Table 1.

Studies describing pulse oximetry training initiatives: Anaesthesia and perioperative care*

WHERE: country (LMIC designation), sites	WHEN: year of training	WHO: population trained	WHY: purpose of training	WHAT: structure of training	HOW: pulse oximetry related outcomes
African Region
Benin (UMIC), 36 hospitals nationwide [20]	2016-2017	Surgeons, anaesthesia providers, nurses, and other perioperative staff	SSC implementation	3-d Mercy Ships led workshop	Always using a pulse oximeter increased from 86.6 to 97.0% 12-18 mo after training among 17 hospitals selected for follow-up.
Burkina Faso (LIC), 57 hospitals nationwide [21]	2013	Anaesthetists	To improve the practice of pulse oximetry and SCC implementation	Lifebox workshop	Systematic use of pulse oximetry during anaesthesia increased from 73% to 100% of hospitals. Prior to training, 17% of hospitals had a PACU and used the pulse oximeter from theatre to monitor patients post-operatively. After training, 94% of hospitals used post-operative pulse oximetry monitoring.
Cameroon (LMIC), 25 hospitals nationwide [22]	2017-2018	Operating room staff	SSC implementation	3-d multidisciplinary training course developed by Mercy Ships	“Always” or “often” intraoperative pulse oximetry use increased from 74% before training to 93% 4 mo after training.
Republic of Congo (LMIC), 1 hospital in Dolisie [23]	2014	Operating team personnel	SSC implementation	4-d pilot SSC training course developed by Mercy Ships	Intraoperative pulse oximetry “always” use increased from 0% before training to 86% 15 mo after training.
Ethiopia (LIC), 1 hospital in Addis Ababa [24]	2011-2012	Plastic and reconstructive surgery surgeons, anaesthetists, nurses, and other perioperative staff	Implement anaesthetic pre-assessment, SSC, continuous pulse oximetry monitoring in recovery areas, improved observation protocols in recovery areas, and the development of an HDU	Teaching sessions and simulation workshops	Pulse oximetry used intraoperatively in 98% of cases during the 8 mo after training. Continuous pulse oximetry available for all recovery beds after training.
Ethiopia (LIC), 1 hospital in Addis Ababa (primarily), 9 hospitals in southwestern Ethiopia (pulse oximeters only) [25]	2012-2018	Anaesthesia providers	Improve morale and retention, establish postgraduate physician training, SSC implementation, develop PACU	Lifebox workshop	Pulse oximeters: 6-mo follow-up showed retained pulse oximetry knowledge and use. SSC: >90% use of SSC. PACU: Patients now monitored postoperatively in PACU.
Ghana (LMIC), 1 nurse anaesthetist school in Kumasi [26]	Since 1987	Nurse anaesthetists	To improve anaesthetic patient care and safety	18-mo training programme in collaboration with University of Utah	In 2000, pulse oximetry was not used in the affiliate hospital. In 2009, 70% of the district and regional hospitals use pulse oximetry, including in PACUs.
Ghana (LMIC), 1 nurse anaesthetist school in Accra [27]	Since 2009	Nurse anaesthetists	To increase the number of anaesthesia providers	18-mo training programme	95% of graduates (representing 39 hospitals across 7 of the 10 regions) surveyed had access to pulse oximetry at their hospital.
Guinea (LIC), 6 hospitals nationwide [28]	2012-2013	Surgeons, anaesthetists, and nurses	To evaluate three different methods of SSC implementation	Training delivered by Mercy Ships: 1) team training in operating room and classroom (surgeon AND anaesthesia provider or nurse); 2) individual training in operating room and classroom (surgeon or anaesthesia provider); 3) individual training in the classroom only (anaesthesia provider)	4 of 6 hospitals had no pulse oximetry. Pulse oximetry was occasionally available in the other 2. No pulse oximeters were provided as part of the study. However, participants agreed that it would be a valuable addition in the OR and recovery wards. Multidisciplinary courses more impactful than single discipline at 3-6 mo.
Kenya (LMIC), 3 sub-district hospitals in Western Kenya [29]	2013-2014	Non-anaesthetist clinicians (nurses, clinical officers, medical officers, nurse aid)	Safer surgical care when no anaesthetist is available	5-d Every Second Matters-Ketamine (ESM-Ketamine) training course	Surgeries able to be performed when ESM-Ketamine protocol enacted, pulse oximeters alerted desaturation events.
Liberia (LIC), 2 hospitals in Monrovia [30]	2008-2009	Surgical team	SSC implementation	2-week training programme	Pulse oximetry use increased from 34.9% to 88.2% in Hospital 1 and 75.7% to 88.5% in Hospital 2 after training.
Madagascar (LIC), 21 hospitals nationwide [31-33]	2015-2016	Operating room staff	SSC implementation	3-d multidisciplinary course	Prior to training, no hospital routinely used pulse oximetry due to lack of supply. 3-4 mo after training, 63% of participants surveyed reported “Always” using pulse oximetry in theatre and 11% using it “most of the time.” 12-18 mo after training, 88% of participants surveyed reported “Always” using pulse oximetry in theatre and 9% using it “most of the time.”
Malawi (LIC), 27 hospitals [34]	2014	Anaesthesia providers	Perioperative monitoring	1-d Lifebox workshop	Improved pulse oximetry knowledge via MCQs immediately after training that was maintained after 8 mo. 82% of donated pulse oximeters were located at follow up. 97% of located pulse oximeters were in regular use at follow up. 8% relative reduction in the odds of desaturation event for every 10 cases during first 100 cases after training.
Niger (LIC), 40 public hospitals nationwide [35]	2014	Anaesthesiologists and surgeons	Pulse oximetry use, hypoxia management, implementation of SSC	Lifebox workshop	Average number of pulse oximeters in each hospital increased from 1 to 8. Logbook for notification and management of hypoxia introduced.
Togo (LIC), providers nationwide [36]	2012	Anaesthesia providers	To improve surgical and anaesthesia safety	Lifebox workshop	An audit of a maternity unit in 2014 demonstrated all patients receiving anaesthesia were monitored with pulse oximetry perioperatively and pulse oximetry training and provision enabled early hypoxia detection and interventions.
Uganda (LIC): 12 hospitals nationwide [37]	2007	Anaesthesia providers	Identify pulse oximetry gaps and training needs for perioperative monitoring	2 half-day Global Oximetry project workshop with refresher 1 y later	Test scores improved for all but two participants after training. All participants were able to demonstrate basic oximetry use after training. Demonstrating a change of practice.
Uganda (LIC), providers nationwide [38]	2011	Non-physician anaesthetists	Oximetry and hypoxia management	2.5 d Lifebox training course	Pulse oximetry knowledge improved from a median score of 36 / 50 to 41 / 50 (P < 0.0001) immediately after course. 3-5 mo later, the median score was 41 / 50 (P = 0.001 compared with immediate post-training test scores), and 95% of oximeters were in routine clinical use. Participants felt oximeters improved patient safety.
Zambia (LMIC), no site specified [39]	No year noted. Abstract presented in 2016.	Physicians and clinical officers throughout Zambia	Improve anaesthesia capacity, SSC, and pulse oximetry monitoring to reduce maternal mortality	1-d Lifebox workshop and 3-d Safe Anesthesia From Education (SAFE) obstetric anaesthesia courses	Lifebox MCQ, SAFE MCQ, and SAFE skills scores all improved after the training course.
European Region
Moldova (UMIC), 1 hospital in Chisinau [40]	2010	Operating Room Staff	SSC implementation	Train-the-trainer approach with months long progressive rollout using course materials developed by WHO, Harvard School of Public Health, the World Federation of Societies of Anaesthesiologists, and the Association of Anaesthetists of Great Britain and Ireland, and intraoperative teaching	Pulse oximeters in operating stations increased from 14 to 100%. Pulse oximetry use in cases increased from 16 to 99.6%. Hypoxemic episodes lasting 2 min or longer per 100 h of oximetry decreased from 11.5 to 6.4 (P < 0.002).
South-East Asia Region
India (LMIC), 4 hospitals in 1 state [41]	2007	Anaesthetists	To increase oximetry provision and perioperative monitoring	Training manual designed for Global Oximetry (GO) subproject initially used in Uganda	10 mo after training, 11 / 12 pulse oximeters were still regularly used. Anaesthetists report early detection of hypoxia, improved perioperative monitoring, and enhanced team communication.
Nepal (LMIC), 12 districts nationwide [42]	2014-2015	Anaesthesia assistants	To provide anaesthesia assistant continuing professional development	A refresher course of 5 d, 1 y with tablet-based self-learning modules and clinical case logs, regular educational mentor communication, a midcourse 2-week contact time at an anaesthesia assistant training site, regular text messaging, and clinical and MCQ examinations	Pulse oximetry was used in 98% of cases.
Thailand (UMIC), 1 hospital in Bangkok and 1 hospital in Pitsanulok [43]	Ongoing. Anaesthesia training for physicians began in 1951 and anaesthetic nurses in 1965.	Anaesthesia residents, anaesthesia fellows, and anaesthetic nurses from Thailand and nearby countries	Increasing anaesthesia workforce in the region	3-y residency for physicians, 1-y programme for nurse anaesthetists	In 2016, 25 new anaesthesiologists and 40 anaesthesia nurses trained each year. Pulse oximetry monitoring now standard.
Western Pacific Region
The Philippines (LMIC): 16 hospitals in Cebu province [37]	2007	Acute care doctors and nurses	Identify pulse oximetry gaps and training needs for perioperative monitoring	1 d training course (for doctors and nurses) in the use of oximeters	Use of the oximeters throughout the project, demonstrating a change of practice.
Vietnam (LMIC): 15 hospitals in Binh Dinh province [37]	2007	Anaesthesia providers	Identify pulse oximetry gaps and training needs for perioperative monitoring	1 d Global Oximetry project workshop with refreshers 6 mo and 1 y later	All participants were able demonstrate basic oximetry use after training.

LMIC – lower middle-income country, UMIC – upper middle-income country, SSC – World Health Organization’s (WHO) Safe Surgical Checklist, d – days, mo – months, LIC – low-income country, HDU – high dependency unit, PACU – post-anaesthesia care unit, y – year, MCQ – multiple choice question

*Stratified by WHO Regions.