Using global surgical indicators to improve trauma care in Latin America

Editor’s note: This is the first in a series of articles that the Bulletin will be publishing on The Lancet Commission on Global Surgery’s (LCoGS) efforts to improve access to, and quality of, surgical care starting in Latin America. Additional articles on this topic will be published in future issues of the Bulletin.

Meeting the global demand for surgical services has quickly escalated to become a top priority for both professional and public health organizations.^1,2 During the last few years, attention has focused specifically on the challenges that surgical systems face in addressing the growing global burden of surgical disease. In 2015, LCoGS published a report titled “Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development,” which concluded that “surgery is an indivisible, indispensable part of health care.” Accordingly, the development of integrated health systems capable of providing safe and affordable surgical care would profoundly affect the health and socioeconomic opportunities of much of the world.²

The LCoGS report introduced six core surgical indicators to assess surgical systems, four of which have since been published in the World Bank’s world development indicators (see Table 1).³ In the same year, the World Health Assembly (WHA) passed resolution WHA 68.15, Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage.⁴

Table 1. LCoGS core indicators and associated trauma program/system element

Category	LCoGS indicator	Description	Proposed trauma program/ system element focus
Preparedness	1	The geographic accessibility of surgical facilities	Prehospital system and integration with hospital registry
	2*	The density of specialist surgical providers	Acute care surgeon/fellowships; trauma program manager
Delivery	3*	The number of surgical procedures provided per 100,000 population	Trauma and emergent/essential hospital/societal registries
	4	30-day perioperative mortality rates	Trauma and emergent/essential hospital/societal registries, formal trauma PIPS, and trauma morbidity/mortality review process
Impact	5*	The risk of impoverishing expenditure when surgery is required	Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration
	6*	The risk of catastrophic expenditure when surgery is required	Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration

Now that the provision of global surgical care is a priority for many key stakeholders, the goal is to find an effective strategy for data collection, analysis, and interpretation that will lead to the establishment of regional surgical systems tailored to address the health care priorities of these environments.

The data suggest that trauma is one of the leading causes of preventable death around the world and disproportionately affects low- and middle-income countries (LMICs).⁵ Therefore, trauma program development may play a crucial role in improving health and surgical systems overall. With this in mind, we have started a grassroots approach to integrate LCoGS indicators as part of trauma system development, while fostering collaborations between acute care surgery divisions in high-income countries (HICs) and LMICs to narrow the gaps in education, training, research, and workforce in Latin America.⁶

The effective implementation of the LCoGS indicators measurement, specifically in trauma care settings, can provide consistent mechanisms for collecting these data, while guiding multidisciplinary efforts to improve Latin America’s trauma systems. We suggest that an academic-based model geared toward simultaneous LCoGS indicators measurement and trauma system development can be effective, and this article demonstrates anecdotal support for this model based on our experience in Colombia.^7-9

This article highlights the confluence of trauma system development with LCoGS indicators measurement and suggests enhancing education and research efforts within trauma systems to ensure successful implementation of the recommendations that the LCoGS set forth. These observations serve as a call to action for our partners in both HICs and LMICs in the Americas to accurately evaluate trauma system development as part of a collaborative process that improves the provision of emergent and essential surgical care in LMICs.

Measuring surgical indicators in a trauma system

As global surgery research expands, a fundamental component of the process is the implementation of a consistent set of goals to accurately gauge progress. The LCoGS indicators can serve as a measuring tool to assess key elements of trauma program development. For example, a collaboration between both HIC and LMIC trauma surgeons aimed at regionalizing trauma care in Cali, Colombia, started in 2014. It allowed development of a joint needs assessment for Colombia intended to develop core elements of trauma programs highlighted by the American College of Surgeons Committee on Trauma (ACS COT).¹⁰ (See Table 2) Our initial efforts focused on four of the core elements—prehospital trauma care; trauma education (trauma nurse manager and acute care surgeon training and workforce); trauma registry; and performance improvement and patient safety (PIPS)—and provided an opportunity for exploration into indicators 1, 2, 3, and 4. Because proven metrics that assessed and predicted the needs of designated trauma programs in Colombia had never been developed, we proposed using the LCoGS indicators for trauma program and system development. An acute care surgery team of students, surgical residents, acute care surgery faculty, and nursing leadership from both HICs and LMICs obtained baseline data of LCoGS core surgical indicators 1, 2, 3, and 4 through retrospective review of available hospital data. Using LCoGS indicators, we learned a great deal regarding trauma program evaluation during this pilot project.

Assessment of each of the core trauma program elements mentioned previously revealed notable overlap with surgical systems development and the LCoGS indicators 1, 2, 3, and 4 (see Table 3). Specifically, prehospital trauma care is closely related to the geographic accessibility of surgical facilities (indicator 1) and the golden hour of trauma care.¹¹ The acute care surgery profession and practice in Latin America, along with the development of acute care surgery fellowships, augments surgical workforce density (indicator 2) and promulgates emergent and essential surgery education and training regionally.⁹ Trauma registries provide data regarding number of procedures per 100,000 population (indicator 3) for trauma, and emergent and essential surgeries. Finally, a formal trauma PIPS program and trauma morbidity and mortality (M&M) process provides mortality data in order to generate corrective action plans regarding intraoperative and postoperative mortality rate (indicator 4).

Single-month summer research experiences conducted over a three-month period by medical students during the third year of global surgery program implementation revealed a few key successes. Internationally, measurement of indicator 1—two-hour geographical access to surgical facilities—has proven difficult to assess and is the least reported indicator.^3,12 By focusing on process improvement and data collected from prehospital care, we have identified a new approach to measuring indicator 1, and more importantly, to assess prehospital care quality improvement. The development of standardized service intake forms and enhanced communication between the field, the emergency department, and surgical/trauma personnel—along with the Panamerican Trauma Society trauma registry expansion, which now includes prehospital care—all contribute to the generation of prospective data that can estimate two-hour access while also improving the prehospital care system. A data collection mechanism is proposed among private and public acute care facilities, including the following: The Hospital de Fundación del Valle de Lilli and Hospital de Universidad del Valle in Cali, Colombia; several private and public acute care facilities in Medellin, Colombia; and private, public, or professional emergency medical service (EMS) providers in both cities. The data collection mechanisms in these facilities include the duration of prehospital delay in reaching a hospital, surgical system readiness at the hospital, and the time to definitive surgical care.

Most early LCoGS indicator implementation has occurred in low-income countries with fragmented prehospital care. However, middle-income cities, such as Cali and Medellin, Colombia, which have multisectoral and geopolitical limitations but more mature health systems, have provided some background information in urban prehospital care capacity. Our preliminary findings indicate that insurance contracts between hospitals and EMS often supersede surgical and trauma facility triage. The result often is additional costly time delays due to unnecessary interfacility transfers.

Furthermore, a quality improvement study will make it feasible to transfer data from independent prehospital data systems to trauma hospital registries. This study provides the ability to assess prehospital care as a factor in trauma outcomes and integrates prehospital with hospital data collection in trauma registries, providing an opportunity for individual patient and systems of care evaluation and improvement.

Certain aspects of indicator data collection proved challenging. It was difficult to locate hospital data that were consistently collected and that accurately reflected the LCoGS indicator being measured. For example, indicator 2 (surgical workforce density) was conflated on both ends of the spectrum. We found that surgeons tend to have multiple independent hospital contracts, potentially inflating reported workforce density.  In addition, other credentialed health care professionals are permitted to perform surgical procedures in Colombia as surgeon assistants. As a result, the data is skewed in the opposite direction. Indicator 3 (volume of surgical procedures) was affected by the underrecording of operations that occur outside of the operating theater (for example, procedures that trauma or acute care surgeons perform in the emergency room), amounting to the exclusion of approximately 40 percent of surgical cases at an academic hospital. Furthermore, because only public sector records were readily accessible, operations performed in the private sector were excluded.

It is also important to note that in the U.S., the trauma nurse manager (TNM) plays a key role in trauma programs and systems (see Table 3). Our experience with domestic stakeholders from the nursing profession and the Ministry of Health has shown that TNMs are grossly underrepresented in Colombia. Support of nursing education and training in the region could augment the capacity for a national trauma system while also promoting gender-balanced leadership in the health and surgical care workforce. The Especializacion en Enfermeria en Trauma, Emergencia Quirurgica y Cuidado Critico del Trauma (The Specialization of Trauma, Emergency Surgery, and Surgical Critical Care Nursing) is an initiative in Colombia that seeks to expand the domestic nursing leadership. Although the proliferation of TNMs would not change the value of indicator 2 under its current definition, which focuses on the physician workforce, the development of a regionally appropriate indicator of surgeons, anesthesia providers, obstetricians, and nurses would be affected.

Call to action

Achieving adequate surgical capacity within resource-poor settings is a multidisciplinary challenge. Research efforts have focused on surveying the scope of the issue, and the next step is to explore effective methods to meet these capacity issues. Our early work, and the existing literature on the global burden of surgical disease, prompts a call to action for Latin America with a particular focus on trauma programs and systems development. We assert that a focus on trauma is relevant in light of the strength of regional relationships between the trauma and surgical societies and the extent to which trauma accounts for the burden of surgical disease in the region.^13-16 The development of trauma systems regionally will not only strengthen education, training, and the surgical workforce, but also will improve the global health care community’s ability to collect data on surgical indicators, thereby improving quality, value, and outcomes.

Given some of the challenges to reliable data collection, we recommend the LCoGS core indicators be addressed through a Latin America Surgical and Trauma Indicators Working Group within existing organizations such as the Panamerican Trauma Society. This group would be charged with identifying mechanisms that allow trauma and surgical systems to implement measurement of indicators, and properly assess strengths and weaknesses of regional and national surgical planning efforts.

Ultimately, this call to action will help strengthen comprehensive national surgical plans in countries where surgical and trauma care improvement is interdependent. Given the enormity of the challenge at hand—that is, building and strengthening surgical systems globally—we recognize the need for innovative mechanisms to evaluate, standardize, and improve critical information, such as core surgical indicators, across Latin America. The integration of an enhanced surgical system with trauma system development may be a particularly effective approach.⁷

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References

1. Rose J, Chang DC, Weiser TG, Kassebaum NJ, Bickler SW. The role of surgery in global health: Analysis of United States inpatient procedure frequency by condition using the global burden of disease 2010 framework. PLoS One. 2014;9(2):e89693.
2. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;6736(15):1-56.
3. The World Bank. World development indicators. Available at: data.worldbank.org/data-catalog/world-development-indicators. Accessed February 17, 2017.
4. World Health Organization. Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage Report by the Secretariat. May 16, 2014. Available at: apps.who.int/gb/ebwha/pdf_files/EB135/B135_3-en.pdf. Accessed February 17, 2017.
5. World Health Organization. Department of Violence and Injury Prevention and Disability. Injuries and Violence: The Facts. 2010. Available at: apps.who.int/iris/bitstream/10665/44288/1/9789241599375_eng.pdf. Accessed February 17, 2017.
6. Ng-Kamstra JS, Greenberg SLM, Abdullah F, et al. Global Surgery 2030: A roadmap for high income country actors. BMJ Glob Heal. 2016;1(1):1-12.
7. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M, Tarpley J. Role of collaborative academic partnerships in surgical training, education, and provision. World J Surg. 2010;34(3):459-465.
8. Peck GL, Paula F, Hanna J, et al. Can we augment the U.S. trauma fellow’s operative training? The PTS fellowship: A U.S. surgical critical care fellow’s experience in Colombia. Panam J Trauma, Crit Care Emerg Surg. 2014;3(1):1-7.
9. Blitzer D, Gupta R, Peck G. Extending the acute care surgery paradigm to global surgery. JAMA Surg. 2016;151(6):586-587.
10. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2014.
11. Cowley RA. A total emergency medical system for the State of Maryland. Md State Med J. 1975;24(7):37-45.
12. The Lancet Commission on Global Surgery. Global indicator initiative. Surgical indicators report. December 2015.  Available at: www.lancetglobalsurgery.org/indicators. Accessed February 27, 2017.
13. Peden M, McGee K, Krug E, eds. Injury: A leading cause of the global burden of disease, 2000. World Health Organization. 2002. Available at: www.who.int/violence_injury_prevention/publications/other_injury/injury/en/. February 27, 2017.
14. Pan American Health Organization. Statistics on homicides, suicides, accidents, injuries, and attitudes towards violence. Available at: www1.paho.org/English/AD/DPC/NC/violence-graphs.htm. Accessed March 1, 2017.
15. Krug EG, Dahlberg LL, Mercy JA, et al, eds. World report on violence and health. World Health Organization. 2002. Available at: whqlibdoc.who.int/publications/2002/9241545615_eng.pdf. Accessed March 1, 2017.
16. U.S. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system. Fatal injury data. Available at: www.cdc.gov/injury/wisqars/fatal.html. Accessed February 27, 2017.