Lacey LaGrone, MD
Nominated From: University of Washington
Research Site: Peru
Research Area: Health Systems; Trauma
Primary Mentor: Dr. Charles Mock
Trauma quality improvement in Latin America
The study objectives are two-fold, one, to assess current presence of trauma quality improvement (QI) programs in Lima, Peru. We hypothesize that implementation of any of the defined trauma QI programs in Lima, Peru, will be infrequent. Second, to identify what trauma care staff perceive to be the barriers and facilitators to implementation of trauma quality improvement programs in Lima, Peru. This second objective is significant in providing a spring-board for development of location appropriate trauma QI measures.
Factors which may contribute to barriers or facilitators for trauma quality improvement implementation include: morbidity and mortality conferences, trauma registries, and audits. We anticipate that several factors will have a direct impact on quality improvement implementation: staff and policy. Staff have a direct impact as they are the implementers, there are “cues to action” which would mobilize the motivated, and trained staff – these are to be investigated. With regard to policy, the presence of legal protection for practicing physicians, and the presence of local or national mandates for quality improvement would directly impact QI implementation.
On this same level of removal from the center of the framework, is staff education. Educating the staff is the first step towards implementation. Once staff are aware, and capable, then the other listed motivational factors become important. These include, from the health belief model, the perceived severity, susceptibility, benefits and barriers to QI implementation. Moving more peripherally again, the importance of peer influence is not to be understated. The trauma care community within Latin America is becoming progressively more organized, largely through the efforts of the Panamerican Trauma Society. The growing popularity of QI means that more and more frequently surgeons encounter other surgeons who have instituted morbidity and mortality conferences, trauma registries, or trauma audits at their hospitals – resulting in a changing norm.
Finally, on the left side of the framework are the patients, as a subset of the public in general. Increasing awareness of the public regarding disparity in trauma outcomes between high, middle and low-income countries will increase public and media buy-in to the idea of quality improvement measures. More particularly, patients are well-positioned to advocate for excellence. These factors are likely to impact quality improvement through influence of staff motivation, and through potential policy impact.
Globally, one in ten persons die from injury, and more disability-adjusted life years are lost due to injury than malaria, HIV, and TB combined. Latin America experiences an annual trauma incidence over 60% higher than the world average, and injury is the leading cause of death in men aged 15-59 in this region. Not only is the incidence of trauma exceptionally high in Latin America, but many outcomes are inferior to those observed in high-income settings. The Panamerican Trauma Society (PTS) has responded to this crisis by leading initiatives to implement the World Health Organization’s (WHO) Guidelines for Trauma Quality Improvement (QI) Programmes. Trauma QI programs are designed to identify areas for improvement in care, implement an evidence-based corrective intervention, and then follow-up to monitor effectiveness. There is a strong evidence-base for the effectiveness of trauma QI programs, in one review, 34 of 36 studies evaluated reported a positive impact of the QI measure assessed. Evidence suggests that trauma QI programs are largely absent in Latin American hospitals. Thus, the indication for trauma QI programs is soundly established, but an effective and generalizable means of implementation is yet to be identified.