Harvard Internal Medicine-Pediatrics Noon Conference Feb 3, 2011
1. Prospective Study of Surgical Care Scale-Up in a Rural, Resource-Limited Setting Duncan Maru, MD, PHDMed-Peds Noon Conference, February 3, 2011
2. Didactic Objectives Think critically about the design of implementation research studies in resource-limited settings Think about the process of applying to NIH during residency Give Duncan feedback without making him cry (*ANSWER KEY: KEEP IT SIMPLE*) 1
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4. Approximately 11% of death and disability are attributable to surgical diseases2
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6. But: no studies have yet prospectively studied the implementation process3
10. Study the process using mixed quantitative and qualitative methodologies at the hospital-, staff-, and patient levels4
11. Study Objectives Rigorously study an innovative model for surgical care (IMEESC-plus) Pilot an implementation research methodology that can be used in a larger multi-site study Generate data for larger scale-up of surgical care worldwide 5
12. Setting: Bayalpata Hospital Infrastructure development and capacity building, not care provision alone Government collaboration: Government partnership contract for 5 years signed June 2009 – June 2014 Currently one of the highest levels of clinical care in the Far West (2 million people) Over 50,000 patients seen to date
54. Study Objectives Rigorously study an innovative model for Surgical Care (IMEESC-plus) Pilot an implementation research methodology that can be used in a larger multi-site study Generate data for larger scale-up of Surgical Care worldwide 25
55. Levels of Analysis Important to Implementation Science Hospital Operations Human Resources Patients 26
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57. Specific Aim 1:We will quantify the raw financial inputs into the system, including total costs and broken down by pharmaceutical, capital equipment, consumables, and facilities construction and maintenance. We hypothesize that the overall construction and two-year operating costs of implementing the WHO surgical model will be $0.50 per capita in the district. 27
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59. Specific Aim 2:We will tabulate the pharmaceutical and consumable items utilized during the roll-out process. We will assess institutional adherence to supply chain protocols for appropriate stocking of emergency and surgical equipment and consummable goods. This will be based on the WHO Monitoring and Evaluation Tool. We hypothesize there will be a steady compliance to stocking protocols, with approximately 5-10% missing stock items on a monthly basis throughout the study period. 28
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61. Specific Aim 3: We will document the scale-up process qualitatively from the staff’s perspectives. This will be done through three modalities: open-ended, semi-structured interviews of staff at three-monthly periods; non-participant observation of planning meetings; and focus groups with staff at three-monthly periods. The primary domains of analysis will include: human resource management, supply chains, in-hospital work flows, and patient-level interactions.29
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63. Specific Aim 4: We will assess staff adherence to the Surgical Safety Checklist. We hypothesize that adherence rates will improve rapidly over the first six months of implementation to achieve 95% adherence and then stabilize subsequently.30
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65. Specific Aim 5: We will assess how rapidly hospital staff achieve 95% compliance with resuscitation protocols, as determined by a post-resuscitation evaluation form. We hypothesize that this will occur within six months of implementation.31
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68. Specific Aim 7: We will assess how rapidly improvements occur in patient follow-up one week following discharge from the hospital. Based on existing experience at the hospital, we hypothesize that 50% of patients will be brought back for a one-week follow-up visit by three months, 65% by six months, and 80% by one year.33
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70. Specific Aim 8: We will assess the speed by which newly implemented essential Surgical Care are able to achieve target major complication rates (<5%). We hypothesize that the time to achieve this will be within one year.34
71. Study Objectives Rigorously study an innovative model for Surgical Care (IMEESC-plus) Pilot an implementation research methodology that can be used in a larger multi-site study Generate data for larger scale-up of Surgical Care worldwide 35
83. Institutional Supporters: Abbot Laboratories, AMD and the Open Architecture Network, America Nepal Medical Foundation (ANMF), BWH COE in Quality and Safety, Buddha Air, Cents of Relief, Child Health Foundation, CIWEC Clinic (Menlha Nursing Home), Ella Lyman Cabot Trust, EquityEditors Association, Ford Foundation, Frederick Lovejoy Foundation, Google Grants, Nepal Ministry of Health and Population (MOHP), New Aid Foundation, Partners in Health, QBC Diagnostics, Quidel Corporation, Singapore Internet Research Center, Ten Friends, The Hunger Site, The International Foundation, The Shelley and Donald Rubin Foundation, Until There's a Cure Foundation, UpToDate, William Prusoff Foundation, Yale University
