Perioperative Care and the Importance of Continuous Quality Improvement—A Controlled Intervention Study in Three Tanzanian Hospitals

Introduction Surgical services are increasingly seen to reduce death and disability in Sub-Saharan Africa, where hospital-based mortality remains alarmingly high. This study explores two implementation approaches to improve the quality of perioperative care in a Tanzanian hospital. Effects were compared to a control group of two other hospitals in the region without intervention. Methods All hospitals conducted quality assessments with a Hospital Performance Assessment Tool. Changes in immediate outcome indicators after one and two years were compared to final outcome indicators such as Anaesthetic Complication Rate and Surgical Case Fatality Rate. Results Immediate outcome indicators for Preoperative Care in the intervention hospital improved (52.5% in 2009; 84.2% in 2011, p<0.001). Postoperative Inpatient Care initially improved to then decline again (63.3% in 2009; 70% in 2010; 58.6% in 2011). In the control group, preoperative care declined from 50.8% (2009) to 32.8% (2011, p <0.001), while postoperative care did not significantly change. Anaesthetic Complication Rate in the intervention hospital declined (1.89% before intervention; 0.96% after intervention, p = 0.006). Surgical Case Fatality Rate in the intervention hospital declined from 5.67% before intervention to 2.93% after intervention (p<0.0010). Surgical Case Fatality Rate in the control group was 4% before intervention and 3.8% after intervention (p = 0.411). Anaesthetic Complication Rate in the control group was not available. Discussion Immediate outcome indicators initially improved, while at the same time final outcome declined (Surgical Case Fatality, Anaesthetic Complication Rate). Compared to the control group, final outcome improved more in the intervention hospital, although the effect was not significant over the whole study period. Documentation of final outcome indicators seemed inconsistent. Immediate outcome indicators seem more helpful to steer the Continuous Quality Improvement program. Conclusion Specific interventions as part of Continuous Quality Improvement might lead to sustainable improvement of the quality of care, if embedded in a multi-faceted approach

Sodium Thiosulfate Reduces Acute Kidney Injury in Patients Undergoing Cytoreductive Surgery Plus Hyperthermic Intraperitoneal Chemotherapy with Cisplatin: A Single-Center Observational Study

Background: Cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) represents a multimodal treatment concept for patients with peritoneal surface malignancies. The use of intraperitoneal cisplatin (CDDP) is associated with a risk of acute kidney injury (AKI). The aim of this study is to evaluate the protective effect of perioperative sodium thiosulfate (STS) administration on kidney function in patients undergoing CRS and CDDP-based HIPEC. Patients and Methods: We retrospectively analyzed clinical data of all patients who underwent CRS and CDDP-based HIPEC at our hospital between March 2017 and August 2020. Patients were stratified according to the use of sodium thiosulfate (STS vs. no STS). We compared kidney function and clinical outcome parameters between both groups and determined risk factors for postoperative AKI on univariate and multivariate analysis. AKI was classified according to acute kidney injury network (AKIN) criteria. Results: Of 238 patients who underwent CRS and CDDP-based HIPEC, 46 patients received STS and 192 patients did not. There were no significant differences in baseline characteristics. In patients who received STS, a lower incidence (6.5% vs. 30.7%; p = 0.001) and severity of AKI (p = 0.009) were observed. On multivariate analysis, the use of STS (OR 0.089, p = 0.001) remained an independent kidney-protective factor, while arterial hypertension (OR 5.283, p < 0.001) and elevated preoperative urea serum level (OR 5.278, p = 0.032) were predictors for postoperative AKI. Conclusions: The present data suggest that STS protects patients from AKI caused by CRS and CDDP-based HIPEC. Further prospective studies are needed to validate the benefit of STS among kidney-protective strategies

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

eine kontrollierte Interventionsstudie in drei tansanischen Krankenhäusern

Introduction: Some essential surgical services have been shown to reduce death and disability in Sub-Saharan Africa. However, in-patient mortality in Sub- Saharan hospitals is disturbingly high. The present study evaluates two interventions and their implementation approaches targeting the quality of perioperative services in a Tanzanian public hospital. Results were assessed in comparison to a) a control group of two other public hospitals in the same region without quality improvement program, and b) final patient outcome indicators. Methods: All hospitals annually assessed quality of services with the Hospital Performance Assessment Tool (HPAT). In pre- and postoperative care respectively, immediate outcome indicators (HPAT results) were compared to final outcome indicators (Anaesthetic Complication Rate, Surgical Case Fatality Rate), and to the control group before and after intervention. Results: Immediate outcome indicators for Preoperative Care in the intervention hospital improved from 52.5% in 2009 to 84.2% in 2011 (p<0.001). Postoperative Inpatient Care was 63.3% in 2009, 70% in 2010 and 58.6% in 2011. In the control group, preoperative started at 50.8% (2009) and declined to 32.8% (2011, p <0.001). Postoperative inpatient Care did not significantly change. Anaesthetic Complication Rate in the intervention hospital declined (1.89% before intervention; 0.96% after intervention, p = 0.006). Surgical Case Fatality Rate in the intervention hospital was 5.67% before intervention and 2.93% after intervention (p<0.001), compared 4% before intervention and 3.8% after intervention (p = 0.411) in the control group. There was no Anaesthetic Complication Rate available in the control group. Compared to the control group, final outcome improved more in the intervention hospital, although the effect was not significant over the whole study period. Discussion: Changes in immediate outcome for Preoperative Care seemed more sustainable, possibly due to the fact that the introduction of a checklist combined several aspects of a potentially successful quality improvement intervention, amongst others availability at the point of care and a documented target standard. Documentation of final outcome indicators seemed inconsistent. Immediate outcome indicators appear more useful to direct the Continuous Quality Improvement approach in the intervention hospital. Conclusion: Specific targeted interventions in a Continuous Quality Improvement program have the potential to lead to sustainable improvement of the quality of perioperative services, if implemented in a multi-faceted approach.Einführung: Chirurgische Basis- und Notfallversorgung kann nachweislich Invaliditäts- und Letalitätsraten in Subsahara-Afrika senken. In strukturschwachen Ländern ist jedoch die Mortalität von stationär aufgenommenen Patienten alarmierend hoch. Die vorliegende Studie untersuchte zwei Interventionen im Rahmen eines kontinuierlichen Qualitätsverbesserungsprogrammes zur Verbesserung der perioperativen Versorgungsqualität in der chirurgischen Abteilung eines tansanischen Krankenhauses der Regelversorgung. Die Resultate wurden verglichen mit a) der Versorgungsqualität in den chirurgischen Abteilungen zweier anderer Krankenhäuser, die im Studienzeitraum kein Qualitätsmanagement-Programm durchführten, und b) mit langfristigen Ergebnisindikatoren. Methoden: Alle Krankenhäuser benutzten ein Qualitätssicherungsinstrument zur jährlichen Überprüfung der Versorgungsqualität (Hospital Performance Assessment Tool). Veränderungen der unmittelbaren Ergebnisindikatoren für die prä- und postoperative Versorgung nach den jeweiligen Interventionen wurden mit langfristigen Ergebnisindikatoren verglichen (Komplikationsrate der Anästhesie, Gesamtletalität in der Gruppe der chirurgischen Patienten). Die Implementationsstrategie in der präoperativen Versorgung beinhaltete die Einführung einer Checkliste, die Implementationsstrategie in der postoperativen Versorgung war die Erweiterung eines vorbestehendes Weiterbildungsprogramm um als Schwachstellen erkannte Themengebiete. Ergebnisse: Die unmittelbaren Ergebnisindikatoren für die präoperative Versorgung im Interventionskrankenhaus verbesserten sich über den Studienzeitraum (2009 52,5%; 2011 84,2%, p<0,001). Die postoperative Versorgung verbesserte sich im ersten Jahr, um dann wieder abzufallen (2009 63,3%; 2010 70%; 2011 58,6%). In der Kontrollgruppe verschlechterte sich die präoperative Versorgung (2009 50,8%; 2011 32,8%, p<0,001), während die postoperative Versorgung keine signifikanten Veränderungen zeigte. Die Komplikationsrate der Anästhesie im Interventionskrankenhaus sank über den Studienzeitraum (1,89% vor Intervention; 0,96% nach Intervention, p=0,006). Die Letalität der chirurgischen Patienten im Interventionskrankenhaus fiel von 5,67% vor Intervention auf 2,93% nach Intervention (p<0,001). Die Letalität der chirurgischen Patienten in der Kontrollgruppe war 4% vor Intervention und 3,8% nach Intervention (p = 0,411). Die Komplikationsrate der Anästhesie war in der Kontrollgruppe nicht verfügbar. Die langfristigen Ergebnisindikatoren verbesserten sich im Interventionskrankenhaus mehr als in der Kontrollgruppe, dieser Effekt war jedoch nicht signifikant. Diskussion: Die Einführung einer Checkliste in der präoperativen Versorgung erschien in dieser Studie nachhaltiger, verglichen mit der Intervention in der postoperativen Versorgung. Der Grund hierfür ist möglicherweise eine Kombination mehrerer Aspekte, die die langfristige Qualitätsverbesserung begünstigen, hierunter eine unmittelbare Verfügbarkeit der Checkliste und ein direkt möglicher Abgleich mit dem geforderten Standard, sowie die Möglichkeit von Supervision und Unterricht am Krankenbett. Die Dokumentation der langfristigen Ergebnisindikatoren stellte sich insgesamt lückenhaft dar. Unmittelbare Ergebnisindikatoren erschienen besser geeignet zur Steuerung eines kontinuierlichen Qualitätsverbesserungsprogramms. Schlussfolgerung: Zielgerichtete Interventionen können in der perioperativen Versorgung zu nachhaltiger Qualitätsverbesserung führen, wenn sie im Rahmen eines kontinuierlichen Qualitätsverbesserungsprogrammes einem multimodalen Ansatz folgen

Correction: Perioperative Care and the Importance of Continuous Quality Improvement-A Controlled Intervention Study in Three Tanzanian Hospitals.

[This corrects the article DOI: 10.1371/journal.pone.0136156.]

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 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 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

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