
10. Rate of Discussion on Risk for Blood Loss	35	17.4	4	33	15.6	2.34	[2.04, 2.68]	< .001
11. Rate of Discussion on Risk for Airway Difficulty/Aspiration	36	18	58	25.1	7.1	1.53	[1.32, 1.76]	< .001
12. Rate of Discussion on Sterility of Instruments and Equipment	70	34.7	102	44.2	9.5	1.49	[1.34, 1.66]	< .001
13. Rate of Surgeon’s Discussion on Patient-specific Concerns	27	13.5	34	14.8	1.3	1.11	[0.95, 1.30]	0.184
14. Rate of Anesthetist’s Discussion on Patient-Specific Concerns	20	9.9	34	14.7	4.8	1.57	[1.32, 1.87]	< .001
15. Rate of Surgeon’s Discussion on Anticipated Procedure level of Difficulty and Duration	47	23.3	95	41.1	17.8	2.30	[2.04, 2.60]	< .001
16. Rate of Discussion on Equipment/Instrument Problems During Surgery	11	5.5	41	17.7	12.2	3.71	[2.94, 4.68]	< .001
17. Rate of Discussion on Patient’s Post-op Recovery	45	22.3	59	25.5	3.2	1.20	[1.06, 1.36]	0.005
Checklist Utilization Indicators
18a. Rate of Surgical Safety Checklist Utilization (Any Method)	140	69.3	196	84.8	15.5	2.48	[2.21, 2.78]	< .001
18b. Rate of Surgical Safety Checklist Utilization (On Paper, Read Aloud)	45	32.1	56	28.6	−3.5	0.84	[0.69, 1.03]	0.089
18c. Rate of Adherence to Surgical Safety Checklist Items	1	0.5	9	3.9	3.4	8.15	[3.95, 16.82]	< .001

*Generalized Estimating Equations (GEE) estimates population average effects; it provides estimates that predict the odds of an outcome on a population level. Example statement: The odds of prophylactic antibiotic being administered before incision are increased five-fold after exposure to SS2020 interventions; the change is statistically significant (p < .001).

Table 3. Percent change of performance indicators for surgical procedures observed at baseline and endline, by hospital type

	National Hospitals*			Provincial Hospitals
	% Baseline	% Endline	% Change	% Baseline	% Endline	% Change
Safety Items
1. Patient Identity, Consent, and Procedure Confirmation Rate	23.6	16.7	−6.9	44.4	60.6	16.2
2. Appropriate Prophylactic Antibiotic Administration Rate	65.3	78.6	13.3	59.6	95.4	35.8
3. Pulse Oximetry Usage Rate	97.2	100	2.8	90.9	97.2	6.3
4. Rate of Surgical Instruments Free of Visible Soil	48.6	71.4	22.8	54.5	79.8	25.3
5. Rate of Observed Chemical Sterilization Tape	55.6	73.8	18.2	34.7	39.4	4.7
6. Rate of Appropriate Operative Site Cleansing	97.2	100	2.8	91.9	98.2	6.3
7. Rate of Vaginal Preparation with Providone-Iodine (for caesarean sections only)	23.1	14.7	−8.4	27.5	46.3	18.8
8. Instrument, Sponge, and Needle Count Verifications	19.4	50.6	31.2	61.6	88.1	26.5
9. Rate of Post-op Decontamination of All (used and unused) Instruments	27.8	98.8	71	95.9	95.4	−0.5
Communication Items
10. Rate of Discussion on Risk for Blood Loss	9.7	14.3	4.6	16.3	46.3	30
11. Rate of Discussion on Risk for Airway Difficulty/Aspiration	2.8	1.2	−1.6	14.4	47.7	33.3
12. Rate of Discussion on Sterility of Instruments and Equipment	4.2	19	14.8	42.4	55	12.6
13. Rate of Surgeon’s Discussion on Patient-specific Concerns	19.4	7.2	−12.2	7.2	19.3	12.1
14. Rate of Anesthetist’s Discussion on Patient-Specific Concerns	15.3	1.2	−14.1	6.1	26.6	20.5
15. Rate of Surgeon’s Discussion on Anticipated Procedure level of Difficulty and Duration	4.2	11.9	7.7	28.3	60.6	32.3
16. Rate of Discussion on Equipment/Instrument Problems During Surgery	0	11.9	11.9	9.3	27.5	18.2
17. Rate of Discussion on Patient’s Post-op Recovery	15.3	15.5	0.2	25.3	33.9	8.6
Checklist Utilization Indicators
18a. Rate of Surgical Safety Checklist Utilization (Any)	54.2	61.9	7.7	72.7	98.2	25.5
18b. Rate of Surgical Safety Checklist Utilization (On Paper, Read Aloud)	0	9.6	9.6	25	26.2	1.2
18c. Rate of Adherence to Surgical Safety Checklist Items	0	0	0	1	8.3	7.3

*National Hospitals category excludes cases from Hub Hospital

Table 4. Qualitative results: key findings and illustrative quotations