King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
Karonga District Hospital, Karonga District Health Office, Karonga, Malawi.
Injury. 2021 Apr;52(4):793-805. doi: 10.1016/j.injury.2021.01.013. Epub 2021 Jan 14.
It is known that outcomes after injury care in low-and-middle income countries (LMICs) are poorer than those in high income countries. However, little is known about healthcare provider competency to deliver quality injury care in these settings. We developed and used clinical vignettes to evaluate injury care quality in an LMIC setting.
Four serious injury scenarios, developed from agreed best practice, testing diagnostic and management skills, were piloted with high and low-income setting clinicians. Scenarios were used with primary and referral facility clinicians in Malawi. Participants described their clinical course of action (assessment, diagnostic, treatment and management approaches) for each scenario, registering one point per agreed best practice response. Mean percentage total scores were calculated and univariable and multivariable comparison made across provider groups, facility types, injury care frequency and training level.
Fourteen Doctors, 51 Clinical Officers, 20 Medical Assistants from 11 facilities participated. Mean percentage total vignette scores varied significantly with clinician provider group (Doctors 63.1% vs Clinical Officers 49.6%, p<0.001, Clinical Officers vs Medical Assistants 39.4% p=0.001). Important care aspects most frequently included or omitted were: following chest injury, 88.2% reported chest drain insertion, 7.1% checked for tracheal deviation; following penetrating abdominal injury and shock, 98.8% secured IV access, 0% mentioned tranexamic acid; following severe head injury, 88.2% proposed CT or neurosurgical transfer, 7.1% ensured normotension; and following isolated open lower leg fracture, 90.1% arranged orthopaedic consultation, 2.4% assessed distal neurological status.
These clinical vignettes proved easy to use and collected rich data. This supports their use for assessing and monitoring clinical care quality in other similar settings.
众所周知，中低收入国家（LMICs）的创伤护理结果不如高收入国家。然而，人们对这些环境中医疗保健提供者提供高质量创伤护理的能力知之甚少。我们开发并使用临床病例来评估 LMIC 环境中的创伤护理质量。
从商定的最佳实践中开发了四个严重伤害场景，测试诊断和管理技能，在高收入和低收入环境中的临床医生中进行了试点。这些情景在马拉维的基层和转诊医疗机构的临床医生中使用。参与者描述了他们对每个情景的临床行动过程（评估、诊断、治疗和管理方法），每个商定的最佳实践反应得 1 分。计算了平均总分百分比，并对提供者组、设施类型、创伤护理频率和培训水平进行了单变量和多变量比较。
来自 11 个设施的 14 名医生、51 名临床医生和 20 名医疗助理参加了研究。临床医生提供者组的平均总病例评分差异显著（医生 63.1%，临床医生 49.6%，p<0.001，临床医生与医疗助理 39.4%，p=0.001）。最常包括或遗漏的重要护理方面包括：胸部受伤后，88.2%报告进行胸腔引流插入，7.1%检查气管偏移；穿透性腹部损伤和休克后，98.8%确保 IV 通路，0%提到氨甲环酸；严重头部损伤后，88.2%建议进行 CT 或神经外科转移，7.1%确保正常血压；孤立性开放性小腿骨折后，90.1%安排骨科会诊，2.4%评估远端神经状态。
这些临床病例证明易于使用且收集了丰富的数据。这支持了它们在评估和监测其他类似环境中的临床护理质量方面的使用。
