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CSPH Talk
1. Prospective Study of Surgical Care Scale-Up in a Rural, Resource-Limited Setting Selwyn Rogers, MD, MSc andDuncan Maru, MD, PHD October 4, 2011Center for Surgery and Public Health Nyaya Health
6. Conflicts of Interest We report no financial conflicts of interest. As with any scientific or service endeavor, we have significant intellectual interests at stake, though we hope to remain objective and self-reflective. 2
16. Study Objectives Rigorously study an innovative model for surgical care (IMEESC-plus) Pilot an implementation research methodology that can be used in a larger multi-site study Generate data for larger scale-up of surgical care worldwide 6
17. Setting: Bayalpata Hospital Infrastructure development and capacity building, not care provision alone Government collaboration: Government partnership contract for 5 years signed June 2009 â June 2014, on a government-owned complex Currently one of the highest levels of clinical care in the Far West (2 million people) Over 75,000 patients seen to date
18. The ease with which young people die in Achham and the ease with which it is accepted continues to horrify me. -RumaRajbhandari, MD, MPH, March 22, 2011. 8
19. Implementation science done well should be able to enhance, not compromise, both service and research quality. 9
20. Good study design involves collecting the right amount of data, hopefully nothing less but certainly nothing more. 10
25. Study Objectives Rigorously study an innovative model for Surgical Care (IMEESC-plus) Pilot an implementation research methodology that can be used in a larger multi-site study Generate data for larger scale-up of Surgical Care worldwide 12
26. Specific Aim 1: Description of Implementation To describe the logistics of the implementation process of IMEESC-Plus: the conditions with which patients present and the financial, staffing, pharmaceutical, and consumable supply inputs required to address these conditions. What basic implementation parameters can one expect? What parameters matter for planning purposes? 13
32. Specific Aim 2: Measuring quality of the implementation To assess the quality of the resulting IMEESC-Plus services during the course of the implementation process: adherence of staff to resuscitation and operating protocols, supply chain reliability, performance of morbidity and mortality conferences, patient follow-up rates, and rates of complications. How do you measure and monitor quality of surgical service implementation? (Distinct from, was the implementation itself high-quality?) 15
39. Surgical Safety Measures: Background Different surgical teams and contexts will bring different practices, tools, techniques But: there should be a shared set of quality measures across these different contexts Goal here is to develop some basic metrics that can be used for both internal QI and external monitoring/accountability. All data will be collected as force-choice fields, nothing free-hand. Form itself would be site-specific, based on work-flows and local documentation systems. 18
40. Surgical Safety Measures: Domains of Analysis Emergency room/pre-op Operating room/intra-op Inpatient unit/post-op Facilities and supplies systems Community/follow-up 19
41. Surgical Safety Measures: Pre-Op Fetal heart rate documented [obstetrics] Indication documented Time from decision to incision Pre-operative evaluation and documentation of airway 20
42. Surgical Safety Measures: Intra-op Time out performed prior to surgery Pulse oximeter working throughout the case Appropriate perioperative antibiotic use* Appropriate size suture documented 21
43. Surgical Safety Measures: Post-op Vital signs recorded within 30 minutes post-op Postoperative exam documented by nurse within 30 minutes Appropriate postoperative antibiotic use 22
44. Surgical Safety Measures: Facilities X-ray machine in working order, with technician to operate it Electricity present throughout duration of surgery Number of days that the surgical theater is open^ Suction machine verified and working pre-operatively Oxygen source verified and working pre-operatively Documentation of appropriate temperature strip from autoclave of surgical instruments 23
45. Surgical Safety Measures: Follow-up Hours to reach hospital from home Use of ambulance Paid CHW available in patientâs ward Number of deliveries at hospital, cesarean and non-cesarean Successful follow-up by CHW within 72 hours 24
55. The Nepali Ministry of Health & Achham District Health officials: Dr. Deepak Gaylal, Mr. SailendraShrestha, Mr. JhanakDhungana
56. Institutional Supporters: Abbot Laboratories, AMD and the Open Architecture Network, America Nepal Medical Foundation (ANMF), BWH COE in Quality and Safety, Buddha Air, Cents of Relief, Child Health Foundation, CIWEC Clinic (Menlha Nursing Home), Ella Lyman Cabot Trust, EquityEditors Association, Ford Foundation, Frederick Lovejoy Foundation, Google Grants, Nepal Ministry of Health and Population (MOHP), New Aid Foundation, Partners in Health, QBC Diagnostics, Quidel Corporation, Singapore Internet Research Center, Ten Friends, The Hunger Site, The International Foundation, The Shelley and Donald Rubin Foundation, Until There's a Cure Foundation, UpToDate, William Prusoff Foundation, Yale University