RESUMO
BACKGROUND: An estimated 5 billion people worldwide lack access to timely safe surgical care (Gawande in Lancet 386(9993):523-525, 2015). A mere 6% of all surgical procedures occur in the poorest countries where over a third of the world's population lives (Meara et al. in Surgery 158(1):3-6, 2015). Mobile surgical units like the Cinterandes Foundation endeavor to bring surgical care directly to these communities who otherwise would lack access to safe surgery. This study examines the barriers patients encounter in seeking surgical care in rural communities of Ecuador and their impressions on how mobile surgery addresses such barriers. METHODS: Open interviews were conducted with Cinterandes' patients who had undergone an operation in the mobile surgical unit between 06/25/2013 and 06/25/2014 (n = 101). Interviews were structured to explore two main domains: (1) examining barriers patients have in accessing surgery, (2) assessing patients' opinion of how mobile surgery helped in overcoming such barriers. RESULTS: Patient inconvenience (70%), cost (21%), and lack of trust in local hospitals (24%) were the main cited barriers to surgical access. Increased patient convenience (53%), cheaper surgical care (34%), and trust in Cinterandes (47%) were the main cited benefits to mobile surgery. CONCLUSION: Mobile surgery provided by Cinterandes effectively overcomes many barriers patients encounter when seeking surgical care in rural Ecuador: decreased patient wait times, limited number of referrals to multiple locations, and decreased cost. Partnering with local clinics within the communities and bringing care much closer to patients' homes may provide a better patient friendly health care delivery system for rural Ecuador.
Assuntos
Acessibilidade aos Serviços de Saúde , Unidades Móveis de Saúde , Serviços de Saúde Rural , Procedimentos Cirúrgicos Operatórios , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Equador , Honorários e Preços , Humanos , Lactente , Entrevistas como Assunto , Pessoa de Meia-Idade , Unidades Móveis de Saúde/economia , Aceitação pelo Paciente de Cuidados de Saúde , Procedimentos Cirúrgicos Operatórios/economia , Confiança , Adulto JovemRESUMO
INTRODUCTION: Trauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs. METHODS: We conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru. RESULTS: 336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent - 45% occurred less than every three months and poorly attended - 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation - notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16-10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73-19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59-14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice. CONCLUSIONS: M&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care.
Assuntos
Melhoria de Qualidade/organização & administração , Centros de Traumatologia/organização & administração , Centros de Traumatologia/normas , Bolívia/epidemiologia , Colômbia/epidemiologia , Análise Custo-Benefício , Estudos Transversais , Equador/epidemiologia , Humanos , Peru/epidemiologia , Avaliação de Processos em Cuidados de Saúde , Desenvolvimento de Programas , Ferimentos e Lesões/terapiaRESUMO
According to facts given by the World Health Organization, one in ten deaths worldwide is due to an external cause of injury. In the field of pre-hospital trauma care, adequate and timely treatment in the golden period can impact the survival of a patient. The aim of this paper is to show the design of a complete ecosystem proposed to support the evaluation and treatment of trauma victims, using standard tools and vocabulary such as OpenEHR, as well as mobile systems and expert systems to support decision-making. Preliminary results of the developed applications are presented, as well as trauma-related data from the city of Cuenca, Ecuador.
Assuntos
Sistemas de Apoio a Decisões Clínicas/organização & administração , Registros Eletrônicos de Saúde/organização & administração , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Aplicativos Móveis , Ferimentos e Lesões/terapia , Equador , Sistemas Inteligentes , Sistemas de Informação/organização & administração , Aprendizado de Máquina , Vocabulário Controlado , Ferimentos e Lesões/diagnósticoRESUMO
BACKGROUND: The advanced trauma life support course is not available or affordable to rural areas in low-income countries. A trauma continuing education course was created to educate physicians of rural hospitals in the jungles of Ecuador. METHODS: A basic trauma care course was designed based on local resources and location of injury, including rudimentary health posts in the jungle, rural hospitals, and definitive referral centers. Course effectiveness was evaluated by a comparison of test scores before and after the course. A multiple choice questionnaire was given. Comparison to previous test scores was also performed. Paired Student's t test was used for statistical analysis. An objective structured clinical examination (OSCE), based on the course design, was administered. RESULTS: Twenty-six rural physicians participated in the course. Mean test scores significantly improved from pretest to post-test (72% to 79%; p = 0.032). Knowledge deficiencies in prehospital care, extremity injury care, and patient evaluation adjuncts significantly improved from 23% to 87%, 23% to 100%, and 31% to 100%, respectively. Test results after the course showed improvements in all major categories tested. Twelve of the 26 participants were repeat test takers from a course provided 2 years earlier. These participants showed improved pretest scores compared with their highest previous test score (76.8% versus 68.5%; p = 0.0496). Compared with first-time test takers, these participants showed improved pretest (76.8% versus 68.4%) as well as post-test (81% versus 76%) scores. Twenty-five of the 26 physicians participated in the OSCE, with a pass rate of 76%. The OSCE identified various strengths and deficiencies based on patient location and available resources. In rudimentary health posts, management was adequate for hemorrhage control (65%), immobilization (77%), and early transfer to rural hospitals (92%). Prehospital communication was inadequate (53%). Rural hospital management was adequate for primary evaluation (60%) and resuscitation (74%) but poor in secondary patient evaluation (53%), adjuncts (25%), and transfer to definitive referral centers (11%). OSCE scores differed from multiple choice questionnaire test results. DISCUSSION: Where there is no advanced trauma life support, a tailored trauma course and evaluation can be effective in educating local providers. A well-designed competency evaluation (multiple choice questionnaire and OSCE) is helpful in identifying deficient local aspects of trauma care. The course design and evaluation methods may serve as a model for continuing trauma care education in developing countries.
Assuntos
Educação Médica Continuada , Serviços de Saúde Rural , Traumatologia/educação , Equador , Hospitais Rurais , Humanos , Cuidados para Prolongar a VidaRESUMO
Whenever we perform surgical procedures in modern operating rooms with state of the art technology, or attend patients in the comfort of our office, we should reflect on the fact that millions of people have no access to the most elemental surgical care. At the same time that mankind progresses, the gap between those who can benefit from the advances of science and the underprivileged societies, widens every day. We believe that surgeons have the obligation to strive for excellence in their practice; however, the benefits of their art and science should also extend those unfortunate populations in distant and remote areas. Therefore, efforts to develop means of reaching out to such countries and communities should also be the responsibility of conscientious physicians.