LaGrone Lacey N, Romaní Pozo Diego A, Figueroa Juan F, Artunduaga Maria A, Huaman Egoavil Eduardo, Rodriguez Castro Manuel J A, Foianini Jorge Esteban, Rubiano Andrés M, Rodas Edgar B, Mock Charles N
University of Washington, Seattle, USA.
Universidad Peruana Cayetano Heredia, Lima, Peru.
Injury. 2017 Sep;48(9):1985-1993. doi: 10.1016/j.injury.2017.03.003. Epub 2017 Apr 7.
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.
We conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru.
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.
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.
创伤质量改进（QI）项目已被证明能改善治疗结果并降低成本。在低收入和中等收入国家（LMICs），这是高度优先事项，这些国家每年有200万人因可救治的创伤死亡。我们试图确定四个低收入和中等收入国家创伤QI项目的改进领域。
我们对四个安第斯中等收入国家（玻利维亚、哥伦比亚、厄瓜多尔和秘鲁）的创伤护理提供者进行了一项调查。
336名医生、医学生、护士、管理人员和辅助医疗专业人员对横断面调查做出了回应，除玻利维亚回应率为14%外，所有纳入国家的回应率均超过90%。87%的受访者报告其所在医院召开发病率和死亡率（M&M）会议。会议报告显示频率往往较低——45%的会议每三个月内召开次数少于一次，且参会人数较少——63%的会议到场的主治医生人数为五人或更少。只有23%的会议有标准化的选择标准，大多数缺乏记录——仅35%的会议有记录。重要的是，只有13%的参与者表示讨论后会例行采取某种纠正措施。多变量分析显示，存在标准化病例选择标准（OR 3.48，95% CI 1.16 - 10.46）、M&M会议的书面记录（OR 5.73，95% CI 1.73 - 19.06）以及明确的后续跟进计划（OR 4.80，95% CI 1.59 - 14.50）与有效的M&M会议相关。22%的受访者在设有创伤登记处的医院工作。52%的受访者所在机构进行尸检，但其中只有32%报告尸检结果曾被用于改善医院实践。
M&M会议在拉丁美洲安第斯地区经常召开，但往往缺乏方法的严谨性，因此效果不佳。QI项目成熟的下一步包括优化尸检和登记处数据的使用，以及对M&M会议进行系统的后续跟进并采取纠正措施，以确保这些活动能使临床护理有明显改善。
