Setting Up an Open Heart Surgical Program in a Developing Country

Probal Ghosh
Asian Cardiovasc Thorac Ann 2005;13:299-301

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The Asian Cardiovascular & Thoracic Annals is the official journal of The Asian Society for
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EDITORIAL
Setting Up an Open Heart
Surgical Program in a Developing
Country
Probal Ghosh, FRCS
Austria
In the Art of War, Sun Tzu accented on knowing the
terrain. To set up an open heart surgical program in
the developing world, one has to start with the same
principles.
THE PLACE
The type of hospital will influence the funding and
priorities, and thus the mechanics and planning of setting
up. The required facilities and amount of investment
will also differ according to the nature of the open
heart surgical (OHS) center (stand-alone, part of a heart
center, unit of a franchise, or department in a general
hospital). The geography and economics of the region,
size of the population, state of the infrastructure, and
communications facilities may be critical in the initial
phase. If a new building is planned, it is better to be
involved from the beginning and avoid the mistakes
of many famous centers in the West, whose current
incarnation is the result of local compromises. Try to
have operating room (OR) space of at least 8 × 10 m
plus anterooms for pump and patient preparation. If initial
financial outlay is restricted, plan in a modular manner
so that additional features can be added at a later time.
If an old OR is refurbished for cardiac surgery, ensure
enhanced power supply.1 Similarly, the intensive care
unit (ICU) should be next to the OR to minimize transit
time and avoid too much interaction with visitors or
attendants, who are perpetually present in developing
countries, another cultural difference from the West.
Avoid Western hospital architecture of bygone eras,
such as ICU towers. Try to have each ICU segment of
6 beds with adequate space around the bed (approximately
18 m2), including one isolation bed.2 It is advisable to
acquire information on contemporary ergonomics of
OR and ICU planning.
THE TEAM
A skeleton team requires 1 surgeon, 2 assistants, 2
nurses (1 scrub, 1 circulating), an anesthetist, and a
perfusionist; but more people would soon be required
to run a viable OHS program. A common trend is to
acquire a large number of doctors. Often, more people
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means less work per person, which in turn affects
expertise. A rule of thumb would be: up to 150 cases/year
for 1 operator + 2 associates, 150–240 cases/year for
2 operators + 4 associates, 300–400 cases/year for
3 operators + 5 associates. More important is the quality
of the staff and cohesion of the team, with hierarchal
responsibilities allocated and accepted by all. The
motivation of all personnel, their advancement prospects,
and personal ambitions have to be considered. Even if the
center grows into a prosperous practice, it might not be
enough just to share profit; it may be expedient to share
credit from the beginning. In a developing country, it is
easier to get young doctors to join a new team, but at
some stage, turnover of staff vs. long-term stability will
have to be considered. It may be necessary to train more
people than needed as some will leave and others will not
come up to expectation. Former trainees, residents, and
patients are the best public-relations assets. It is better
to forge long-term loyalties from the beginning.
Physician’s assistants, nurse assistants, and medical
students have been used to overcome manpower
shortages and lower costs. Such substitutes work better
when a program is up and running. In a general hospital
setup, there may not be the scope for committed residents
to assist, and one may have to carry on the program
with residents on rotation from other departments.
One might poach trained anesthetists, perfusionists,
respiratory therapists, OR and ICU nurses from nearby
established centers to start a program. Even then, to ensure
a smooth first case, it is better to organize a dummy
run in OR and ICU. One model has been to import
an entire team to break-in local recruits. Availability
of other specialists should be considered. When the
OHS center is in a general hospital, that is usually not
a problem; otherwise, collaboration of local specialists
must be incorporated.
THE FIRST CASE
In primitive conditions, one could start with a small
bedside 2-channel (electrocardiograph and invasive
pressure) monitor that can also be used in the ICU.
ASIAN CARDIOVASCULAR & THORACIC ANNALS
Setting Up an OHS Center
In 1977 in Kerala and in 1984 in New Delhi, the
only respirator available to me was old Bird Mark IV.
In Kerala, the heart-lung machine was fabricated by the
local ironsmith. The pharmaceutical input of today’s
fast-tracking was not available, but all other principles
were utilized. Professor Victor in Madras in the 1970s
adopted an even more bare-bones approach and refined
the principles.3 Such extreme improvisations may not
be necessary in the 21st century. Even with financial
constraints, insist on acquiring a pump with at least
3 roller heads and provision for add-ons. Initially, the
surgeon might be the only fully trained member of the
team and may have to be in the ICU round the clock
for bedside monitoring. This is the time to train other
members of the team.4 What is lacked in gadgetry, can
be partially offset by quality of manpower and care.
SUPPORT SERVICES AND SUPPLY CHAIN
Bulk purchase lowered the cost of imported disposables
and devices in India, but it required enormous efforts to
get import licenses and customs clearance, and created
storage problems. As international manufacturers now
have distributors in most major cities, it is easier today to
acquire these products on an as-needed basis. However,
many small towns in developing countries face delays
in ordering or transport, which affect the supply chain
and may lead to cancellation of cases. Initial minimum
support services include access to 24-hour laboratory
facilities, a blood bank, and sterilization facilities.
Three-phase electrical supply linkage is critical, and
a committed generator hooked to the cardiac OR is
a must. Uninterrupted power supply is preferable but
often prohibitively expensive for smaller units.
Setting up in the 21st century, one has to address the
changed priorities, new technologies, easily available
products and devices. Try to invest in low-maintenance-
cost viable technologies of tomorrow with broad-based
applications, rather than in high-end gizmos. At times,
it is cheaper and more expedient to make a quantum
leap at a later date than to proceed through the whole
process of technology evolution. An appropriate and
high-utilization rate of expensive equipment needs to
be established. Lessons from the evolution and current
shrinkage of cardiac surgical centers in the West will
soon lead to more cautious expansion of surgical facilities
in developing countries, while the investment may be
directed to interventional facilities.
REFERRAL CHAIN
Referral depends on credibility. The problem is how
to get the first 10 cases to show expertise and build
a reputation. Neither a Western education and training
in well-known centers nor all the relevant certificates
will guarantee acceptance by the community. Affluent
ASIAN CARDIOVASCULAR & THORACIC ANNALS 300
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Ghosh
patients in any community tend to think that the grass
is greener elsewhere; that trend is more pronounced
in poorer countries. The perception of a care gap is
widespread in developing countries. Besides availability
and accessibility, affordability is a major determinant
of acceptance by the populace in any poorer country.
Most patients want continuity of care and they prefer
cardiac surgeons who will remain in their community.
Expectations from visiting foreign experts are
different.
Payments to cardiologists or general practitioners are
unfortunate realities in many developing countries.
I never paid for referral and suffered slow initial growth
in all 3 centers. Payment may initially facilitate referral,
specially to private hospitals, but it may be regretted
at a later date. Cardiac surgeons of tomorrow need to
move into a secondary rather than the traditional tertiary
role (general practitioner–cardiologist–cardiac surgeon).
Even then, cardiac surgeons cannot emulate urologists
who hold a critical stake in the entire value chain from
diagnostics to patient work-up, treatment, and follow-
up. Emerging new technology may enable even primary
care physicians to organize all cardiac investigations and
thus become the gatekeepers. Acquiring skill in imaging
will give surgeons more control of the referral chain.
A franchise relationship offers an initial boost in patient
referral, similar to the temporary benefit of a famous
foreign expert visiting to operate on a few patients.
CASE SELECTION
Start low key despite your wealth of experience.
Inevitably, there will be a plethora of high-risk patients
who should be avoided in the first 20 cases. The adequacy
of different treatment options must be kept in mind.
Thus, the worth of diverse treatments may be similar
while vastly differing in approach, technology, cost,
and the price to the patient. Many patients come so
late that poor results are inevitable. In the initial phase,
defer them. Sooner or later you will be compelled to
offer in your repertoire something different from local
competitors. Choose an area of innovation carefully,
considering the weakest link in your chain and not
your own extent of competence. Also, stay within the
range of comprehension of local peers. Visiting foreign
experts have an advantage here; operative outcomes do
not affect the standing of visiting celebrities, whereas a
single high-profile death or morbidity in the initial phase
can ruin a local surgeon’s reputation.
WORKPLACE AMBIENCE
Written extensive protocols for a standardized approach
must be developed from the beginning for all aspects of
cardiac surgical care. These should include preoperative
preparation, operative protocol, and postoperative care,
2005, VOL. 13, NO. 4
Ghosh
and be available to all concerned. A standardized
approach and written protocols tend to eliminate
mistakes, particularly in the early training period of
the team. An academic atmosphere from the beginning
will enhance the quality of service, and it does not
require any academic title or rank. Mistakes must be
discussed to avoid recurrence. Monthly mortality and
morbidity analysis is essential. In the absence of a
database program, even entry in a simple Excel chart
will help enormously. Patient education should be stressed
from the first encounter. The best course lies in honest
assessment of the odds, providing all the information
that the patient and the family ask for, and avoiding
compulsion.5 The range of service options and likely
immediate and long-term outcomes should be detailed.
After admission, patients need to be informed of their
role in the process. Regular follow-up and continuity of
care needs to be arranged.
COST OF SERVICE
Affordability is critical for most cardiac surgical patients
in developing countries. Notwithstanding the legendary
financial successes of a handful private clinics in India,
China, Brazil, and Venezuela, most developing countries
do not have efficient health insurance systems. Even
where insurance systems exist, they operate mostly on a
reimbursement basis. The prospective total hospital bill
needs to be as close as possible to break-even in depressed
economies. Surgeons may have to help in organizing
finances for patients from the lower socioeconomic strata.5
Government funds, charities, and trusts may subsidize
costs. Any measure in cost-containment is an additional
boost to the viability of OHS centers. Despite the violation
of advocated sterilization protocols, many surgeons in
developing countries use re-sterilized stabilizers for
minimally invasive coronary bypass, and pass on the
cost-saving to their patients. The cost per operation
is related to the number of operations performed per
year. Break-even point approaches at 80–100 cases/year
on the initial minimal outlay.6 The price to the patient
needs to reflect this break-even level. While package
deals for different categories of OHS are becoming the
norm in many developing countries, provision must be
made for those who require prolonged hospitalization
and critical care. Thus, if projected early output is less
than 100 cases/year, the financial drain will be enormous,
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Setting Up an OHS Center
and the skill of the team and patient outcome will be
suboptimal. Past experience of other local centers may
not help as even in developing countries, cardiac surgery
is going to shrink in the near future. Financing for OHS
centers is available from banks nowadays. However, the
maximum repayment period is still relatively short, which
puts a tremendous strain on the surgical team to meet
the required return on investment.
QUALITY OF CARE
Survival of an OHS center depends on fulfilling the
need of the community. It is not enough to deliver good
quality care; it is equally important to let it be known.
Detailed documentation and building a database with
risk adjustment is essential from the very beginning.
Periodic analyses and annual reports should be part of
the regular interaction with local medical associations
and other peers. Public awareness of available facilities
may be transmitted through the press and other media.
An internet website may facilitate the process. The
perception of a care gap should be allayed by focusing
on national standards, criteria, and guidelines, rather
than Western parameters.
There is no magic recipe for success in setting up an
OHS center in a developing country. Each community
is unique; one has to address its unique features and
needs, while planning the why, where, how, and when
of the setup.
REFERENCES
1. Scannell JG, Brown GE, Ellison RG, Groves LK, Laufman H,
Sabiston DC, et al. Optimal resources for cardiac surgery. Report
of the Inter-Society Commission for Heart Disease Resources.
Ann Thorac Surg 1971;12:213–35.
2. von der Mosel HA. Common mistakes in planning intensive care
units. Hosp Eng 1977;31:13–6.
3. Victor S, Kabeer M, Nayak VM. KISS approach to cardiac surgery.
Ann Thorac Surg 1996;62:1890–1.
4. Banerjee A. Starting an open heart programme: problems at square
one. In: Open heart surgery. Shetty KR, Parulkar GB, editors.
New Delhi: Tata McGraw Hill, 1987:822–6.
5. Muralidharan S. Developing cardiac surgery in smaller
cities. Travails and triumphs. Ind J Thorac Cardiovasc Surg
2004;20:64–6.
6. McGregor M, Pelletier G. Planning of specialized health facilities.
Size vs. cost and effectiveness in heart surgery. N Engl J Med
1978;299:179–81.
ASIAN CARDIOVASCULAR & THORACIC ANNALS
 Setting Up an Open Heart Surgical Program in a Developing Country
Probal Ghosh
Asian Cardiovasc Thorac Ann 2005;13:299-301
This information is current as of January 21, 2011

Updated Information including high-resolution figures, can be found at:

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