Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

Abstract

Introduction Trauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs. Methods We conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru. Results 336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent – 45% occurred less than every three months and poorly attended – 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation – notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16–10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73–19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59–14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice. Conclusions M&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

“…168 Studies identified in this review used these guidelines to both study what QI activity undertaken as well as studies applying recommended QI practices such as preventable death panels. 70 72 114 140 162 The other non-study literature identified had not been applied for health system assessment by studies in this review. 14 169–171…”

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation: A scoping review on the implementation of TQIPs across income levels

“…Another key theme was the importance of adaptability. A focus on tailoring the intervention to the local context to ensure success and sustainability was apparent [9,16,21,22,30,33,35,36]. The implementation of a multi-hospital injury surveillance program in Mozambique was driven by local data collectors that enhanced the sustainability of the project [16].…”

“…Increased dissemination of results is a critical facilitator to establish prolonged TQIP support, through enhancing engagement and QI understanding. A trauma care provider survey in the Andean region concluded that increased QI dissemination can empower local providers to participate in health systems and drive change [35]. The increase in peer-reviewed QI reports from LMICs emphasises dissemination through publications as a viable means of providing guidance for future programs and expanding QI knowledge [45].…”

Standardization of Trauma, General Surgical Morbidity and Mortality Conferences: Development and Dissemination of a “Toolkit” in Peru

“…This project represents ''phase two'' of a multi-phase project to implement quality M&M conferences in Peru. Phase one included a baseline assessment of existing practices in Peru and Latin America and a review of global implementation of the WHO TQIP guidelines [11][12][13]. It revealed standardized case selection criteria, documentation of M&M conclusions and a clear plan for follow-up to predict M&M conferences which are perceived to result in institutional change [11][12][13].…”