Download Intermittent and Mobile Surgical Services: Logistics and Outcomes

World J. Surg. 29, 1335–1339 (2005)
DOI: 10.1007/s00268-005-7632-4
Intermittent and Mobile Surgical Services: Logistics and Outcomes
Edgar Rodas, M.D.,1 Anita Vicuña, M.D.,1 Ronald C. Merrell, M.D.2
1
Cinterandes Foundation, Cuenca, Ecuador
Medical Informatics and Technology Applications Consortium, Department of Surgery, Virginia Commonwealth University,
1101 E. Marshall Street, PO Box 980480, Richmond, Virginia 23298-0565, USA
2
Published Online: September 15, 2005
Abstract. A program of intermittent surgical services utilized a mobile
facility to support multiple primary care sites in Ecuador. The fiscal and
clinical outcomes of the program were analyzed. From 1994 to 2003 the
mobile program responded to requests from 15 of 22 provinces of Ecuador for surgical care. The sites served could not offer permanent surgical
care. Criteria for inclusion and follow-up were set. Medical records were
kept in accordance with standards of the Ministry of Health. Standards of
care and critical care pathways were instituted. The program had a
permanent staff supplemented by volunteers. Cases were recorded and
outcomes noted with respect to complications. The cost of the surgical
aspect of the program was entirely covered by a foundation through
donations and public service contracts. Financial records of the foundation were reviewed and the costs analyzed. A total of 4545 operations were
done largely in general surgery specialties. The program made 40 to 50
excursions each year and proved to be a stable element of medical care
delivery. There were no deaths, four major complications, and three
minor complications. The cost per operation was less than $100. Comparison to U.S. and international volunteer organizations are reported.
This program of intermittent mobile surgical services in coordination
with fixed primary care constitutes a sustainable, high quality clinical
program fully integrated into existing care of a national health ministry.
In-country resources may provide greatly enhanced services at low cost
and should be considered as an alternative.
Surgical services require extensive resources and facilities.
Building a facility in a remote area with low population density
leads to low utilization. Placing surgical resources in such a site
means the surgical personnel operate rarely and lose individual
and team surgical skills [1]. Itinerant surgery is condemned on
ethical grounds by the American College of Surgeons because the
surgeon is not available for patient care throughout the course of
surgical recovery [2]. However, intermittent surgery in a comprehensive health plan identifies the role of the surgeon as a part
of overall care without the medical or ethical need to be present
throughout a patient!s course. The surgeon or surgical team is
present for the time needed and then leaves the remainder of care
to appropriate colleagues.
Correspondence to: Ronald C. Merrell, M.D., e-mail: Ronald.merrell@
vcu.edu
Intermittent surgical service allows teams with full competence
to bring the resources when needed and provide high quality care.
Intermittent surgical care can be made even more effective if the
surgical resources needed can be made fully mobile. Military
practitioners have done this since the time of Baron Larrey!s
ambulance in the Napoleonic wars [3]. Mobile surgical units are
providing surgical care in New Zealand and in the military. Recently U.K. Health Secretary John Reid launched a program of
surgical vans to augment surgical services in the National Healthy
Service [4]. In the United States eye surgery is offered by mobile
surgical units, although the American Academy of Ophthalmology expressed concern in a November 2003 press release [5].
Surgical services can be provided to areas of extraordinary need
by visiting surgeons, and there are numerous humanitarian
organization that provide these services with volunteer surgeons
and donations [6]. Operation Smile can provide a cleft lip procedure for a donation of $750, and Interplast provides such an
operation for a donation of $700 [7, 8]. This study assesses a
program of intermittent care provided by a national foundation in
Ecuador utilizing mobile surgical services integrated into a comprehensive system of medical care under the auspices of the
Ministry of Health of Ecuador.
Ecuador is a nation of some 13 million people with an annual
expenditure for health of $78 per capita [9]. The Ministry of
Health provides health care with ultimate responsibility for all
health care and licensure in the country. The ministry is the agent
of last resort, as about one-fourth of the nation!s population has
benefits through the Social Security system via its hospitals and
clinics. This service provides for patients who are employed and
pay for the service through their employers. There are private
services provided by clinics and hospitals throughout the country.
The private sector represents only about 15% of all services. The
ministry services are severely strapped for resources and are
frequently confronted with labor issues. Therefore, humanitarian
services have been important for the care of poor patients.
The poor patients find routine surgical care difficult to obtain
because the ministerial hospitals are first responsive to emergencies, which are numerous. Therefore, an agrarian worker
could go to the city for repair of, for example, a debilitating
inguinal hernia. The trip over poor roads may take 8 to 12 hours
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World J. Surg. Vol. 29, No. 10, October 2005
Fig. 1. Cinterandes 24-foot Isuzu mobile operating room.
and would require leaving his family behind without an income.
At the definitive care facility, emergencies routinely determine a
delay of several weeks before an elective operation. The recovery
period must, at least in part, be spent at the definitive care facility
because of the difficulty of the return trip. The patients would
clearly be better served if services could be brought to them for
care near their home in a delivery mode not subject to emergencies or labor difficulties.
In 1994, the Cinterandes Foundation was organized by faculty
members at the University of Cuenca under the leadership of Dr.
Edgar Rodas to address the basic surgical needs of people in rural
Ecuador. The volunteer physicians were the professors of the
young physicians doing their year of rural service in the poorest
areas of the country where they are the mainstay of primary care.
The faculty had always received their calls and continued to
provide guidance and mentoring after graduation and internship
as the young physicians contended with the medical issues of
isolated populations. The Foundation launched its work in 1994
with a mobile surgical unit that supported primary care clinics
with surgical consultation and treatment in a wide area. This report analyzes the organization and outcomes of this endeavor.
Materials and Methods
A 24-foot Isuzu van was modified to accommodate an operating
room (OR) and preparation room (Fig. 1). The OR has a standard table, overhead light, and anesthesia machine. The other
equipment in the room is suction, cautery, and when needed a
laparoscopic tower. The preparation room has storage, scrub sink,
and changing area. The truck has air conditioning and its own
water supply. The patients generally walk up the entrance on the
side of the truck and are taken to the OR. After the operation, a
stretcher is raised to the level of the OR by a hydraulic lift on the
back of the truck and passed through the back door (Fig. 2). The
stretcher is placed next to the OR table, and the patient is
Fig. 2. Back of the Cinterandes truck demonstrating the hydraulic lift for
transferring patients to and from the truck.
transferred. The patient on the stretcher is then lowered to the
ground by the hydraulic lift. Preoperative care and postoperative
care are usually provided by the primary care clinic, which may
have as many as 20 beds. In more remote areas the truck can
bring tents for preoperative care. The medical personnel are
transported to the site by bus. The truck is indeed quite small, but
its size is dictated by the need to traverse extremely difficult roads
and cross small rivers. The truck has been in continuous use since
1994.
The program has strict protocols for sterility, sterile technique,
patient selection, and patient management, including anesthesia
and quality assurance. Follow-up is complete and involves contact
with the primary care physicians, who see all patients during their
recovery and provide information to the program. If there were a
serious complication, arrangements could be made for transfer or
local treatment.
Rodas et al.: Mobile Surgical Services
1337
Fig. 4. Cinterandes has consistently met the needs of the people of rural
Ecuador during the past decade, as seen by the number of cases
performed each year during the overnight trips plus individual day trips.
Fig. 3. Page from Cinterandes manual for primary care procedures.
The program is sanctioned by the Ministry of Health and is
welcomed by the regional authorities. The program provides clear
guidelines for primary care participants (Fig. 3). The primary care
clinic contacts Cinterandes and clears a date for a visit by the
intermittent surgery team. The doctors at the distant site review
the patients who seem to qualify, and a tentative list for surgery is
established. A medical record is initiated and completed when the
team arrives at the distant site for a preoperative clinic the night
before surgery. The surgical list is finalized, and preoperative
orders are put in effect. The team usually operates just one full
day because that is the limit of the beds for follow-up care in the
small clinics. However, if beds are available there are 2 operating
days.
The Ministry of Health and Cinterandes maintain the medical
records independently. However, patients are eventual fully
integrated into the Ministry of Health program. The Cinterandes
records are the source for this report. The program is financed by
donations of money, materials, and labor. The program was
analyzed as a care model and a financial model with a benchmark
of surgical outcomes.
Fig. 5. Cinterandes operations by surgical specialty from 1994 to 2003
(4545 cases).
Results
The Cinterandes program provided 4545 operations as of
December 31, 2003 [10]. Note the relatively consistent annual
work pattern in Figure 4. The numbers over the bars indicate the
total number of service trips and the lower number indicates how
many of those trips were of 2 day!s duration. Thus the truck and
occasionally a second operating room in the small clinic perform
nearly eight operations each service day. The number of trips
indicates that the truck is out at least every week. Some service
days are in areas close to the headquarters in Cuenca, whereas
others may require a whole day of travel. The Foundation has
worked in 15 of 22 provinces of Ecuador from the tropical coast to
the high Andean plateau to the Amazon rainforest. The Foundation has several general surgeons, a urologist, a gynecologist,
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World J. Surg. Vol. 29, No. 10, October 2005
Table 1. Most common operations performed in the Cinterandes mobile surgery unit and the relative value units for professional services not including
anesthesia.
Procedure
No.
CPT
RVU
U.S. value per case @ $70 per RVU
U.S. value of service
Cholecystectomy
Inguinal hernia
Ventral hernia
Circumcision
Orchidopexy
226
699
557
767
362
47600
49505
49560
54152
54640
11.03
7.56
11.50
2.30
6.86
$772.10
529.20
805.00
161.00
480.20
Total
$174,494.60
369,910.80
448,385.00
123,487.00
173,832.40
$1,290,109.80
RVU: relative value units; CPT: current procedural terminology
This table summarizes 9 years work, and Table 3 reports annual finances.
and several anesthesiologists who constitute the core team. Volunteer surgeons from the United States and other colleagues
from Ecuador supplement them. The program has a full-time
mechanic/driver and nurse!s aide. Volunteer students and residents provide assistance in the OR and supplemental patient care
for the small clinics during the visits.
Figure 5 shows the operations by specialty, and Table 1 lists
the most common operations and their relative value units
(RVU). There have been no deaths in the work of the program
and only four major complications (Table 2). There have been
two wound infections in the program, and 1 of 18 laparoscopic
procedures was converted to an open procedure. The incidence of
complication was therefore far less than 1%. All wounds are
dressed, and no patients with significant co-morbidities are submitted to an operation. The program also excludes extremely
young children. Resources are simply not available for the followcare, and with this large amount of work there is no way to
accommodate for intensive care, blood bank services, or longterm care.
The stable budget for the program is about (US$) 114,000
(Table 3). This includes $52,000 in cash as donations, grants,
public health contracts, and patient donations. Although patients
are not charged for services, donations are offered on occasion.
An additional $37,000 in donated materials is available as medications, surgical materials, laparoscopic consumables, and service
for the truck. Professional services are reflected in the value of the
RVUs noted in Table 1. The volunteer time value of $25,000
reflects a blend of national and international volunteers, and the
RVU numbers reflect the service value if only U.S. volunteers
were involved. The expenses of the program are barely over
$50,000 with $32,000 for personnel, $10,000 for office supplies,
$5,000 for vehicle maintenance and fuel, and $5,000 for medical
supplies (Table 4). In this stable finance configuration the cost
per operation is less than $100 excluding the donated materials
and service. For a comparable surgical humanitarian organization, the cost per case is seven and eight times that. Similar
diagnosis-related groups (DRGs) and current procedural terminology (CPT) in the United States would generate payments of
some $10,000 per case (Table 5). However, the advantage of a
program in-country staffed by local faculties is evident when
routine surgical care is the issue.
Table 2. Major complications of 4545 cases performed from 1994 to 2003
by Cinterandes.
No.
Complication
Serious Complications
Death
Cardiac arrest
Pulmonary embolism
GI injury, hernia
Bleeding requiring transfusion
Other complications
Wound infection
Laparotomy conversion
0
1
1
1
1
2
1
GI: gastrointestinal
Table 3. Cinterandes resources
Cinterandes Resources
Public health Contract
Patient Contributions
Student Tuition
Foundation Grants
Miscellaneous Donations
Materials
Drugs
Suture, OR
Laparoscopic Materials
General
Services Donated
Physician Volunteer
Non-Physician Volunteer
Grand Total
Amount
(U.S. dollar)
$
$
$
$
$
$
7,000
8,000
10,000
12,000
15,000
52,000
$
$
$
$
$
10,000
10,000
15,000
2,000
37,000
$ 20,000
$ 5,000
$ 25,000
$ 114,000
Table 4. Cinterandes annual expenses.
Category
U.S. dollars
Personnel
Fuel, maintenance
Medical supplies
Office materials
Total
32,003.48
5,337.89
4,890.09
9,624.02
51,855.48
Discussion
Humanitarian care delivered in the United States is in general
prohibitively expensive. Humanitarian care delivered by U.S.
teams abroad is far less expensive but still greatly more expensive
than this regional program. The choice of site and personnel
should be determined by the experience and care required. Some
procedures and care needs are so extraordinary that only a major
U.S. facility can be considered because the procedures require
Rodas et al.: Mobile Surgical Services
1339
Table 5. Most common operations performed in Cinterandes mobile surgery unit from 1994 to 2003 showing CPT and DRG payments for similar
operations performed.
Most common operations: (1994–2003)
No.
DRG
Cholecystectomy
Inguinal hernia
Ventral hernia
Circumcision
Orchidopexy
Total
226
699
557
767
362
171
162
160
461
340
Typical U.S. charge
U.S. value of service
$16,132
5,414
8,352
5,745
4,674
$3,645,832
3,784,386
4,652,064
4,406,415
1,691,988
18,180,685
DRG: diagnosis-related group; CPT: current procedural terminology
Note: Compare total to budget in Table 3.
surgical and staff skills unavailable in remote regions. However, a
significant sector of surgical care can be provided at low cost by
well organized in-country programs.
Acknowledgment
This work was funded in part by a grant from NASA.
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