Developing a multi-faceted approach to improving and uplifting trauma care in the periphery.
Introduction Rural trauma care in South Africa is under resourced and the quality of rural trauma care appears to be uneven. This project aimed to assess the quality of rural trauma care in Sisonke Health District and to develop targeted quality improvement programmes to improve it. Methodology A strategic planning methodology consisting of a situational analysis, planning synthesis and implementation was used in the project and was integrated with a health system’s model of inputs, process and outcome to provide a structured overview of the whole process. A number of academic constructs from fields outside of health care were used to analyse the quality of care and to develop targeted quality improvement programmes. Results The table below summarises the results of this project by placing each of the published papers in this thesis into the integrated grid. The various tools that were adopted to assist with the project included error theory and quality metrics for trauma and acute surgery. These are also situated within the grid. Analysis of the inputs of rural trauma care revealed that there were major deficits in terms of the human resources available to manage the large burden of trauma seen in rural hospitals. Analysis of the process revealed deficits in the transfer process and the quality of documentation and observation of trauma patients in our system. Analysis of the outcomes revealed a high incidence of error associated with rural trauma care and poor outcomes for a number of conditions such as burns. Synthesis and Implementation involved the development of a number of strategies and a review of their efficacy. These included a surgical outreach programme, restructured morbidity and mortality meetings, error-awareness training and the use of tick-box clerking sheets. The impact of these various programmes was mixed. The surgical outreach programme was successful at delivering surgical care in the districts but less successful at transferring surgical skills to rural staff. The morbidity and mortality meetings, and the errorawareness training changed the culture of the institution and increased the understanding of the danger of error. The tick-box initiative revealed how difficult it is to change human behaviour. A number of audits have suggested that there is a general improvement in the quality of care. This has resulted in improved outcomes for the management of penetrating abdominal trauma and burns care. Conclusion Rural trauma care has many deficits and these translate into poor outcomes. Addressing these deficits is difficult and requires a multi -faceted approach. Undertaking quality improvement programmes in an ad hoc manner may be counter-productive and using a structured systematic approach may allow planners to contextualise their interventions. Currently trying to increase the inputs and resources available for rural trauma care is difficult and most of the intervention should aim at refining and improving the process of care. A number of projects have emerged from this thesis.