District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries.
BACKGROUND
Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly.


METHODS
Consensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8.


RESULTS
Panellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1--0.58; Round 2--0.66; Round 3--0.76; and Round 4--0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage--vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation--a large bore IV was placed within 15 min of patient arrival; referral--if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer.


CONCLUSIONS
This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs.
Department of Surgery, University of Washington, Seattle, WA, USA; School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana; Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa. Electronic address: stewarb@uw.edu.
Barclay T
BT
Stewart
School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
Adam
A
Gyedu
School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
Robert
R
Quansah
Eastern Regional Health Directorate, Ghana Health Service, Koforidua, Ghana.
Wilfred Larbi
WL
Addo
Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana.
Akis
A
Afoko
School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
Pius
P
Agbenorku
Department of Surgery, Eastern Regional Hospital, Koforidua, Ghana.
Forster
F
Amponsah-Manu
Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
James
J
Ankomah
Ghana Health Service, Accra, Ghana.
Ebenezer
E
Appiah-Denkyira
Department of Obstetrics and Gynecology, Upper East Regional Hospital, Bolgatanga, Ghana.
Peter
P
Baffoe
Department of Surgery, University of Cape Coast, Cape Coast, Ghana.
Sam
S
Debrah
School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
Peter
P
Donkor
Department of Surgery, Eastern Regional Hospital, Koforidua, Ghana.
Theodor
T
Dorvlo
Department of Emergency Medicine, Police Hospital, Accra, Ghana.
Kennedy
K
Japiong
Surgeons OverSeas (SOS), New York, NY, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Surgery, Columbia University, New York, NY, USA.
Adam L
AL
Kushner
Department of Surgery, University of Cape Coast, Cape Coast, Ghana.
Martin
M
Morna
Ghana Health Service, Accra, Ghana.
Anthony
A
Ofosu
Department of Anesthesia, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
Victor
V
Oppong-Nketia
Eastern Regional Health Directorate, Ghana Health Service, Koforidua, Ghana; Department of Surgery, University of Development Studies, Tamale, Ghana.
Stephen
S
Tabiri
Department of Surgery, University of Washington, Seattle, WA, USA; Harborview Injury Prevention & Research Center, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA.
Charles
C
Mock
D003697:Delphi Technique; D004632:Emergency Medical Services; D005869:Ghana / Q000453:epidemiology; D006767:Hospitals, District / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008485:Medical Audit; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D058996:Quality Improvement / Q000458:organization & administration*; D012017:Referral and Consultation; D014218:Triage / Q000592:standards*; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000628:therapy
Developing country; Ghana; Global surgery; Quality improvement; Trauma