• Large sums wasted on unnecessary preoperative investigations and related routine repetitions of the same

It has been found that one fourth of all operating room based waste is attributed to anaesthesia-related material while a large sum of money is wasted on unnecessary preoperative investigations and for the repeat of such investigations on a routine basis.

These observations were made in a correspondence sent to the Editor of the Sri Lankan Journal of Anaesthesiology, Prof. V. Pinto (Professor of Anaesthesiology and Critical Care attached to the Peradeniya University's Medical Faculty) and published in the said Journal's 30th Volume's Second Issue in October, 2022, on “Anaesthetists seeing through the economic crisis of Sri Lanka” which was authored by N. Wijesuriya (Consultant Anaesthetist attached to the Colombo North Teaching Hospital, Ragama).

Sri Lanka is currently facing the worst economic crisis since its Independence in 1948. The medical services immediately felt this in the first quarter of the year as essential drugs, consumables and other essential items were in short supply because the Government could not secure foreign currency.

The Covid-19 pandemic had a large impact on anaesthesia, intensive care and pain services due to the shortage of resources and staff infection rates. Health services were just recovering when this major economic crisis along with the political and social turmoil hit the country. Fuel shortages have deepened the crisis by affecting staff attendance, delaying the release and transportation of medical items from the Customs and the Health Ministry's Medical Supplies Division (MSD), and restricting patient attendance.

In this context, The College of Anaesthesiologists (a physician specialised in anaesthesiology  who is concerned with the total perioperative care of patients before, during and after surgery) and Intensivists (a board certified physician who provides special care for critically ill patients often in intensive care units, also known as a critical care physician) of Sri Lanka came forward to find ways to minimise the impact of this crisis on anaesthesia, intensive care and pain management services in the country. Towards this end, The College established a crisis management committee. The College also understood the need for identifying available and required stocks, identifying donors and communicating with them while increasing the efficiency of the use of the available resources.

The College closely collaborated with the Ministry, the MSD and the National Medicines Regulatory Authority (NMRA) and obtained details of the monthly requirement, the stocks available in the MSD, institutional stocks and items with a short supply even though it was not an easy task to identify items related to the practice, since the lists were not grouped, and as it was a tedious task to go through multiple lists obtained from the MSD.

The crisis management committee coordinated with the provincial council members of The College of Anaesthetists who liaised with the consultant anaesthetists of the respective hospitals in order to find out the requirements using online forms.

The College established a separate account 'Heal Sri Lanka' and commenced a donation campaign to supply essential medications to needy hospitals. Many locals, expats and organisations contributed towards this project. The College succeeded in collecting Rs. 3,545,297.25 to this account which were used to purchase many essential drugs such as atracurium (neuromuscular blocking agent), potassium chloride (mineral supplement used to treat or prevent low amounts of potassium in the blood), noradrenaline (used to increase and maintain the blood pressure in limited, short-term serious health situations), dobutamine (used in the treatment of cardiogenic shock and severe heart failure), amiodarone (antiarrhythmic medication used to treat and prevent a number of types of cardiac dysrhythmias) and essential equipment such as spinal needles and catheters. The College also received direct supplies of drugs worth Rs. 9,117,000 from donors from the United Kingdom (UK), the United States of America and Hong Kong. The NMRA was extremely efficient in fast tracking the registration process of unregistered drugs coming through donations. Sri Lankan anaesthetists working in the UK worked tirelessly with the Sri Lanka Medical and Dental Association in the UK and the Sri Lankan High Commission in the UK to collect funds and send anaesthetic consumables to The College. All these donations were distributed to all Provinces in a fair and transparent manner.

Another aspect that was considered was to reduce wastage. Due to advances in anaesthesia related specialties, health expenditures have escalated in the recent past. The ever increasing cost of anaesthesia drugs and consumables have important implications in resource limited countries. The focus was on minimising wastage throughout the perioperative period. The laboratory services were also struggling to perform routine preoperative investigations due to the lack of reagents. Blood transfusion services were also facing shortages due to limited donors, and the lack of blood collection bags and reagents.

The College updated and published guidelines on preoperative assessment and investigations. Strategies to reduce the wastage of medications and consumables were formulated. It was advised to postpone non-essential routine surgeries so as to save items for essential surgeries.

Continuous medical education was also considered extremely important in order to keep the workforce updated. The College organised webinars to help raise awareness on managing the crisis among clinicians including on topics such as the “Anaesthetist’s role in the current health crisis”, “How low flow anaesthesia (a technique of anaesthetic management which uses a reduced fresh gas flow administered and controlled via a rebreathing system) helps in the economic crisis – Strategies to minimise expenditure” and the “Economic crisis – The ideal setting to implement patient blood management in Sri Lanka”.

The preparatory courses for postgraduate exams including the selection examination for the postgraduate Doctor of Medicine (MD) programme, the Certificate in Competence in Anaesthesia and the final MD and other medical education programmes were continued uninterrupted via The College’ zoom platform. The resuscitation council of The College continued courses amidst challenges faced due to fuel shortages for both the faculty and the participants, long power cuts disrupting online access and the Covid-19 infection.

The College added that it is struggling but standing together despite the worst fear that the current brain drain will impact anaesthesia, intensive care and pain services being provided to the poorest people of the country in the future.