BACKGROUND: 

Provision of timely, safe, and affordable surgical care is an essential component of any high-quality health system. Increasingly, it is recognized that poor quality of care in the perioperative period (before, during, and after surgery) may contribute to significant excess mortality and morbidity. Therefore, improving access to surgical procedures alone will not address the disparities in surgical outcomes globally until the quality of perioperative care is addressed. We aimed to identify key barriers to quality perioperative care delivery for 3 “Bellwether” procedures (cesarean delivery, emergency laparotomy, and long-bone fracture fixation) in 5 low- and middle-income countries (LMICs).

METHODS: 

Ten hospitals representing secondary and tertiary facilities from 5 LMICs were purposefully selected: 2 upper-middle income (Colombia and South Africa); 2 lower-middle income (Sri Lanka and Tanzania); and 1 lower income (Uganda). We used a rapid appraisal design (pathway mapping, ethnography, and interviews) to map out and explore the complexities of the perioperative pathway and care delivery for the Bellwether procedures. The framework approach was used for data analysis, with triangulation across different data sources to identify barriers in the country and pattern matching to identify common barriers across the 5 LMICs.

RESULTS: 

We developed 25 pathway maps, undertook >30 periods of observation, and held >40 interviews with patients and clinical staff. Although the extent and impact of the barriers varied across the LMIC settings, 4 key common barriers to safe and effective perioperative care were identified: (1) the fragmented nature of the care pathways, (2) the limited human and structural resources available for the provision of care, (3) the direct and indirect costs of care for patients (even in health systems for which care is ostensibly free of charge), and (4) patients’ low expectations of care.

CONCLUSIONS: 

We identified key barriers to effective perioperative care in LMICs. Addressing these barriers is important if LMIC health systems are to provide safe, timely, and affordable provision of the Bellwether procedures.

中文翻译：

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低收入和中等收入国家围手术期护理质量的障碍：一项定性快速评估研究

背景： 

提供及时、安全和负担得起的外科治疗是任何高质量卫生系统的重要组成部分。越来越多的人认识到，围手术期（术前、术中和术后）护理质量差可能导致死亡率和发病率显着增加。因此，在解决围​​手术期护理质量问题之前，单靠改善外科手术的可及性并不能解决全球手术结果的差异。我们旨在确定 5 个低收入和中等收入国家 (LMIC) 的 3 个“领头羊”手术（剖宫产、急诊剖腹手术和长骨骨折固定术）提供优质围手术期护理的主要障碍。

方法： 

有意从 5 个中低收入国家中选择了 10 家代表二级和三级医院的医院：2 家中高收入（哥伦比亚和南非）；2 中低收入国家（斯里兰卡和坦桑尼亚）；和 1 个收入较低的国家（乌干达）。我们使用快速评估设计（路径映射、人种学和访谈）来绘制和探索 Bellwether 程序的围手术期路径和护理提供的复杂性。框架方法用于数据分析，通过跨不同数据源的三角测量来识别国家中的障碍，并通过模式匹配来识别 5 个中低收入国家的共同障碍。

结果： 

我们制作了 25 张通路图，进行了超过 30 次观察，并对患者和临床工作人员进行了超过 40 次访谈。尽管障碍的程度和影响在 LMIC 环境中有所不同，但确定了安全有效的围手术期护理的 4 个主要共同障碍：(1) 护理途径的分散性，(2) 可用于围手术期护理的人力和结构资源有限提供护理，(3) 患者护理的直接和间接成本（即使在表面上免费提供护理的卫生系统中），以及 (4) 患者对护理的低期望。

结论： 

我们确定了 LMIC 有效围手术期护理的主要障碍。如果 LMIC 卫生系统要提供安全、及时和负担得起的 Bellwether 程序，那么解决这些障碍很重要。