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INTRODUCTION
In several South American countries, such as Bolivia, Ecuador, Venezuela, Paraguay, and Peru, anesthesiology was practiced for many years without a legal framework to regulate the professional practice of the specialty, education, and training. In this context, many healthcare providers with low level of training in anesthesia, including surgeons, registered nurses, and even other less skilled providers performed anesthesia procedures during the second half of the 20th century.1 In a not-so-distant past, these previously described situations were common in Peru. However, since 2005, when the first technical Anesthesiology standard was approved by the Peruvian Health Ministry (PHM), profound changes in professional practice were initiated in all healthcare institutions, whether public, private or mixed, where any procedure of the specialty was performed.2
TECHNICAL STANDARDS IN SOUTH AMERICA
In South America, as detailed in Complementary material 1, Uruguay, Colombia, and Argentina have the oldest regulations regarding specialized work in the field of Anesthesiology established during the second half of the 20th century. These standards were developed by both national governments and national scientific societies, and have been updated in various countries over the decades.
It is noteworthy that, as in the case of Colombia, the approach to update its standards on safety in anesthesiology through an initial process of consensus of experts using the modified Delphi method, finally resulted in the submission of the official document for discussion and approval by a national congress session. The described methodology could be used to review and update the Peruvian standards based on the initial revised document prepared by a team of experts from various sectors such as the national society, private and public organizations, and PHM officials.
First Peruvian anesthesia technical standard
In 1999, the Peruvian Society of Anesthesia, Analgesia, and Resuscitation (SPAAR) issued the "Minimum Standards for the Ethical Exercise of Anesthesia, Analgesia, and Resuscitation in Peru" with the purpose of preventing risks to the patient in the operating room. These standards were approved by resolution 1655 of the National Council of the Medical College of Peru. Finally, this document recommended that the standards should be reviewed at least every 3 years by a joint commission including members of the PHM and SPAAR. 3
In 2004, a technical committee for anesthesia services was created, made up of 13 anesthesiologists from the highest complexity Peruvian hospitals in both the public and private sectors, as well as members of the PHM. This committee drafted a proposal for a technical standard, which was validated by 36 senior anesthesiologists from different Peruvian institutions, including members of the board of directors of the Peruvian Society of Anesthesia, Analgesia, and Resuscitation.4 Most of the document (except for annexes on reference and counter-reference criteria, flow by levels of care, and continuous medical training for anesthesiologists) became the first Peruvian technical standard approved in 2005. The overall objective of the standard 2) was to ensure optimal patient care in the Anesthesiology services in all of the Peruvian health facilities, through a set of technical and administrative guidelines. The standard provided a detailed regulatory framework for patient care processes according to the level of complexity of the health facility, in order to meet the needs of patients requiring quality anesthesia care. According to the standard, the heads of the anesthesiology services and all the procedures associated with the specialty in every hospital should be under the leadership of a physician anesthesiologist. However, in the case of lower complexity healthcare institutions, such responsibility would be attributed to a physician anesthesiologist or a non-anesthesiologist physician with competencies in the field. The anesthesiologists assigned to attend emergency surgeries in the operating room (OR) would be full-time emergency OR practitioners and were prohibited from participating in simultaneous surgical procedures. The standard defined the roles of the anesthesiologist-in-chief and the staff anesthesiologists, and the requirements for certified and unskilled nursing staff. It also established the number of personnel needed for the different activities in the OR, anesthesia offices, post-anesthesia care unit (PACU), and pain management unit as shown in Table 1. Additional important aspects related to the standard are summarized in Complementary material 2.
Table 1 Personnel requirements of the Peruvian anesthesiology services.
| Staff | Area | Type of shift | |
|---|---|---|---|
| Anesthesiologists | Clinical Surgical Anesthesia | Ordinary Shift | Emergency Shift |
| Anesthesia Office* | One specialist pershift | NA | |
| OR | One specialist per OR | One specialist per emergency OR | |
| PACU | One specialist per shift | One specialist per shift | |
| Pain Management Unit | Ordinary shift | Emergency shift | |
| Pain Management Office | One specialist per shift | NA | |
| Pain Management Procedures | One specialist per shift | NA | |
| Certified nursing staff | Area | Type of shift | |
| Surgical Clinicai Anesthesia | Ordinary shift | Emergency Shift | |
| OR | One nurse per shift/ OR for administrative work. One or more nur-ses per OR according to complexity | One or more nurses per OR according to complexity | |
| PACU | One nurse per shift and every 3 patients | One nurse per shift every 3 patients and | |
| Pain Management Unit | Ordinary shift | Emergency shift | |
| Pain Management Office | One nurse per shift | NA | |
| Pain Management Procedures | One nurse or more on demand | NA | |
| Unskilled nursing staff | Area | Type of shift | |
| Surgical Clinicai Anesthesia | Ordinary Shift | Emergency shift | |
| OR | One unskilled nurse per shift/OR | One unskilled nurse per emergency shift and one per OR according to the complexity | |
| PACU | One per shift with 3 patients of high complexity or 6 of low complexity | One per shift with 3 patients of high complexity or 6 of low complexity | |
NA: Not assigned; OR: Operating room; PACU: Post-anesthesia care unit. * Office assigned for preoperative anesthesia assessment.
Source: Adapted by the authors from 2.
Second Peruvian anesthesia technical standard
In 2011, the PHM approved the second technical standard 5 with the following objectives: standardization of care processes in anesthesiology, pain management, and resuscitation; the promotion of the rational use and adequate flow of resources used in anesthesia care; enhanced compliance with safety measures to reduce risks for patients and health care personnel; and, strengthening of anesthesiology education and research competencies.
This document amended the first anesthesia standard. One of the key aspects was the requirement that every anesthesia procedure performed at any healthcare facility, should be conducted by a physician who completed a residency in Anesthesiology. The duration of the Peruvian residency program in Anesthesiology is three years and 2 additional years for sub-specialties such as Cardiovascular and Obstetric Anesthesiology.6 The standard required healthcare institutions to adopt clinical practice guidelines that serve as documents for standardizing all anesthetic, pain, and resuscitation procedures. The anesthesia care process was divided into three periods: pre-anesthesia, intraoperative, and post-anesthesia. The standard also classified the professional risks of the personnel working in the Anesthesiology services.5 The details of both topics are shown in Complementary material 3, This standard provided a list of drugs, including Dantrolene, used in anesthesia care according to the hospital complexity. However, there is currently a shortage of Dantrolene in Peru 7 because the sanitary registration expired 8, and hence its availability is limited to a few public and private institutions. In some facilities, Dantrolene was made available through foreign donations. Consequently, a coordinated action is needed among all the public and private stakeholders involved, to ensure its availability throughout the country.
Furthermore, the second standard required the anesthesiologist to use the Spanish version of the World Health Organization's Surgical Safety Checklist. 5 However, it began to be implemented since 2010 in the PHM hospitals of the capital. 9 All the Anesthesiology services in these hospitals received the document to be completed by the surgical team members after their respective training. The nursing staff members submitted the information in the document based on questions asked to the principal surgeon and anesthesiologist, according to the stages of surgical care therein described. Following the enforcement of the second standard, completion of the checklist became mandatory at the national level for all healthcare facilities (public and private) performing surgery.
Consequences of the implementation of the Peruvian standards
Ten years after the implementation of the last standard, the significant consequences on Peruvian surgical patients and workforce density are clearly evident. In particular, monitoring of the national indicators of surgical care has enabled the assessment of their impact as shown in Table 2 [developed based on references 6,9-18]. Thus, the workforce increased from only 3 anesthesiologists per 100,000 inhabitants in 2005 to 7 specialists in 2020. Likewise, the volume of surgeries experienced a growing trend, reaching 3,511 surgeries per 100,000 inhabitants in 2019 prior to the beginning of the SARS-CoV-2 pandemic. These figures represent a significant progress towards achieving the recommended goal of 5,000 surgeries by 2030 19. Regarding perioperative mortality, in the decade prior to the adoption of the first standard, a total of 11.4 anesthesia-associated cardiac arrests were reported, as compared to 2.97 reported after the implementation of the standards.
Table 2 Monitoring of anesthetic and surgical care indicators performance in Peru before and after the implementation of the anesthesia technical standards.
| Indicators | Monitoring of indicators | ||
|---|---|---|---|
| Before implementation | After implementation | ||
| Surgical workforce density | 3 anesthesiologists per 100,000 inhabitants in 2005 | 36.6 surgical specialists per 100,000 inhabitants in 2016 (5.4 anesthesiologists per 100,000 inhabitants in 2016) | 46.5 surgical specialists per 100,000 inhabitants in 2020 (7 anesthesiologists per 100,000 inhabitants in 2020) |
| Surgical volume | NA | 1,969 surgeries per every 100,000 inhabitants in 2015 | 3,511 surgeries per every 100,000 inhabitants in 2019 |
| Perioperative mortality | 11.4 intraoperative cardiac arrests attributable to anesthesia per 10,000 cases in the period from 1995 to 1997 (Mortality 4.14 patients per 10,000 cases) * | 2.97 intraoperative cardiac arrests attributable to anesthesia per 10,000 cases in the period from 2011 to 2015 (Mortality 0.54 patients per 10,000 cases). Total (all causes) intraoperative mortality: 5.26 per 10,000 surgeries in the same period. *, † | |
| Protection against impoverishing and catastrophic expenditure | 37% of Peruvian population in 2004 | 69% of Peruvian population in 2014 | 95.16% of Peruvian population in 2020 |
*Data about perioperative mortality reported in two third-level hospitals, not national data. Study conducted prior to the implementation of the standards (the study population was 9,568 patients). NA: Data not available. † The study population was 74,096 surgeries.
These initiatives improved Peruvian patients' safety as evidenced by a reduction in postoperative mortality and heightened the professional status, hence attracting more physicians to Anesthesiology to improve workforce density. These national indicators experienced a significant improvement after the standards entered into force. In the light of the foregoing, it can be concluded that the implementation of the standards for the provision of safer anesthesia has been a cornerstone contribution to the advancement of Peruvian anesthesia and surgical care.
ETHICAL DISCLOSURES
Ethics committee approval
This article is not a clinical study, but rather a historical perspective of the specialty, so it would not require approval by an ethics committee.
Protection of human and animal subjects
The authors declare that no experiments were performed on humans or animals for this study. The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).
ACKNOWLEDGMENTS
CSZ: wrote the manuscript, searched the databases (Medical College of Peru and Superintendencia Nacional de Salud-SUSALUD) for the required data, and approved the final manuscript.
MNJ: searched the databases (Medical College of Peru and Superintendencia Nacional de Salud-SUSALUD) for the required data and approved the final manuscript.
