Systems-based Quality Improvement as a Tool to Implement the Surgical Safety Checklist in Rwanda

Objective: Effective strategies for implementation of the World Health Organization's Surgical Safety Checklist (SSCL) are not well characterized in resource-limited settings. Our objective was to utilize a systems-based quality improvement (QI) approach to initially implement a single; high-priority item from the SSCL. Setting: Butaro Hospital; a rural district hospital in northern Rwanda. Methods: A surgical service QI team was formed and trained with support of local leadership and expatriate staff trained in QI methodology. The team identified perioperative antibiotic administration as the first SSCL area for improvement. Baseline performance was measured by sampled chart review of Cesarean sections. Using systems-based QI methods and the Model for Improvement; a protocol for choice and timing of perioperative antibiotics was identified as the necessary intervention; developed; and then implemented. The impact on performance and spread of QI was measured. Results: At baseline; only 5.2 of Cesarean section patients received both correct choice and timing of a prophylactic antibiotic agent. After development of the protocol; appropriate choice and timing of antibiotic was observed in 61.7 of cases (p 0.001). This initial QI initiative stimulated additional projects to implement other components of the SSCL and to improve quality of surgical and anesthetic care. Conclusions: Implementing one component of the SSCL using QI methodology focused on stakeholder engagement; measurement; and team-based development of iterative systems of improvements facilitated a cultural change at Butaro Hospital. Training and support in QI methods can create an environment in which the SSCL and other efforts for quality in surgical and anesthetic care can be more readily implemented

The AP-2 complex is excluded from the dynamic population of plasma membrane-associated clathrin.

Numerous biologically relevant substrates are selectively internalized via clathrin-mediated endocytosis. At the plasma membrane the AP-2 complex plays a major role in clathrin coat formation, interacting with both cargo and clathrin. Utilizing simultaneous dual-channel total internal reflection fluorescence microscopy we have analyzed components of the AP-2 complex (alpha- and beta 2-adaptin) during clathrin-mediated endocytosis. Although in static images enhanced green fluorescent protein-tagged AP-2 markers significantly co-localized with clathrin and other components of clathrin-coated pits, AP-2 did not seem to be present in clathrin spots that appeared to undergo internalization or motility parallel to the plane of the plasma membrane. Two populations of clathrin at the plasma membrane seem to exist, the dynamic and the static, and AP-2 appears to be only found within the latter. These results suggest that colocalized clathrin/AP-2 puncta may represent loci for coated pit production and that previous models that assumed AP-2 was retained within clathrin coats during endocytosis may need to be re-evaluated.

Movement of plasma-membrane-associated clathrin spots along the microtubule cytoskeleton.

The current understanding of the role of plasma- membrane-associated clathrin suggests that clathrin-coated pits form at the sites of activated receptors and then, following internalization, the clathrin coat is rapidly shed. Utilizing total internal reflection fluorescence microscopy (TIR-FM), we have documented linear lateral motion of cell-surface-associated dsRed-clathrin spots parallel to the plasma membrane. Clathrin spot motility was observed in multiple cell lines (MDCK, CHO, Cos-7 and HeLa). In MDCK cells dsRed-clathrin spots moved along linear pathways up to 4 micro m in length with rates of approximately 0.8 micro m/s. Spots did not generally undergo internalization during movement. The motion of these puncta was coincident with the microtubule cytoskeleton, and depolymerization of microtubules reduced spot motility over 10-fold. Over-expression of the microtubule-associated protein tau-EGFP decreased spot run length by 40% without affecting the rate of movement. Thus dsRed-clathrin puncta move along the microtubule cytoskeleton parallel to the cell surface.