Table II.2.2, Guide to infrastructure, supplies and anaesthesia standards at three levels of health-care facilities - WHO Guidelines for Safe Surgery 2009

Level 1 - Small hospital or health centre (Should meet at least ‘highly recommended’ anaesthesia standards)	Level 2 - District or provincial hospital (Should meet at least ‘highly recommended’ and ‘recommended’ anaesthesia standards)	Level 3 - Referral hospital (Should meet at least ‘highly recommended’, ‘recommended’ and ‘suggested’ anaesthesia standards)
Rural hospital or health centre with a small number of beds (or urban location in an extremely disadvantaged area); sparsely equipped operating room for ‘minor’ procedures Provides emergency measures in the treatment of 90–95% of trauma and obstetrics cases (excluding caesarean section) Referral of other patients (for example, obstructed labor, bowel obstruction) for further management at a higher level	District or provincial hospital (e.g. with 100–300 beds) and adequately equipped major and minor operating rooms Short-term treatment of 95–99% of major lifethreatening conditions	A referral hospital with 300–1000 or more beds and basic intensive care facilities. Treatment aims are the same as for level 2, with the addition of: Ventilation in operating room and intensive care unit Prolonged endotracheal intubation Thoracic trauma care Homodynamic and inotropic treatment Basic intensive care unit patient management and monitoring for up to 1 week: all types of cases, but possibly with limited provision for: – Multi-organ system failure – Haemodialysis – Complex neurological and – cardiac surgery – Prolonged respiratory failure – Metabolic care or monitoring

Level 1 - Small hospital or health centre (Should meet at least ‘highly recommended’ anaesthesia standards)

Level 2 - District or provincial hospital (Should meet at least ‘highly recommended’ and ‘recommended’ anaesthesia standards)

Level 3 - Referral hospital (Should meet at least ‘highly recommended’, ‘recommended’ and ‘suggested’ anaesthesia standards)

Rural hospital or health centre with a small number of beds (or urban location in an extremely disadvantaged area); sparsely equipped operating room for ‘minor’ procedures
Provides emergency measures in the treatment of 90–95% of trauma and obstetrics cases (excluding caesarean section)
Referral of other patients (for example, obstructed labor, bowel obstruction) for further management at a higher level

District or provincial hospital (e.g. with 100–300 beds) and adequately equipped major and minor operating rooms
Short-term treatment of 95–99% of major lifethreatening conditions

A referral hospital with 300–1000 or more beds and basic intensive care facilities. Treatment aims are the same as for level 2, with the addition of:
Ventilation in operating room and intensive care unit
Prolonged endotracheal intubation
Thoracic trauma care
Homodynamic and inotropic treatment
Basic intensive care unit patient management and monitoring for up to 1 week: all types of cases, but possibly with limited provision for:
–
Multi-organ system failure
–
Haemodialysis
–
Complex neurological and
–
cardiac surgery
–
Prolonged respiratory failure
–
Metabolic care or monitoring

Essential procedures	Essential procedures	Essential procedures
Normal delivery Uterine evacuation Circumcision Hydrocoele reduction, incision and drainage Wound suturing Control of haemorrhage with pressure dressings Debridement and dressing of wounds Temporary reduction of fractures Cleaning or stabilization of open and closed fractures Chest drainage (possibly) Abscess drainage	Same as level 1 with the following additions: Caesarean section Laparotomy (usually not for bowel obstruction) Amputation Hernia repair Tubal ligation Closed fracture treatment and application of plaster of Paris Acute open orthopaedic surgery: e.g. internal fixation of fractures Eye operations, including cataract extraction Removal of foreign bodies: e.g. in the airways Emergency ventilation and airway management for referred patients such as those with chest and head injuries	Same as level 2 with the following additions: Facial and intracranial surgery Bowel surgery Paediatric and neonatal surgery Thoracic surgery Major eye surgery Major gynaecological surgery, e.g. vesico-vaginal repair
Personnel	Personnel	Personnel
Paramedical staff or anaesthetic officer (including on-the-job training) who may have other duties as well Nurse–midwife	One or more trained anaesthetists District medical officers, senior clinical officers, nurses, midwives Visiting specialists, resident surgeon, obstetrician or gynaecologist	Clinical officers and specialists in anaesthesia and surgery

Essential procedures

Normal delivery
Uterine evacuation
Circumcision
Hydrocoele reduction, incision and drainage
Wound suturing
Control of haemorrhage with pressure dressings
Debridement and dressing of wounds
Temporary reduction of fractures
Cleaning or stabilization of open and closed fractures
Chest drainage (possibly)
Abscess drainage

Same as level 1 with the following additions:
Caesarean section
Laparotomy (usually not for bowel obstruction)
Amputation
Hernia repair
Tubal ligation
Closed fracture treatment and application of plaster of Paris
Acute open orthopaedic surgery: e.g. internal fixation of fractures
Eye operations, including cataract extraction
Removal of foreign bodies: e.g. in the airways
Emergency ventilation and airway management for referred patients such as those with chest and head injuries

Same as level 2 with the following additions:
Facial and intracranial surgery
Bowel surgery
Paediatric and neonatal surgery
Thoracic surgery
Major eye surgery
Major gynaecological surgery, e.g. vesico-vaginal repair

Personnel

Paramedical staff or anaesthetic officer (including on-the-job training) who may have other duties as well
Nurse–midwife

One or more trained anaesthetists
District medical officers, senior clinical officers, nurses, midwives
Visiting specialists, resident surgeon, obstetrician or gynaecologist

Clinical officers and specialists in anaesthesia and surgery

Drugs	Drugs	Drugs
Ketamine 50 mg/ml injection Lidocaine 1% or 2% Diazepam 5 mg/ml injection, 2 ml or midazolam 1 mg/ml injection, 5 ml Pethidine 50 mg/ml injection, 2 ml Morphine 10 mg/ml, 1 ml Epinephrine (adrenaline) 1 mg Atropine 0.6 mg/ml Appropriate inhalation anaesthetic if vaporizer available	Same as level 1, but also: Thiopental 500 mg/g powder or propofol Suxamethonium bromide 500 mg powder Pancuronium Neostigmine 2.5 mg injection Ether, halothane or other inhalation anaesthetics Lidocaine 5% heavy spinal solution, 2 ml Bupivacaine 0.5% heavy or plain, 4 ml Hydralazine 20 mg injection Frusemide 20 mg injection Dextrose 50% 20 ml injection Aminophylline 250 mg injection Ephedrine 30/50 mg ampoules Hydrocortisone (?) Nitrous oxide	Same as level 2 with the following additions: Propofol Nitrous oxide Various modern neuromuscular blocking agents Various modern inhalation anaesthetics Various inotropic agents Various intravenous antiarrhythmic agents Nitroglycerine for infusion Calcium chloride 10% 10 ml injection Potassium chloride 20% 10 ml injection for infusion

Drugs

Ketamine 50 mg/ml injection
Lidocaine 1% or 2%
Diazepam 5 mg/ml injection, 2 ml or midazolam 1 mg/ml injection, 5 ml
Pethidine 50 mg/ml injection, 2 ml
Morphine 10 mg/ml, 1 ml
Epinephrine (adrenaline) 1 mg
Atropine 0.6 mg/ml
Appropriate inhalation anaesthetic if vaporizer available

Same as level 1, but also:
Thiopental 500 mg/g powder or propofol
Suxamethonium bromide 500 mg powder
Pancuronium
Neostigmine 2.5 mg injection
Ether, halothane or other inhalation anaesthetics
Lidocaine 5% heavy spinal solution, 2 ml
Bupivacaine 0.5% heavy or plain, 4 ml
Hydralazine 20 mg injection
Frusemide 20 mg injection
Dextrose 50% 20 ml injection
Aminophylline 250 mg injection
Ephedrine 30/50 mg ampoules
Hydrocortisone
(?) Nitrous oxide

Same as level 2 with the following additions:
Propofol
Nitrous oxide
Various modern neuromuscular blocking agents
Various modern inhalation anaesthetics
Various inotropic agents
Various intravenous antiarrhythmic agents
Nitroglycerine for infusion
Calcium chloride 10% 10 ml injection
Potassium chloride 20% 10 ml injection for infusion

Equipment: capital outlay	Equipment: capital outlay	Equipment: capital outlay
Adult and paediatric self-inflating breathing bags with masks Foot-powered suction Stethoscope, sphygmomanometer, thermometer Pulse oximeter Oxygen concentrator or tank oxygen and a drawover vaporizer with hoses Laryngoscopes, bougies	Complete anaesthesia, resuscitation and airway management systems including: Reliable oxygen sources Vaporizer(s) Hoses and valves Bellows or bag to inflate lungs Face masks (sizes 00–5) Work surface and storage Paediatric anaesthesia system Oxygen supply failure alarm; oxygen analyser Adult and paediatric resuscitator sets Pulse oximeter, spare probes, adult and paediatric^* Capnograph^* Defibrillator (one per operating suite or intensive care unit)^* Electrocardiograph monitor^* Laryngoscope, Macintosh blades 1–3(4) Oxygen concentrator(s) (cylinder) Foot or electric suction Intravenous pressure infusor bag Adult and paediatric resuscitator sets Magill forceps (adult and child), intubation stylet or bougie Spinal needles 25G Nerve stimulator Automatic non-invasive blood pressure monitor	Same as level 2 with these additions (per each per operating room or intensive care unit bed, except where stated): Electrocardiograph monitor^* Anaesthesia ventilator, reliable electric power source with manual override Infusion pumps (two per bed) Pressure bag for intravenous infusion Electric or pneumatic suction Oxygen analyser^* Thermometer (temperature probe^*) Electric warming blanket Electric overhead heater Infant incubator Laryngeal mask, airways sizes 2, 3, 4 (three sets per operating room) Intubating bougies, adult and child (one set per operating room) Anaesthetic agent (gas and vapour) analyser Depth of anaesthesia monitors are being increasingly recommended for cases at high risk of awareness but are not standard in many countries.

Equipment: capital outlay

Adult and paediatric self-inflating breathing bags with masks
Foot-powered suction
Stethoscope, sphygmomanometer, thermometer
Pulse oximeter
Oxygen concentrator or tank oxygen and a drawover vaporizer with hoses
Laryngoscopes, bougies

Complete anaesthesia, resuscitation and airway management systems including:

Reliable oxygen sources
Vaporizer(s)
Hoses and valves
Bellows or bag to inflate lungs
Face masks (sizes 00–5)
Work surface and storage
Paediatric anaesthesia system
Oxygen supply failure alarm; oxygen analyser
Adult and paediatric resuscitator sets
Pulse oximeter, spare probes, adult and paediatric^*
Capnograph^*
Defibrillator (one per operating suite or intensive care unit)^*
Electrocardiograph monitor^*
Laryngoscope, Macintosh blades 1–3(4)
Oxygen concentrator(s) (cylinder)
Foot or electric suction
Intravenous pressure infusor bag
Adult and paediatric resuscitator sets
Magill forceps (adult and child), intubation stylet or bougie
Spinal needles 25G
Nerve stimulator
Automatic non-invasive blood pressure monitor

Same as level 2 with these additions (per each per operating room or intensive care unit bed, except where stated):

Electrocardiograph monitor^*
Anaesthesia ventilator, reliable electric power source with manual override
Infusion pumps (two per bed)
Pressure bag for intravenous infusion
Electric or pneumatic suction
Oxygen analyser^*
Thermometer (temperature probe^*)
Electric warming blanket
Electric overhead heater
Infant incubator
Laryngeal mask, airways sizes 2, 3, 4 (three sets per operating room)
Intubating bougies, adult and child (one set per operating room)
Anaesthetic agent (gas and vapour) analyser
Depth of anaesthesia monitors are being increasingly recommended for cases at high risk of awareness but are not standard in many countries.

Equipment: disposable	Equipment: disposable	Equipment: disposable
Examination gloves Intravenous infusion and drug injection equipment Suction catheters size 16 FG Airway support equipment, including airways and tracheal tubes Oral and nasal airways	Electrocardiograph electrodes Intravenous equipment (minimum fluids: normal saline, Ringer lactate and dextrose 5%) Paediatric giving sets Suction catheters size 16 FG Sterile gloves sizes 6–8 Nasogastric tubes sizes 10–16 FG Oral airways sizes 000–4 Tracheal tubes sizes 3–8.5 mm Spinal needles sizes 22 G and 25G Batteries size C	Same as level 2 with these additions: Ventilator circuits Yankauer suckers Giving sets for intravenous infusion pumps Disposables for suction machines Disposables for capnography, oxygen analyser, in accordance with manufacturers' specifications: Sampling lines Water traps Connectors Filters and fuel cells

Equipment: disposable

Examination gloves
Intravenous infusion and drug injection equipment
Suction catheters size 16 FG
Airway support equipment, including airways and tracheal tubes
Oral and nasal airways

Electrocardiograph electrodes
Intravenous equipment (minimum fluids: normal saline, Ringer lactate and dextrose 5%)
Paediatric giving sets
Suction catheters size 16 FG
Sterile gloves sizes 6–8
Nasogastric tubes sizes 10–16 FG
Oral airways sizes 000–4
Tracheal tubes sizes 3–8.5 mm
Spinal needles sizes 22 G and 25G Batteries size C

Same as level 2 with these additions:
Ventilator circuits
Yankauer suckers
Giving sets for intravenous infusion pumps
Disposables for suction machines
Disposables for capnography, oxygen analyser, in accordance with manufacturers' specifications:
Sampling lines
Water traps
Connectors
Filters and fuel cells

From: Objective 2, The team will use methods known to prevent harm from administration of anaesthetics, while protecting the patient from pain

Cover of WHO Guidelines for Safe Surgery 2009

WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives.

Geneva: World Health Organization; 2009.

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Table II.2.2Guide to infrastructure, supplies and anaesthesia standards at three levels of health-care facilities