Standardization of Trauma, General Surgical Morbidity and Mortality Conferences: Development and Dissemination of a "Toolkit" in Peru.

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.

Does Access to Point-of-Care Medical Information Improve Trauma and General Surgeons' Clinical Knowledge in a Middle-Income Country? A Mixed-Methods Study with Random Assignment.

BACKGROUND: Investing in continued medical education strengthens surgical systems. This study assessed the effectiveness of an evidence-based practice (EBP) tutorial and access to UpToDate (UTD) to improve EBP and understand how and why providers practice using evidence. STUDY DESIGN: This is a mixed-methods, implementation study at 9 public hospitals in Peru consisting of a didactic session for surgeons on EBP and Google Translate and support of applications for UTD access. Change in clinical knowledge scores (CKS), access and use of UTD, and impact of language pre-and postintervention were measured. Qualitative interviews uncovered reasons for these changes. RESULTS: Intervention participants had lower CKS at follow-up compared with baseline (odds ratio [OR] of higher score 0.41 [0.18,0.98]; p = 0.044), and this effect was modified (p = 0.003) to the extent that the reverse was true for control participants (OR 2.30 [1.13,4.71]; p = 0.022). Participants with 1 to 20 years of experience had significantly improved CKS compared with students/residents (1 to 10 years: OR 4.5 [1.1,18]; 11 to 20 years: OR 4.9 [1.4,17]); there was no evidence of a different CKS between providers with >20 years of experience compared with students/residents (OR 1.3 [0.5,3.7]). Administrative disconnect, usability, motivation, education, time, resources, and age influenced point-of-care medical information systems impact on knowledge and EBP. Participants reporting low English proficiency translated medical literature mostly used Google Translate. Those with low/no English reading proficiency had higher odds of reporting a negative impact on research than those with working (p = 0.007) or professional (p < 0.001) proficiency. CONCLUSIONS: Providing education on EBP, free UTD access, and translation solutions did not correlate with increased CKS due to complex barriers to using point-of-care medical information systems.