Table 1 Measures taken by MSF to ensure the provision of quality surgical care in Jabal Akkrad, Syria

Adequate infrastructure, including protection from the external environment and appropriate electricity and lighting.

• The standard design of the field hospital was adapted to meet the functional/medical needs of the hospital, to ensure the ‘safe’ circuit of surgical patients (in terms of hygiene standards) and to accommodate for the challenges around lack of quality space, lack of infrastructure and lack of security, all the while ensuring that quality care of care would not be compromised. Essential for the design and timely implementation of these technical solutions was the presence of highly experienced personnel (medical staff who could clearly identify the functional needs of the hospital and logistics staff with extensive experience in emergency hospital design and set-up).

• An inflatable tent served as the operating theatre in order to ensure a minimum level of cleanliness. To ensure protection from environmental factors (such as rain, wind, dust and falling debris from the roof of the cave), plastic sheets formed a cover for the floor of the tent and wooden frames lined with plastic sheets formed the roof of the tent. The same features were put in place once the field hospital relocated to an abandoned chicken farm.

• An entirely new electrical wiring system was installed, respecting all necessary electrical safety measures. In addition, two generators were installed (one as back up), to ensure a reliable electricity supply during power cuts.

• Establishing the field hospital in the abandoned chicken farm in particular, required a huge coordinated global effort between the field team in Syria, headquarter teams in Brussels and a team based in Turkey: the field team selected the site (the chicken farm) and then sent photos to the emergency team in Brussels who, together with the logistics team, provided the team based in Turkey with a list of all the required materials. The Turkey based team obtained these materials through local procurement and then made the necessary arrangements to transport these materials across the Turkish border into Syria. While these preparations went on, logistics staff in the field set about designing the new hospital. This coordinated effort enabled the hospital to be set up within 3–4 days of relocating from the cave.

• A clandestine supply line from Turkey was essential for obtaining the logistical equipment and materials needed to set up the field hospital

Adequate water and sanitation provisions, waste management being a key priority

• Minimum water requirements were pre-set at 100 L water/anaesthesia and 40–60 L water/person/day in the IPD. At the cave, three water points were installed: one for emergency care, one for scrubbing, and one for sterilisation; at the abandoned chicken farm, a 30,000 L water tank was already in place. To avoid potential contamination of water with previously used toxic chemicals at the farm, the tank was emptied, cleaned, disinfected with chlorine and filled again.

• A new canal system was installed in just four days and water points were installed in seven areas of care-triage, consultation & emergency care, resuscitation, the inpatient department, scrubbing, sterilization, and laboratory.

• Several easy-to-clean tiled toilet units with hand washing points were installed and connected up to a large soak-away pit built outside (not accessible to patients or visitors).

• Surgical activities produce large quantities of organic, liquid and dangerous waste and there should be proper segregation of the waste material produced. While operating from the cave, there was only space enough for one waste pit which therefore had to serve as a refuse for all of the different types of waste. Once the hospital relocated to the abandoned chicken farm, a waste-management zone with an appropriate number of pits was built and waste could be segregated according to protocol.

Availability of all essential disposables, drugs and equipment

• A regular supply of drugs, material and equipment is an essential MSF pre-requisite in order to guarantee no ruptures in care. A clandestine supply line from Turkey ensured this, with supplies being transported across the Turkish border either by truck (with support of the Turkish Red Crescent) or hand-carried.

Strict adherence to hygiene requirements and universal precautions

• Hydro-alcoholic solution was made readily available.

• A clean sufficient water supply and sanitation provisions were ensured (as outlined above).

• In the absence of water hot enough to adequately clean dirty laundry, chlorine was added to the cold water supplying the washing machine.

• Strict adherence to infection control protocols

Mandatory use of sterile equipment for surgical and anaesthesia procedures

• In the cave, dry-heat sterilization was installed

• At the abandoned chicken farm, a gas barrel was installed in a separate and protected ventilated place, and linked to the heater of the autoclave inside the building. To generate the correct circuit of activities (from dirty, to clean, and finally to sterile) the sterilization service was provided in a large space, with two wicket gates for the “entry” and “exit” of material.

Blood transfusion capability

• In the cave, there was no blood bank in place. Even so, several blood transfusions were performed when indicated if suitable donors could be identified on the spot.

• Once the surgical center moved to the abandoned chicken farm, a blood bank was set up with transfusion therapy restricted to life saving indications.

Adequate human resources in quantity and quality

• Human resource requirements focused on sufficiency in numbers and sufficiency in skill level.

• Logisticians had to be recruited to organise the surgical centre, while surgical and aesthesia practitioners were needed to perform the required surgical procedures.

• A recruitment call was made for expatriate staff with previous experience of working in war torn settings. The technical referents devised a simplified design for the surgical centre and then up to 70 Syrian staff (plumbers, carpenters, bricklayers etc.) were employed to rehabilitate the abandoned chicken farm into a hospital with an operating theatre (taking just four days).