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BACKGROUND: Morbidity and Mortality (M&M) conferences allow clinicians to review adverse events and identify areas for improvement. There are few reports of structured M&M conferences in low- and middle-income countries and no report of collaborative efforts to standardize them. METHODS: The present study aims to gather general surgeons representing most of Peru's urban surgical care and, in collaboration, with trauma quality improvement experts develop a M&M conferences toolkit with the expectation that its diffusion impacts their reported clinical practice. Fourteen general surgeons developed a toolkit as part of a working group under the auspices of the Peruvian General Surgery Society. After three years, we conducted an anonymous written questionnaire to follow-up previous observations of quality improvement practices. RESULTS: A four-component toolkit was developed: Toolkit component #1: Conference logistics and case selection; Toolkit component #2: Documenting form; Toolkit component #3: Presentation template; and Toolkit component #4: Code of conduct. The toolkit was disseminated to 10 hospitals in 2016. Its effectiveness was evaluated by comparing the results of surveys on quality improvement practices conducted in 2016, before toolkit dissemination (101 respondents) and 2019 (105 respondents). Lower attendance was reported by surgeons in 2019. However, in 2019, participants more frequently described "improve the system" as the perceived objective of M&M conferences (70.5% vs. 38.6% in 2016; p < 0.001). CONCLUSION: We established a toolkit for the national dissemination of a standardized M&M conference. Three years following the initial assessment in Peru, we found similar practice patterns except for increased reporting of "system improvement" as the goal of M&M conferences.
Subject(s)
Humans , PeruABSTRACT
BACKGROUND: We present outcomes of patients with SARS-CoV-2 undergoing appendectomy in order to aid in clarification of current controversies regarding safety of therapeutic options for emergency surgical diseases in patients with SARS-CoV-2. Peru has the greatest number of per capita deaths due to SARS-CoV-2 of any country and is one of few with a COVID-dedicated hospital. MATERIALS AND METHODS: This prospective observational study included all adult patients with acute appendicitis admitted to an urban, public, COVID-dedicated hospital over two months. Baseline characteristics and post-operative outcomes at 28 days are reported. RESULTS: 58 patients, 35 male and 23 female, ages 15-73 years with SARS-CoV-2 as diagnosed by IgM (12%), IgG (19%) or both (69%) and acute appendicitis as diagnosed using the Alvarado Score and confirmed intraoperatively were enrolled. All patients presented with right lower quadrant pain, 86% with leukocytosis, 88% with nausea/emesis and no patients with respiratory complaints. All patients underwent open appendectomy, 90% under regional anesthesia. Average operative time was 54±25 min, length of stay 2.5±1.5 days. 14% of patients had a post-operative complication, all were minor, four (7%) incisional surgical site infections, one (2%) organ space, and three (5%) incisional seromas, no deaths or serious complications. CONCLUSION: Open surgical management of acute appendicitis with regional anesthesia in adults with pre-operative diagnosis of SARS-CoV-2 is feasible and not associated with an increased frequency or severity of post-operative complications, longer operative time, or extended hospitalization as compared to reports in similar patients without SARS-CoV-2.
ABSTRACT
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.
Subject(s)
Quality Improvement/organization & administration , Trauma Centers/organization & administration , Trauma Centers/standards , Bolivia/epidemiology , Colombia/epidemiology , Cost-Benefit Analysis , Cross-Sectional Studies , Ecuador/epidemiology , Humans , Peru/epidemiology , Process Assessment, Health Care , Program Development , Wounds and Injuries/therapyABSTRACT
Importance: The globalization of medical education-the process by which trainees in any region gain access to international training (electronic or in-person)-is a growing trend. More data are needed to inform next steps in the responsible stewardship of this process, from the perspective of trainees and institutions at all income levels, and for use by national and international policymakers. Objective: To describe the impact of the globalization of medical education on surgical care in Peru from the perspective of Peruvian surgeons who received international training. Design, Setting, and Participants: Observational study of qualitative interviews conducted from September 2015 to January 2016 using grounded theory qualitative research methods. The study was conducted at 10 large public institutions that provide most of the trauma care in Lima, Peru, and included urban resident and faculty surgery and trauma care physicians. Exposures: Access to international surgical rotations and medical information. Main Outcomes and Measures: Outcome measures defining the impact of globalization on surgical care were developed as part of simultaneous data collection and analysis during qualitative research as part of a larger project on trauma quality improvement practices in Peru. Results: Fifty qualitative interviews of surgeons and emergency medicine physicians were conducted at 10 hospitals, including multiple from the public and social security systems. A median of 4 interviews were conducted at each hospital, and fewer than 3 interviews were conducted at only 1 hospital. From the broader theme of globalization emerged subthemes of an eroded sense of agency and a perception of inadequate training on the adaptation of international standards as negative effects of globalization on surgical care in Peru. Access to research funds, provision of incentives for acquisition of advanced clinical training, increased expectations for patient outcomes, and education in quality improvement skills are ways in which globalization positively affected surgeons and their patients in Peru. Conclusions and Relevance: Short-term overseas training of surgeons from low- and middle-income countries may improve care in the surgeons' country of origin through the acquisition of skills and altered expectations for excellence. Prioritization of evidence-based medical education is necessary given widespread internet access and thus clinician exposure to variable quality medical information. Finally, the establishment of centers of excellence in low- and middle-income countries may address the eroded sense of agency attributable to globalization and offer a local example of world-class surgical outcomes, diminishing surgeons' most frequently cited reason for emigration: access to better surgical training.
Subject(s)
Attitude of Health Personnel , Developing Countries , Education, Medical , General Surgery/education , Quality of Health Care , Surgeons/psychology , Traumatology , Education, Distance , Faculty, Medical/psychology , General Surgery/standards , Humans , International Educational Exchange , Internationality , Internship and Residency , Interviews as Topic , Perception , Peru , Qualitative ResearchABSTRACT
OBJECTIVE: To identify sociodemographic, clinical, and endoscopic characteristics in patients with inflammatory bowel disease (IBD). MATERIALS AND METHODS: The study period was from January 2004 to December 2014. The final diagnosis was determined by clinical gastroenterologists experienced in the diagnosis and management of IBD, based on internationally accepted diagnostic criteria. RESULTS: 105 patients with IBD were studied, 77% with ulcerative colitis (UC) and 23% with Crohn's disease (CD). The average age of initial diagnosis for UC and CD was 53.02 and 57.7 years, respectively. Regarding the gender distribution, the male:female ratio was 1.3:1 for UC and 2:1 for CD. Predominant clinical manifestations were: diarrhea (76.5%) in CU and lower gastrointestinal bleeding / abdominal pain (66.6% for each symptom) in EC. The predominant form of presentation was moderate for both CU (49.3%) and EC (62.5%). 47% of patients with UC had extensive colitis and 54.2% of patients with CD had Ileocolitis. 6.2% of the UC patients underwent surgery, whereas 50% of the CD patients required it. CONCLUSIONS: There is a tendency to an increased detection of cases of Crohn's disease in our country and in Latin America with respect to previous studies. There is a prevalence of moderate forms of presentation for both UC and CD, and high percentages of surgery in EC is evident.
Subject(s)
Colitis, Ulcerative/diagnosis , Colitis, Ulcerative/epidemiology , Crohn Disease/diagnosis , Crohn Disease/epidemiology , Adolescent , Adult , Aged , Child , Colitis, Ulcerative/therapy , Crohn Disease/therapy , Female , Hospitals, Urban , Humans , Male , Middle Aged , Peru/epidemiology , Retrospective Studies , Risk Factors , Tertiary Care Centers , Young AdultABSTRACT
OBJECTIVE: To determine the microbiological and resistance profiles of community acquired and nosocomial intra abdominal infections (IAIs) at the Surgery Service of Emergency and surgery critical care units from the Hospital Nacional Guillermo Almenara Irigoyen. MATERIAL AND METHODS: From August 1st, 2013 till July 31st, 2014, patients undergoing surgery/interventional drainage for IAIs were included. RESULTS: The suitable cultures for the analysis were 169 (74 bile and 95 no bile cultures; 142 community acquired and 27 nosocomials). The microorganims more frequently isolated were E. coli (63.3%), K. pneumoniae (12%) and Enterococcus spp. (10%). The 43.5% of E. coli and the 21.23% of Klebsiella were ESBL producers. The carbapenems were the most active agents in vitro (100%), while the quinolones showed high resistance (>50%). CONCLUSIONS: E. coli was the most common microorganism in the IAIs. Because of the quinoloneâ™s high âÅin vitroâ resistance, they should not be recommended as initial empirical therapy.
Subject(s)
Anti-Bacterial Agents/pharmacology , Cross Infection/microbiology , Drug Resistance, Bacterial , Gram-Negative Bacterial Infections/microbiology , Gram-Positive Bacterial Infections/microbiology , Intraabdominal Infections/microbiology , Adolescent , Adult , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Combined Modality Therapy , Community-Acquired Infections/diagnosis , Community-Acquired Infections/drug therapy , Community-Acquired Infections/microbiology , Community-Acquired Infections/surgery , Cross Infection/diagnosis , Cross Infection/drug therapy , Cross Infection/surgery , Drainage , Female , Gram-Negative Bacteria/drug effects , Gram-Negative Bacteria/isolation & purification , Gram-Negative Bacterial Infections/diagnosis , Gram-Negative Bacterial Infections/drug therapy , Gram-Negative Bacterial Infections/surgery , Gram-Positive Bacteria/drug effects , Gram-Positive Bacteria/isolation & purification , Gram-Positive Bacterial Infections/diagnosis , Gram-Positive Bacterial Infections/drug therapy , Gram-Positive Bacterial Infections/surgery , Hospitals, Public , Humans , Intraabdominal Infections/diagnosis , Intraabdominal Infections/drug therapy , Intraabdominal Infections/surgery , Male , Microbial Sensitivity Tests , Middle Aged , Peru , Prospective Studies , Young AdultABSTRACT
Determinar el perfil microbiológico y de resistencia de las infecciones intra abdominales (IIA) adquiridas en la comunidad y nosocomiales en el Servicio de Cirugía de Emergencia y Cuidados Críticos Quirúrgicos del Hospital Nacional Guillermo Almenara Irigoyen. Material y métodos: Desde el 1 de agosto del 2013 al 31 de julio del 2014, se incluyeron a los pacientes con drenaje quirúrgico o intervencionista de las IIA. Resultados: Los cultivos aptos para el análisis fueron 169 (74 biliares y 95 no biliares; 142 de la comunidad y 27 nosocomiales). Los gérmenes más frecuentemente aislados fueron E. coli (63,3%), K. pneumoniae (12%) y Enterococcus spp. (10%). El 43,5% de E. coli y el 21,23% de Klebsiella fueron productoras de BLEE. Los carbapenems mostraron el 100% de suceptibilidad in vitro para las IIA mientras que las quinolonas mostraron una alta resistencia bacteriana (> del 50%). Conclusiones: El microorganismo de mayor prevalencia en las IIA fue la E.coli. Dada la alta resistencia in vitro de los microorganismos a las quinolonas, éstas no deberían recomendarse como tratamiento empírico inicial...
To determine the microbiological and resistance profiles of community acquired and nosocomial intra abdominal infections (IAIs) at the Surgery Service of Emergency and surgery critical care units from the Hospital Nacional Guillermo Almenara Irigoyen. Material and methods: From August 1st, 2013 till July 31st, 2014, patients undergoing surgery/interventional drainage for IAIs were included. Results: The suitable cultures for the analysis were 169 (74 bile and 95 no bile cultures; 142 community acquired and 27 nosocomials). The microorganims more frequently isolated were E. coli (63.3%), K. pneumoniae (12%) andEnterococcus spp. (10%). The 43.5% of E. coli and the 21.23% of Klebsiella were ESBL producers. The carbapenems were the most active agents in vitro (100%), while the quinolones showed high resistance (>50%). Conclusions: E. coli was the most common microorganism in the IAIs. Because of the quinoloneÆs high ôin vitroõ resistance, they should not be recommended as initial empirical therapy...
