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Priorities for content for a short‐course on postoperative care relevant for low‐ and middle‐income countries: an e‐Delphi process with training facilitators

Summary Most surgical and anaesthetic mortality and morbidity occurs postoperatively, disproportionately affecting low‐ and middle‐income countries. Various short courses have been developed to improve patient outcomes in low‐ and middle‐income countries, but none specifically to address postoperative care and complications. We aimed to identify key features of a proposed short‐course addressing this topic using a Delphi process with low‐ and middle‐income country anaesthesia providers trained as short‐course facilitators. An initial questionnaire was co‐developed from literature review and exploratory workshops to include 108 potential course features. Features included content; teaching method; appropriate participants; and appropriate faculty. Over three Delphi rounds (panellists numbered 86, 64 and 35 in successive cycles), panellists indicated which features they considered most important. Responses were analysed by geographical regions: Africa, the Americas, south‐east Asia and Western Pacific. Ultimately, panellists identified 60, 40 and 54 core features for the proposed course in each region, respectively. There were high levels of consensus within regions on what constituted core course content, but not between regions. All panellists preferred the small group workshop teaching method irrespective of region. All regions considered anaesthetists to be key facilitators, while all agreed that both anaesthetists and operating theatre nurses were key participants. The African and Americas regional panels recommended more multidisciplinary healthcare professionals for participant roles. Faculty from high‐income countries were not considered high priority. Our study highlights variability between geographical regions as to which course features were perceived as most locally relevant, supporting regional adaptation of short‐course design rather than a one‐size‐fits‐all model.


Introduction
Globally, postoperative mortality is recognised as a leading cause of death [1]. The majority of mortality and morbidity in relation to surgery and anaesthesia occurs in the postoperative period, disproportionately affecting low-and middle-income countries (LMIC) [2][3][4]. Although postoperative complications are similar in type across nations, their frequency and severity differ, possibly due to international differences in peri-operative care [5,6]. A key component of this may be the lack of appropriately trained care providers [7,8], related to variation in basic training programmes and the availability of postgraduate continuing education, especially for non-physician providers [9][10][11]. 570 Recently, there has been increased interest in anaesthesia short courses to support providers in LMICs, including notably the initiative by the World Federation of

Societies of Anaesthesiologists (WFSA) and the UK-based
Association of Anaesthetists to develop the Safer Anaesthesia from Education (SAFE) courses. The SAFE courses focus on obstetric and paediatric anaesthesia [12], and are predominantly focused on pre-and intra-operative care. Follow-up from SAFE courses suggests that these improve skills, confidence and the teamwork abilities of participants [13][14][15][16]. More recently a multidisciplinary course on operating room care [17]  predominantly dealing with care in the recovery room and handover to ward-based care. Short courses focused on intensive care in low-resource settings, for example BASIC-Low Resource [18], also touch on postoperative care.
However, these emphasise identification and management of the critically ill patient, rather than general postoperative care; 'ability to rescue'; and reducing complication rates.
We could not identify any current short courses that include substantial content on the broader topics of postoperative care despite its importance for safe surgical care. There is a need to explore how, and by what means, it may be possible to bridge this gap. Therefore, the aims of this study were to collaborate with established SAFE course facilitators from LMICs to define key components of a proposed short-course on postoperative care and complications; explore preferred teaching formats to deliver such a short-course; and define participants and facilitators for this type of short-course.

Methods
Ethical approval was obtained from the Oxford Tropical Research Ethics Committee. We chose the Delphi process as a systematic method to determine agreement on a topic through consecutive interactive rounds attended by a panel of experts where participation is anonymous, removing the effect of status [19,20]. This technique has previously been found to be effective in curriculum development [21,22].
We modified the classical Delphi process in three ways to improve geographical reach and expert involvement: the exploratory phase, Delphi process and triangulation phase were undertaken fully online; it was possible for eligible participants to join in any Delphi round; and triangulation of the findings was completed using a website with the option to leave feedback. The study is reported in line with recommendations from the conducting and reporting of Delphistudies guidance [23]. We collected and managed study data using REDCap (Vanderbilt University, Nashville, TN, USA) and electronic data-capture tools hosted by the University of Oxford (Oxford, UK) [24,25]. As per the recently published consensus statement on measures to promote equitable international partnerships [26], we have provided a reflexivity statement in online Supporting Information Appendix S1.  In the second round, we included new items suggested to all panels, and the questionnaire was re-advertised.
Additionally, based on suggestions and feedback, some items were reworded or accompanied by explanatory notes. As in round 1, the experts were asked to rate each item. In the first and second rounds, panellists were asked if their response regarding use of remote teaching would be different if resources were unlimited. For the third and final rounds, for each item the panellists were shown the proportion of responses that said to 'definitely include' it.
With this information in mind, we asked the panellists to indicate with a binary yes/no which items were most important to include on a short-course. Finally, the shortcourse content was grouped by topic into five subcategories, and panellists were asked to rank them in the order of importance.
The Delphi process ran from February to May 2021. As per protocol, we invited the focus group participants to join the study group after conclusion of the Delphi process to participate in interpreting the findings, preparing the manuscript for publication and sharing the findings with their regional networks. To increase the reliability of the findings with a wider readership outside the eligibility criteria, the findings from round 3 of the e-Delphi process for each geographical region was summarised and placed on a website [31]. We asked visitors to provide anonymous feedback on the findings. We sent out invitations for feedback via social media and the personal networks of the study group, as well as targeted invitations to members of the WFSA Education Committee and SAFE steering group, many of whom are involved with the development of shortcourse materials. This process finished in July 2021.
The frequency of responses for each point on the Likert scale was calculated. We included items in the next iteration of the survey according to the following pre-specified criteria: Round 1, an item was ranked 3 or 4 (probably or definitely include) by 50% or more of the experts; and Round 2, an item was ranked 4 (definitely include) by 70% or more of the experts.
Due to a low response rate in the AFR in round 2, we made a post-hoc definition for this region where an item would be included in round 3 if it was ranked 4 by 64% or more of the panel. Online Supporting Information Table S2 shows how round 3 would have looked for the AFR with and without the protocol deviation.
In keeping with the aim of identifying key components for a short-course rather than seeking consensus, we did not define a criterion for consensus. Instead, following round 3, we showed the percentage of agreement for each item that made it through the Delphi process for each of the panels.
We calculated mean and standard deviation (SD) for the five subcategories of course content to rank them in the order of importance. Data analysis was undertaken using R 4.0 (R Foundation, Vienna, Austria).
To reduce the environmental impact of this global study, communication was conducted entirely remotely, using WhatsApp, online survey tools and a website. Based on available evidence [32][33][34], the estimated carbon dioxide equivalents of internet traffic through digital servers were approximated and offset through the United Nations carbon offset platform.
While not included in the carbon offset, there is potential for the findings of this study to be used in the development of further short-course materials. Therefore, there is potential for a considerable impact especially if travel is required for the presence of facilitators. We would encourage course developers and facilitators to take this into account and reduce long distance travel as much as possible and carbon offset where travel is required. WFSA, who are partners in this study, are committed to carbon offsetting travel required for courses run by them as part of their travel policies.  and malaria in pregnancy' [27].

Results
Differences between regions were also apparent in the  Table S3. significant impact on relevance, ownership and teaching capacity, not to mention reducing the financial cost and major environmental impact of long-haul flights for visiting staff.
With regard to the mode of course delivery, digital course delivery modes were considered. Many synchronous and asynchronous learning resources in medicine and surgery are now available, accelerated by the urgency of the COVID-19 pandemic [35], including the obstetric and paediatric SAFE short courses [36], and some evidence is emerging that a shift to online teaching may improve access for LMIC participants [37]. In the preparatory phase,  views. However, it may also have contributed to lack of clarity on the content and participant make-up, which could account for some of the regional disparity (though all were asked identical questions).
We were not included in this study, but for which primary data are emerging in the LMIC context) [40]. Similarly, as fuller data emerge on peri-operative risk in LMICs at national, regional and local levels, this should inform the contextualisation of training to best address local need.
In summary, this study provides an outline of key content to consider when developing a short-course on postoperative care and complications, and highlights that perceived importance differs between geographical regions. We propose that a shift in curriculum development towards more targeted, customisable and locally relevant course content may therefore be appropriate.

Supporting Information
Additional supporting information may be found online via the journal website.
Appendix S1. Reflexivity statement. Table S1. Topic guide for exploratory focus groups.