Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
Konongo-Odumase Government Hospital, Konongo, Ghana.
Injury. 2024 Sep;55(9):111569. doi: 10.1016/j.injury.2024.111569. Epub 2024 Apr 16.
We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at non-tertiary hospitals in Ghana during on-hours (8AM-5PM weekdays) compared to off-hours (nights, weekends, and holidays). We also sought to assess the effectiveness of a standardized trauma intake form (TIF) with built-in decision support prompts to improve care and to assess whether this effectiveness varied between on-hours and off-hours.
A stepped-wedge cluster randomized trial was performed with research assistants directly observing trauma care before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs and mortality were assessed using multivariable logistic regression and generalized linear mixed regression.
Management of 4,077 patients was observed; 1,126 (28 %) during on-hours and 2,951(72 %) during off-hours. At baseline, four of 20 KPIs were performed significantly more often during off-hours. TIF improved care during both on- and off-hours. Seventeen KPIs improved during on-hours and 18 KPIs improved during off-hours. After TIF, six KPIs were performed more often during on-hours, but differences, though significant, were small (1-5 %). Examples of KPIs which were performed more often during on-hours after TIF included: airway assessment (99 % for on-hours vs. 98 % for off-hours), evaluation for intra-abdominal bleeding (91 % vs. 87 %), and spine immobilization for blunt trauma (90 % vs. 85 %) (all p < 0.05). At baseline, mortality among seriously injured patients (Injury Severity Score >9) was higher during on-hours (27 %) compared to off-hours (17 %, p = 0.047). TIF lowered mortality for seriously injured patients during both on-hours (27 % before TIF, 8 % after, p = 0.027) and during off-hours (17 % before, 7 % after, p = 0.004). After TIF, mortality among seriously injured patients was equal between on- and off-hours (8 % vs. 7 %, NS).
At baseline, KPIs of trauma care were slightly better during off-hours compared with on-hours, and mortality was lower among seriously injured patient during off-hours. A quality improvement initiative (the TIF) using built-in decision support prompts improved care strongly in both on- and off-hours and eliminated the mortality difference between on- and off-hours. Use of similar decision support prompts during initial trauma care should be promoted widely in other low- and middle-income countries.
本研究旨在比较加纳非三级医院在工作时间（周一至周五 8 点至下午 5 点）与非工作时间（夜间、周末和节假日）初始创伤护理的关键绩效指标（KPI）的实现情况。我们还评估了内置决策支持提示的标准化创伤摄入表（TIF）在改善护理方面的有效性，并评估了这种有效性在工作时间和非工作时间之间是否存在差异。
采用阶梯式楔形集群随机试验，研究助理在 8 家医院的急诊部门在引入 TIF 前后直接观察创伤护理，持续 17.5 个月。使用多变量逻辑回归和广义线性混合回归评估 KPI 和死亡率的差异。
共观察到 4077 例患者的管理情况；其中 1126 例（28%）在工作时间，2951 例（72%）在非工作时间。在基线时，有 20 个 KPI 中的四个在非工作时间的执行频率明显更高。TIF 改善了工作时间和非工作时间的护理。工作时间有 17 个 KPI 得到改善，非工作时间有 18 个 KPI得到改善。引入 TIF 后，有 6 个 KPI 在工作时间的执行频率更高，但差异虽然显著，但幅度较小（1-5%）。在 TIF 之后，工作时间内更常执行的 KPI 包括：气道评估（工作时间为 99%，非工作时间为 98%）、腹部内出血评估（工作时间为 91%，非工作时间为 87%）和钝伤脊柱固定（工作时间为 90%，非工作时间为 85%）（均 p<0.05）。在基线时，严重受伤患者（损伤严重程度评分>9）的死亡率在工作时间（27%）高于非工作时间（17%，p=0.047）。TIF 降低了严重受伤患者在工作时间（TIF 前为 27%，TIF 后为 8%，p=0.027）和非工作时间（TIF 前为 17%，TIF 后为 7%，p=0.004）的死亡率。引入 TIF 后，严重受伤患者在工作时间和非工作时间的死亡率相当（8%比 7%，无统计学差异）。
在基线时，与工作时间相比，创伤护理的 KPI 在非工作时间稍好，非工作时间严重受伤患者的死亡率较低。一项质量改进倡议（TIF）使用内置决策支持提示，在工作时间和非工作时间均显著改善了护理，并消除了工作时间和非工作时间之间的死亡率差异。在其他中低收入国家应广泛推广使用类似的决策支持提示来进行初始创伤护理。
