response to commentary

Background

Trauma center care has been associated with improved mortality. It is not known if access to trauma center care is also associated with reduced readmissions. We hypothesized that receiving treatment at a trauma center would be associated with improved care and therefore would be associated with reduced readmission rates.

Methods

We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from 2007 to 2008. All hospital admissions and emergency department visits associated with injury were longitudinally linked. Regions were categorized by whether they had trauma centers. We excluded all patients younger than 18 years. We performed univariate and multivariate regression analyses to determine if readmissions were associated with patient characteristics, length of stay for initial hospitalization, trauma center access, and triage patterns.

Results

A total of 211,504 patients were included in the analysis. Of these, 5,094 (2%) died during the index hospitalization. Of those who survived their initial hospitalization, 79,123 (38%) experienced one or more readmissions to any hospital within 1 year. The majority of these were one-time readmissions (62%), but 38% experienced multiple readmissions. Over 67% of readmissions were unplanned and 8% of readmissions were for a trauma. After controlling for patient variables known to be associated with readmissions, primary triage to a trauma center was associated with a lower odds of readmission (odds ratio, 0.89; p < 0.001). The effect of transport to a trauma center remained significantly associated with decreased odds of readmission at 1 year (odds ratio, 0.96; p < 0.001).

Conclusion

Readmissions after injury are common and are often unscheduled. While patient factors play a role in this, care at a trauma center is also associated with decreased odds for readmission, even when controlling for severity of injury. This suggests that the benefits of trauma center care extend beyond improvements in mortality to improved long-term outcomes.

Level of evidence

Epidemiologic study, level III; therapeutic/care management study, level IV.

Background

Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals.

Methods

We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results.

Results

The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine.

Conclusions

The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.

Although international guidelines exist for the prevention of surgical site infections, their implementation in diverse clinical contexts, especially in low and middle-income countries, is challenging due to the lack of available resources and organizational structure of facilities. The goal of this project was to develop a series of video training aids to highlight best practices in surgical infection prevention in hospitals with limited resources and to provide practical solutions to common challenges faced in these settings. Using the validated Clean Cut education framework for infection prevention developed by Lifebox, a charity devoted to improving surgical and anesthetic safety, we partnered with clinicians in one Ethiopian hospital to create six educational videos giving practical guidelines for infection prevention under resource variable conditions. These include: 1) proper use of the WHO Surgical Safety Checklist, 2) hand and skin antisepsis, 3) confirming instrument sterility, 4) maintaining the sterile field, 5) antibiotic prophylaxis, and 6) gauze counting. Gaps in available online educational materials were identified in each of the six areas. Videos were created providing setting-specific education and addressing gaps in existing materials for each of the infection prevention topics. These videos are now integrated into infection prevention curricula through Lifebox in Ethiopia and ongoing data collection to evaluate acceptability and efficacy is ongoing. Surgical education videos on infection prevention topics addressing location-specific resources and workarounds can be useful to hospitals operating in resource-limited settings for training staff and supporting quality and safety efforts in surgery.

Background: Surgical site infections (SSIs) represent a major cause of morbidity and mortality in Ethiopia. Lack of post-discharge follow-up, including identification of SSIs, is a barrier to continued patient care, often because of financial and travel constraints. As part of a surgical quality improvement initiative, we aimed to assess patient outcomes at 30 days post-operative with a telephone call. Patients and Methods: We conducted mobile telephone follow-up as part of Lifebox's ongoing Clean Cut program, which aims to improve compliance with intra-operative infection prevention standards. One urban tertiary referral hospital and one rural district general hospital in Ethiopia were included in this phase of the study; hospital nursing staff called patients at 30 days post-operative inquiring about signs of SSIs, health-care-seeking behavior, and treatments provided if patients had any healthcare encounters since discharge. Results: A total of 701 patients were included; overall 77% of patients were reached by telephone call after discharge. The rural study site reached 362 patients (87%) by telephone; the urban site reached 176 patients (62%) (p < 0.001). Of the 39 SSIs identified, 19 (49%) were captured as outpatient during the telephone follow-up (p < 0.001); 22 (34%) of all complications were captured following discharge (p < 0.001). Telephone follow-up improved from 65%-78% in the first half of project implementation to 77%-89% in the second half of project implementation. Conclusion: Telephone follow-up after surgery in Ethiopia is feasible and valuable, and identified nearly half of all SSIs and one-third of total complications in our cohort. Follow-up improved over the course of the program, likely indicating a learning curve that, once overcome, is a more accurate marker of its practicability. Given the increasing use of mobile telephones in Ethiopia and ease of implementation, this model could be practical in other low-resource surgical settings.

The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.

Background

The operating room (OR) is one of the most expensive areas of a hospital, requiring large capital and recurring investments, and necessitating efficient throughput to reduce costs per patient encounter. On top of increasing costs, inefficient utilization of operating rooms results in prolonged waiting lists, high rate of cancellation, frustration of OR personnel as well as increased anxiety that negatively impacts the health of patients. This problem is magnified in developing countries, where there is a high unmet surgical need. However, no system currently exists to assess operating room utilization in Ethiopia.

Methodology

A prospective study was conducted over a period of 3 months (May 1 to July 31, 2019) in a tertiary hospital. Surgical case start time, end time, room turnover time, cancellations and reason for cancellation were observed to evaluate the efficiency of eight operating rooms.

Results

A total of 933 elective procedures were observed during the study period. Of these, 246 were cancelled, yielding a cancellation rate of 35.8%. The most common reasons for cancellation were related to lack of OR time and patient preparation (8.7% and 7.7% respectively). Shortage of facilities (instrument, blood, ICU bed) were causes of cancelation in 7.7%. Start time was delayed in 93.4% (mean 8:56 am ± 52 min) of cases. Last case completion time was early in 47.9% and delayed in 20.6% (mean 2:54 pm ± 156 min). Turnover time was prolonged in 34.5% (mean 25 min ± 49 min). Total operating room utilization ranged from 10.5% to 174%. Operating rooms were underutilized in 42.7% while overutilization was found in 14.6%.

Conclusion

We found a high cancellation rate, most attributable to late start times leading to delays for the remainder of cases, and lack of preoperative patient preparation. In a setting with a high unmet burden of surgical disease, OR efficiency must be maximized with improved patient evaluation workflows, adequate OR staffing and commitment to punctual start times. We recommend future quality improvement projects focusing on these areas to increase OR efficiency.

Background

We previously developed and pilot tested Clean Cut, a program to prevent postoperative infections by improving compliance with the WHO Surgical Safety Checklist (SSC) and strengthening adherence to infection control practices. This protocol describes the CheckList Expansion for Antisepsis and iNfection Control in Cesarean Section (CLEAN-CS) trial evaluating our program's ability to reduce infections following CS and other obstetric and gynecological operations in Ethiopia.

Methods/design

CLEAN-CS is a cluster-randomized stepped wedge interventional trial with five clusters (two hospitals per cluster). It aims to assess the impact of Clean Cut on six critical perioperative infection prevention standards including antiseptic practices, antibiotic administration, and routine SCC use. The trial involves baseline data collection followed by Clean Cut training and implementation in each cluster in randomized order. The intervention consists of (1) modifying and implementing the SSC to fit local practices, (2) process mapping each standard, (3) coupling data and processes with site-specific action plans for improvement, and (4) targeted training focused on process gaps. The primary outcome is 30-day CS infection rates; secondary outcomes include other patient-level complications and compliance with standards. Assuming baseline SSI incidence of 12%, an effect size of 25% absolute reduction, and the ability to recruit 80-90 patients per cluster per month, we require a sample of 8100 patients for significance. We will report our study according to CONSORT.

Discussion

A cluster-randomized stepped wedge design is well-suited for evaluating this type of surgical safety program. The targeted standards are not in doubt, yet compliance is frequently difficult. Solutions are available and may be recognized by individuals, but teams dedicated to improvement are often lacking. Clean Cut was successfully piloted but requires a more rigorous methodological assessment. We seek to understand the qualities, characteristics, and resources needed to implement the program, the magnitude of effect on processes and outcomes, and to what degree it can enhance compliance with care standards. Challenges include a fraught social and political environment, pandemic travel restrictions, and a limited budget.

Trial registration

ClinicalTrials.gov NCT04812522 (registered on March 23, 2021); Pan-African Clinical Trials Registry PACTR202108717887402 (registered on August 24, 2021).