Immediate Outcome Indicators in Perioperative Care: A Controlled Intervention Study on Quality Improvement in Hospitals in Tanzania.

Outcome assessment is the standard for evaluating the quality of health services worldwide. In this study, outcome has been divided into immediate and final outcome. Aim was to compare an intervention hospital with a Continuous Quality Improvement approach to a control group using benchmark assessments of immediate outcome indicators in surgical care. Results were compared to final outcome indicators. Surgical care quality in six hospitals in Tanzania was assessed from 2006-2011, using the Hospital Performance Assessment Tool. Independent observers assessed structural, process and outcome quality using checklists based on evidence-based guidelines. The number of surgical key procedures over the benchmark of 80% was compared between the intervention hospital and the control group. Results were compared to Case Fatality Rates. In the intervention hospital, in 2006, two of nine key procedures reached the benchmark, one in 2009, and four in 2011. In the control group, one of nine key procedures reached the benchmark in 2006, one in 2009, and none in 2011. Case Fatality Rate for all in-patients in the intervention hospital was 5.5% (n = 12,530) in 2006, 3.5% (n = 21,114) in 2009 and 4.6% (n = 18,840) in 2011. In the control group it was 3.1% (n = 17,827) in 2006, 4.2% (n = 13,632) in 2009 and 3.8% (n = 17,059) in 2011. Results demonstrated that quality assurance improved performance levels in both groups. After the introduction of Continuous Quality Improvement, performance levels improved further in the intervention hospital while quality in the district hospital did not. Immediate outcome indicators appeared to be a better steering tool for quality improvement compared to final outcome indicators. Immediate outcome indicators revealed a need for improvement in pre- and postoperative care. Quality assurance programs based on immediate outcome indicators can be effective if embedded in Continuous Quality Improvement. Nevertheless, final outcome indicators cannot be neglected

Surgical key procedures in 2011 in the individual surgical wards of the intervention hospital.

<p>Individual immediate outcome indicators in the three surgical wards of the intervention hospital in 2011.</p

Surgical key procedures over 2006, 2009, 2011 in the intervention hospital.

<p>The black line indicates the benchmark of 80%. One key procedure (ward round, surgical performance) score over benchmark in 2006, one (surgical performance) in 2009 and in 2011. There are four key procedures (preoperative care; ward performance; ward round; surgical performance) with an immediate outcome indicator of more than 80%.</p

Surgical key procedures over 2006, 2009 and 2011 in the intervention hospital.

<p>Immediate outcome indicators in surgical care in the intervention hospital 2006, 2009, 2011.</p>*<p>indicates significant change,</p><p>↑indicates improvement,</p><p>↓indicates decline.</p

Surgical key procedures over 2006, 2009, 2011 in the control group.

<p>The black line indicates the benchmark of 80%. One key procedure (surgical performance) scores over benchmark in 2006, one (surgical performance) and in 2011 there is no key procedures with an immediate outcome indicator of more than 80%. Five procedures (discharge (observation); inpatient care; ward performance; postoperative care; surgical performance) have lower performance levels in 2011 than in 2006.</p

Surgical key procedures over 2006, 2009 and 2011 in the control group.

<p>Immediate outcome indicators in surgical care in the control group 2006, 2009, 2011.</p>*<p>indicates significant change,</p><p>↑indicates improvement,</p><p>↓indicates decline.</p

Structure of the Hospital Performance Assessment Tool.

<p>There are twelve focal points (maternity, surgery, pediatrics, medicine, laboratory, pharmacy, radiology, blood bank, management, maintenance, waste and hygiene, water and power). Key procedures consist of individual items that are structured in form of checklists. The assessment is conducted with the checklist of the items. The checklist with all items for the key procedure “discharge (observation)” in the clinical focal point surgery is given.</p

Thiopental inhibits global protein synthesis by repression of eukaryotic elongation factor 2 and protects from hypoxic neuronal cell death.

Ischemic and traumatic brain injury is associated with increased risk for death and disability. The inhibition of penumbral tissue damage has been recognized as a target for therapeutic intervention, because cellular injury evolves progressively upon ATP-depletion and loss of ion homeostasis. In patients, thiopental is used to treat refractory intracranial hypertension by reducing intracranial pressure and cerebral metabolic demands; however, therapeutic benefits of thiopental-treatment are controversially discussed. In the present study we identified fundamental neuroprotective molecular mechanisms mediated by thiopental. Here we show that thiopental inhibits global protein synthesis, which preserves the intracellular energy metabolite content in oxygen-deprived human neuronal SK-N-SH cells or primary mouse cortical neurons and thus ameliorates hypoxic cell damage. Sensitivity to hypoxic damage was restored by pharmacologic repression of eukaryotic elongation factor 2 kinase. Translational inhibition was mediated by calcium influx, activation of the AMP-activated protein kinase, and inhibitory phosphorylation of eukaryotic elongation factor 2. Our results explain the reduction of cerebral metabolic demands during thiopental treatment. Cycloheximide also protected neurons from hypoxic cell death, indicating that translational inhibitors may generally reduce secondary brain injury. In conclusion our study demonstrates that therapeutic inhibition of global protein synthesis protects neurons from hypoxic damage by preserving energy balance in oxygen-deprived cells. Molecular evidence for thiopental-mediated neuroprotection favours a positive clinical evaluation of barbiturate treatment. The chemical structure of thiopental could represent a pharmacologically relevant scaffold for the development of new organ-protective compounds to ameliorate tissue damage when oxygen availability is limited

Inhibitors of protein synthesis preserve intracellular ATP-content during oxygen deprivation.

<p>Human neuronal SK-N-SH cells were cultured in an oxygen-free atmosphere for 12–72 h in the presence of 5 µg/ml cycloheximide (closed triangles), 0.1 mM thiopental (closed rhombi), 0.5 mM thiopental (asterisks), or left untreated (closed squares). Cells, cultured in a normoxic atmosphere (open squares) served as a control. ATP content of cells was measured in lysates by an ATP-driven luciferase assay. Determined relative light units (RLU) were normalized to protein content and represent the means ± standard deviations of three independent experiments. Experimental groups were statistically evaluated by performing two-way ANOVA followed by the Bonferroni’s <i>post hoc</i> test. Statistical differences of oxygen deprived SK-N-SH cells (closed squares) compared to oxygen-deprived cells treated with 5 µg/ml cycloheximide (^###, p<0.001), 0.5 mM thiopental (^{<>\raster(60%)="rg3"<>}, p<0.05; ^{<>\raster(60%)="rg3"<><>\raster(60%)="rg3"<>}, p<0.01), 0.1 mM thiopental (^¥¥, p<0.01), or untreated control cells (^§§, p<0.01; ^§§§, p<0.001) are shown.</p

Thiopental induces eEF2 phosphorylation.

<p>SK-N-SH cells were treated with 10 µM –2 mM thiopental for 6 h (A) or with 0.5 mM thiopental for 10 min to 12 h (B) and analyzed by immunoblotting with an anti-human phospho-eEF2 threonine 56 antibody (upper blots) or an eEF2 antibody that detects endogenous levels of eEF2 independently of phosphorylation (lower blots). Data are representative of four independent experiments.</p