District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries |
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| Institution: | 1. Department of Surgery, University of Washington, Seattle, WA, USA;2. School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana;3. Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana;4. Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa;5. Eastern Regional Health Directorate, Ghana Health Service, Koforidua, Ghana;6. Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana;7. Department of Surgery, Eastern Regional Hospital, Koforidua, Ghana;8. Ghana Health Service, Accra, Ghana;9. Department of Obstetrics and Gynecology, Upper East Regional Hospital, Bolgatanga, Ghana;10. Department of Surgery, University of Cape Coast, Cape Coast, Ghana;11. Department of Emergency Medicine, Police Hospital, Accra, Ghana;12. Surgeons OverSeas (SOS), New York, NY, USA;13. Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA;14. Department of Surgery, Columbia University, New York, NY, USA;15. Department of Anesthesia, Komfo Anokye Teaching Hospital, Kumasi, Ghana;p. Department of Surgery, University of Development Studies, Tamale, Ghana;q. Harborview Injury Prevention & Research Center, Seattle, WA, USA;r. Department of Global Health, University of Washington, Seattle, WA, USA;1. Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA;2. Emergency Medical Services Agency, Los Angeles County Department of Health Services, Santa Fe Springs, CA, USA;1. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States;2. Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States;3. The Leonard Davis Institute, Wharton School of Business at the University of Pennsylvania, Philadelphia, PA, United States;4. Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States;5. Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States;6. Department of Emergency Medicine, Jefferson University School of Philadelphia Medicine, PA, United States;1. Department of Surgery, Kern Medical Center, USA;2. Department of Radiology, Kern Medical Center, USA;1. Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Foundation, United States;2. Bureau of Sciences Services, Wisconsin Department of Natural Resources, United States;3. National Farm Medicine Center, Marshfield Clinic Research Foundation, United States;1. Department of Trauma, Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands;2. The Royal Netherlands Navy (R) and Department of Traumatology, Division of Surgery, Medical Center Haaglanden – Bronovo, The Hague, The Netherlands;3. Royal Netherlands Army and Department of Surgery-Trauma, Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands;4. United States Air Force and The Norman M. Rich Department of Surgery, The Uniformed Services University of the Health Science, Bethesda, United States;5. Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands |
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| Abstract: | IntroductionProspective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly.MethodsConsensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8.ResultsPanellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1 – 0.58; Round 2 – 0.66; Round 3 – 0.76; and Round 4 – 0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage – vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation – a large bore IV was placed within 15 min of patient arrival; referral – if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer.ConclusionThis study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs. |
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| Keywords: | Trauma Quality improvement Global surgery Developing country Ghana |
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