**5. Logistics and transportation**

Transportation of the team and equipment is an important part of cleft care during international mission trips, and should not be overlooked. Travel to and from sites can be a costly endeavor, and the logistics must be planned out well before the trip for any hope of coordinated arrival and departure of equipment and personnel. A week-long trip may require months of meticulous planning, including arrangements of passports and visas, housing, meals, social events, and security. If the mission is planned by an international healthcare organization, it is beneficial to have local partnerships or contacts to help navigate the custom regulations when bringing equipment into the host country. The equipment should also be acquired and tested prior to shipping time. Drugs and expendables should be checked for expiration dates and evidence of mishandling or breach in packaging. To further ensure successful transportation, all items should be inventoried and documented.

#### **6. Patient screening and assessment**

One of the most crucial elements in cleft care is to determine surgical priority through proper patient screening and assessment. Children in LMIC are often undernourished, and many have concomitant medical illnesses and infectious diseases, all of which can lead to a lowered healing reserve compared to children normally encountered in developing countries. Therefore, when a cleft patient first contacts a healthcare facility for treatment, he/she needs to be properly assessed by a multidisciplinary team. Blood tests should be ordered to evaluate any metabolic abnormalities and the presence of anemia. Low hemoglobin level may be a marker for poor nutrition, and thus associated with high surgical risk. Traditionally, hemoglobin value of 10 g/dl is considered the lower limit of acceptable surgical candidate; however, the data to support this are lacking [8]. During the first phase of screening, risk factors such as poor nutrition, low hemoglobin, significant airway anomalies, and young age should be considered to disqualify a child as a potential candidate for surgery. A number of studies have identified age as a significant risk factor for surgery in children using death or cardiac arrest as primary end points. These studies suggest that neonates (0–30 days) are at a risk as high as 40 times compared to older children or adults, whereas infants (1–12 months) have a 4- to 5-fold increased risk compared to older children [18–20].

For patients that have passed the initial screening phase, a final assessment and evaluation occurs before the operation, which consists of two parts. A team of surgeons first determine surgical priority of the procedure and its estimated duration. If there are any surgical contraindications to the operation, they are identified at this point and the patient will not be scheduled for surgery. Second, the pediatric anesthesiologist team determines the American Society of Anesthesiologists (ASA) patient classification and provides a second independent opinion on the suitability of patient for the surgery. Most importantly, the cardiac and respiratory status of the patient is carefully evaluated at this time [12]. A patient who has satisfied the criteria for each of these phases is selected for surgery. When indicated, a course of preoperative nasoalveolar molding therapy is advised.

Such a comprehensive and lengthy selection procedure is important to ensure patient safety, as well as to maximize the expected benefits from surgery and proper usage of time and resources. **Figure 1** shows an outline of the steps involved in patient selection.

**Figure 1.** Steps involved in patient selection.

**5. Logistics and transportation**

48 Designing Strategies for Cleft Lip and Palate Care

**Post-operative ward** • 24 hour nursing staff

**Table 1.** List of minimum supplies and equipment required for proper cleft care [8, 9].

**6. Patient screening and assessment**

Transportation of the team and equipment is an important part of cleft care during international mission trips, and should not be overlooked. Travel to and from sites can be a costly endeavor, and the logistics must be planned out well before the trip for any hope of coordinated arrival and departure of equipment and personnel. A week-long trip may require months of meticulous planning, including arrangements of passports and visas, housing, meals, social events, and security. If the mission is planned by an international healthcare organization, it is beneficial to have local partnerships or contacts to help navigate the custom regulations when bringing equipment into the host country. The equipment should also be acquired and tested prior to shipping time. Drugs and expendables should be checked for expiration dates and evidence of mishandling or breach in packaging. To further ensure

• Appropriate dressing and cleaning materials

and other nursing needs

• Oxygen availability

• Vital sign monitoring equipment

• Medications for pain management, antisepsis, nausea,

One of the most crucial elements in cleft care is to determine surgical priority through proper patient screening and assessment. Children in LMIC are often undernourished, and many have concomitant medical illnesses and infectious diseases, all of which can lead to a lowered healing reserve compared to children normally encountered in developing countries. Therefore, when a cleft patient first contacts a healthcare facility for treatment, he/she needs to be properly assessed by a multidisciplinary team. Blood tests should be ordered to evaluate any metabolic abnormalities and the presence of anemia. Low hemoglobin level may be a marker for poor nutrition, and thus associated with high surgical risk. Traditionally, hemoglobin value of 10 g/dl is considered the lower limit of acceptable surgical candidate; however, the data to support this are lacking [8]. During the first phase of screening, risk factors such as poor nutrition, low hemoglobin, significant airway anomalies, and young age should be considered to disqualify a child as a potential candidate for surgery. A number of studies have identified age as a significant risk factor for surgery in children using death or cardiac arrest as primary end points. These studies suggest that neonates (0–30 days) are at a risk as high as 40 times compared to older children or adults, whereas infants (1–12 months) have

successful transportation, all items should be inventoried and documented.

a 4- to 5-fold increased risk compared to older children [18–20].
