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Skip to search form Skip to main content. OBJECTIVE To identify affordable, sustainable methods to strengthen trauma care capabilities in Mexico, using the standards in the Guidelines for Essential Trauma Care, a publication that was developed by the World Health Organization and the International Society of Surgery to provide recommendations on elements of trauma care that should be in place in the various levels of health facilities in all countries. View PDF. Save to Library.

Create Alert. Share This Paper. Topics from this paper. Resuscitation procedure Needs Assessment Large. Citations Publications citing this paper. Lipsitz , Atul Gawande. Surgical and trauma care in low- and middle-income countries: a review of capacity assessments. Kevin J. Trauma care and referral patterns in Rwanda: implications for trauma system development.

EBSCOhost | | Guidelines for Essential Trauma Care: Progress in India.

Georges Ntakiyiruta , Evan G. Emergency department quality and safety indicators in resource-limited settings: an environmental survey Emily L Aaronson , Regan H. Marsh , Moytrayee Guha , Jeremiah D. Schuur , Shada A Rouhani. Assessing and monitoring the quality of care in trauma patient through quality indicators would allow identifying opportunities for improvement whose implementation would improve outcomes in hospital mortality, functional outcomes and quality of life of survivors.

Many quality indicators have been used in this condition, although very few ones have a solid level of scientific evidence to recommend their routine use. The information contained in the trauma registries, spread around the world in recent decades, is essential to know the current health care reality, identify opportunities for improvement and contribute to the clinical and epidemiological research.. Traumatisms are the leading cause of death in individuals under 45 years of age in most countries, and constitute an important cause of disability, suffering and healthcare resource consumption.

Only by knowing what is done and the results obtained can measures for improvement be adopted. Effective monitoring of the quality of the services provided is essential for maintaining and improving such services.

This implies the definition of objectives, the monitoring of results with comparisons versus the established standards, evaluation and interpretation of the results obtained, identification of areas that require improvement, and the implementation of corrective actions which in turn can be re-evaluated, thereby completing the continuous quality improvement cycle..

Severe trauma disease is a genuine challenge for the healthcare system, since it constitutes a major public health problem. According to the definition of the International Organization for Standardization, quality is the degree to which the characteristics of a product or service satisfy the purpose for which it was created.

According to the World Health Organization WHO , quality care is defined as the adequate implementation according to the existing standards of interventions confirmed to be safe, that are economically accessible to the society concerned, and are able to cause an impact upon the mortality, morbidity or disability rates.. Because of its important incidence, associated mortality and sequelae, severe trauma disease requires adequate monitoring of the quality of the provided healthcare with a view to detecting areas amenable to improvement that can contribute to secure better results and outcomes..

Improvement of the quality of emergency care is a generic objective common to all healthcare systems, particularly when the disease in question has a high incidence. It is important to evaluate quality in order to establish strategies for improvement..

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According to the model developed by Donabedian, 9 evaluation of the quality of care has three methodological components or dimensions: evaluation of the structure, evaluation of the care process, and evaluation of the results. Evaluation of the structure is probably the simplest and most objective of all three methods. The structure comprises the minimum characteristics needed to ensure good quality care, though the presence of such characteristics does not actually guarantee quality.

In turn, evaluation of the care process, of how care is provided, is currently the most widely used method. It is more complex than the evaluation of structure but is easier to measure than the quality of the results, and what we obtain is an indirect measure of such quality. Lastly, evaluation of the results appears to be the ideal method for measuring healthcare and, although it is highly complex, 10 it is particularly important in disorders characterized by high incidence and severity, such as trauma disease..

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Two methods traditionally have been used to assess the care process: medical auditing and monitoring.. Medical auditing is the critical and systematic analysis of the quality of medical care, evaluating healthcare practice on a retrospective basis and by the professionals in charge of providing such care. In , a Cochrane review found no study of sufficient scientific quality to clarify whether auditing in trauma is effective in improving the care of serious trauma patients, or whether it contributes to reduce mortality. Monitoring in turn is a continuous and planned quality measurement system that makes use of instruments called indicators, for which concrete optimum levels are established.

An indicator is a quantifiable and objective parameter that specifies those healthcare activities and results or outcomes whose quality we seek to evaluate. Indicators allow us to detect situations that are problematic or amenable to improvement, and they inform of whether improvements occur and whether such improvements are maintained over time. Monitoring has two components: 1 identification, selection and construction of the indicators; and 2 definition of the monitoring plan including at least the periodicity with which the indicator is documented, the mechanisms for data collection, and the methods used for interpreting them.

An indicator is not a phrase but requires a precise definition of all its terms. The construction of indicators is no simple process and must have a number of sections and a definition: denomination of the indicator, dimension, justification, formula, explanation of the terms, type of indicator, indicator target population, data sources and available standards. In order to improve patient care and save lives, we need indicators that are accessible, reliable and valid; that can be used to establish reference points for the quality of care; detect success and possible problems; and which follow the trends over time in order to identify imbalances requiring intervention measures.

Hussey et al. Quality indicators can be classified according to the type of information they afford indicators based on sentinel events, based on indexes, and tracer indicators or the care phase to which they are referred structure, process and outcome indicators Table In the critical care setting, strategies have been proposed in recent years to improve healthcare by incorporating the use of quality indicators as measurement instruments. In the s, the American College of Surgeons ACS proposed quality indicators for the care of severe trauma patients, and this initiative was followed by the publication of a number of revisions.

In this regard, Azaldegui-Berroeta et al. The key indicators referred to critical patient care were contemplated, including those referred to trauma patient care Table Many quality indicators are used in trauma patient care, and some of them are reflected in Tables 2—4. A review published by Stelfox et al. The most common measures were those of pre-hospital and in-hospital processes Structure, process and outcome indicators according to moment of care..

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Dimensions of healthcare evaluated with quality indicators.. CT: computed tomography; ICU: intensive care unit.. Adapted from Santana and Stelfox, In another recent study, 21 an expert committee reviewed the existing literature on quality indicators in trauma care, with the initial consensus-based identification of 84 indicators that were sent to certified trauma care centers in the United States, Canada, Australia and New Zealand for due evaluation to determine whether they afforded important improvements in health, were easy to use and interpret, and globally constituted good indicators.

A total of 31 indicators were finally established that exhibited validity of content and could be used as guides in practices for the improvement of the quality of trauma patient care 21 Table The quality of severe trauma patient management must be measured, but the potential series of indicators used poses a number of problems, such as the scant scientific evidence warranting many of them; specific development on the part of each institution, thus making generalization difficult; and the use of very basic and sometimes limited variables.

Such limited evidence of the quality indicators indicates that there is room for improving and standardizing them and for measuring and managing the quality of trauma patient care. Standardized indicators are necessary in order to establish comparisons among different centers. In addition to hospital survival, we must seek performance indicators that include survival quality after the acute hospital episode and the need for patient rehabilitation and care over the long term. Most of the quality indicators used in the care of trauma patients have scant scientific support.

In contrast, many of the clinical care parameters in trauma cases lack evidence of sufficient robustness to allow them to be used for the development of quality indicators, including for example the time to craniotomy in severe brain injuries, and therefore should be discarded at least until a more solid body of supporting evidence becomes available.. Quality improvement is the commitment and the method used for the continuous improvement of any organization process, with the purpose of reaching and surpassing the patient needs and expectations.

Continuous quality improvement is focused on the patient and forms part of the quality cycle, which starts with the detection of opportunities for improvement. Among these opportunities, priority attention should center on those that afford more efficient results, performing an analysis of their underlying causes, defining criteria, designing evaluating studies, performing an analysis of the actions for improvement, and implementing such actions. Lastly, a re-evaluation should be made and used to again define priority targets for improvement..

The comparison of outcomes with respect to other healthcare systems is able to detect differences which can lead to internal assessments that identify deficiencies in routine practices, and which can be improved upon in order to secure better outcomes. Such comparisons traditionally have been made by contrasting mortality figures.

Although mortality is a robust outcome, raw mortality data are not a good indicator for comparisons among centers. Death can occur in different moments of the care process pre-hospital, during transfer between centers, or following acute hospitalization. Consequently, in-hospital mortality is only a part of the picture. In this regard, different scores can be used to quantify the severity of trauma. Data collection therefore needs to be standardized in order to contrast groups of homogeneous patients.


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Despite arguments that place greater priority on functional and quality of life outcomes than on patient mortality, many trauma registries TRs still do not routinely collect such information. The comparison of trauma center performance outcomes includes short-term morbidity, as well as complications and functional condition at the time of discharge. Function at discharge varies according to the instrument used to measure it and the moment in which such measurement is made.

Those studies that use patient functionality at discharge to evaluate the quality of care must be interpreted with caution, due to broad variability referred to practices at discharge, the availability of rehabilitation beds, and the volume of patients. The evaluation of functional and health-related quality of life outcomes must be made at standardized timepoints after trauma, not at hospital discharge or discharge from rehabilitation, since these times of stay can vary considerably among patients 26 and institutions..

The validity of the functional capacity index—the only specific functionality measure developed for a general trauma context—in predicting long-term outcomes has been questioned.


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  5. Its use is therefore not recommended. The recommendation in trauma patients is to use general health condition or health-related quality of life measures such as the SF and SF, the EQ-5D, the Quality of Wellbeing Scale, etc. Such measures allow the comparison of these patients with other disease groups and with the general population. These measures have been found to be reliable, relatively inexpensive and useful if investment is made to integrate the quality of life and functional outcome measurement systems with the trauma care system.

    The use of quality indicators based on long-term outcomes is essential and should set the trend. The patient clinical and functional conditions at discharge are usually not definitive: the available data indicate that a clinically stable condition is not reached in patients of this kind until one year has gone by.

    Mortality one year after trauma is more significant.