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Early warning scores are points-based or colour-coded systems used to detect changes in physiological parameters and prompt earlier recognition and management of deteriorating patients. Vital signs recorded within a coloured zone corresponding to degree of derangement (‘trigger’) should prompt an action. The report of the UK Confidential Enquiry into Maternal and Child Health recommends the use of modified versions in the obstetric population. Currently, there is limited research into the effects of early warning scores in low-resource settings where maternal mortality remains high, and there is a need for low-cost, simple methods to reduce this. A modified obstetric early warning system (MOEWS) was introduced for parturients who had undergone surgical intervention at Felege Hiwot Referral Hospital, a tertiary centre in Bahir Dar, Ethiopia. A guideline was developed to accompany the MOEWS, together with training of healthcare workers. Prior to introduction, the quality of postoperative monitoring was assessed through retrospective case note review. This was reassessed at 8 months and 11 months postimplementation, with assessment of response to ‘triggers’. A questionnaire and qualitative interviews were undertaken to establish views of healthcare workers on its acceptability and usability. Recording of postoperative vital signs improved with the implementation of the MOEWS and was sustained at both monitoring periods. The number of patients with vital signs within the coloured zones (‘trigger’) was reduced, although documented action to these remained low. Staff were positive towards the MOEWS, its impact on patient care and felt confident using the system. The introduction of a MOEWS in an Ethiopian referral hospital in this study appeared to improve the monitoring of postoperative patients. With modifications to suit the setting and senior clinician involvement, coupled with regular training, the early warning score is a feasible and acceptable tool to cope with the unique demands faced in this low-resource setting.

Several techniques have been described for the percutaneous treatment of trigeminal neuralgia; however, each has significant drawbacks. We propose a new technique for percutaneous balloon compression of the trigeminal ganglion and distal trigeminal nerve using electromagnetic (EM) neuronavigation. The procedure was performed in 17 consecutive patients with trigeminal neuralgia. Patients were then followed up with telephone interview. We also performed a cadaveric validation study to further investigate the accuracy of the technique using dye. Excellent clinical outcomes were achieved with a reduction in the median pain score from 10 out of 10 to 0 out of 10 following the procedure. The cadaveric study also demonstrated a high rate of foramen ovale cannulation. EM-based targeting of the foramen ovale and balloon inflation within Meckel’s cave is a quick, reproducible and straightforward technique for the percutaneous treatment of trigeminal neuralgia.

Development of surgical and anaesthetic care globally has been consistently reported as being inadequate. The Lancet Commission on Global Surgery highlights the need for action to address this deficit. One such action to improve global surgical safety is the introduction of the WHO Surgical Checklist to Operating Rooms (OR) around the world. The checklist has a growing body of evidence supporting its ability to assist in the delivery of safe anaesthesia and surgical care. Here we report the introduction of the Checklist to a major Ethiopian referral hospital and low-resource setting and highlight the success and challenges of its implementation over a one year period. This project was conducted between July 2015 and August 2016, within a wider partnership between Felege Hiwot Hospital and The University of Aberdeen. The WHO Surgical Checklist was modified for appropriate and locally specific use within the OR of Felege Hiwot. The modified Checklist was introduced to all OR9s and staff instructed on its use by local surgical leaders. Assessment of use of the Checklist was performed for General Surgical OR in three phases and Obstetric OR in two phases via observational study and case note review. Training was conduct between each phase to address challenges and promote use. Checklist utilisation in the general OR increased between Phase I and 2 from 50% to 97% and remained high at 94% in Phase 3. Between Phase I and 2 partial completion rose from 27% to 77%, whereas full completion remained unchanged (23% to 20%). Phase 3 resulted in an increase in full completion from 20% to 60%. After 1 year the least completed section was “Sign In” (53%) and “Time Out” was most completed (87%). The most poorly checked item was “Site Marked” (60%). Use of the checklist in Obstetrics OR increased between Phase I and Phase II from 50% to 100% with some improvement in partial completion (50% to 60%) and a notable increase in full completion (0% to 40%). The least completed section was “Time Out” (50%) and “Sign In” was the most completed (90%). The most poorly checked item was “Recovery Concerns” (70%). There was considerable enthusiasm for use of the checklist among staff. The greatest challenge was communication difficulties between teams and high staff turnover. This study records a locally driven, successful introduction of the WHO Surgical Safety Checklist modified for the specific locale and illustrates an increase in use of the checklist over a one year period in both General Surgical and Obstetric OR9s. Local determination and ownership of the Checklist with regular intervention to promote use and train users contributed to this success.