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WHO releases Guidelines for trauma quality improvement programmes
  1. C Mock
  1. Correspondence to Dr C Mock, VIP-NMH WHO, 20 Avenue Appia, Geneva 1292, Switzerland; mockc{at}

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Part of the response to the injury problem needs to encompass strengthening of trauma care. It has been estimated that, out of the 5.8 million people who die from injury each year, over 2 million could be saved by improvements in trauma care capabilities, especially in low-income and middle-income countries. In many circumstances, these improvements could be achieved by low-cost improvements in organisation and planning. Trauma quality improvement (QI) programmes offer a feasible and straightforward way in which to implement such improvements.

QI programmes have been demonstrated to improve the process of trauma care and lower trauma mortality and morbidity in a wide range of circumstances, in countries at a range of economic levels. To promote greater usage of such programmes, WHO, in collaboration with the International Association for Trauma Surgery and Intensive Care (IATSIC) and the International Society of Surgery (ISS), and with the input of other partners and trauma care experts from over 15 countries, has produced and released the Guidelines for trauma quality improvement programmes. This offers recommendations on ways in which trauma QI programmes can be started or enhanced for a wide range of circumstances (including the prehospital setting, hospitals of all sizes, and system-wide) and in countries at all economic levels.

These guidelines provide basic definitions and an overview of the field of QI, so that those not familiar with this field will have a working knowledge of it. Evidence of the benefit of QI in general, and trauma QI in particular, is then laid out. The main part of the publication reviews the most common methods of trauma QI, written in a how-to-do fashion. This covers a wide range of techniques. The first two of these are especially emphasised as ways in which to strengthen trauma QI in the setting of low-income and middle-income countries.

First are morbidity and mortality conferences. These are already being regularly conducted in many hospitals worldwide, but they are often not well utilised to achieve the goal of improving trauma care. Several improvements could change this. These include more attention to detail in the procedures for conducting the conference, such as scheduling, optimising the length of the morbidity and mortality meeting, defining who should attend and who should run the meeting, as well as assuring the types of cases that should be reviewed. Needed improvements also include more attention to detail in identifying problems (especially those relating to systems issues), developing reasonable corrective action plans, following through on implementing these plans, and evaluating whether the corrective action has had its intended consequences.

Second are preventable death panel reviews. These provide for more formal input as to determination of preventability of trauma deaths and identification of factors of care that need to be strengthened. Such input is obtained from a range of clinicians whose involvement not only provides multidisciplinary technical expertise but also investment in the successful conduct of corrective actions that are identified. These guidelines provide how-to-do guidance on constituting the panel, preparing data for the review, conducting the case review process, and documenting and analysing the case discussions. Both morbidity and mortality conferences and preventable death panel reviews are eminently feasible and widely applicable, and are especially relevant to strengthening care of the injured in low-income and middle-income countries.

More advanced QI techniques are also covered, including use of medical records systems to monitor for audit filters, including process-of-care measures, as well as complications, errors, adverse events, and sentinel events. Also covered are statistical techniques for severity adjustment.

Common to all the above techniques are the following: they should lead to implementation of corrective strategies to fix problems that are identified; they should monitor the effectiveness of such corrective strategies; they should ensure that these corrective strategies have had their intended effect (ie, closing the loop). Several types of corrective strategies can be used: guidelines, pathways, and protocols; targeted education; actions targeted at specific providers; and enhanced resources, facilities or communication. The guidelines especially emphasise the use of these corrective strategies. In fact, much can be gained by making sure that already existing QI efforts (no matter how rudimentary) are more effective for identifying problems and implementing corrective action.

The guidelines contain examples of successful implementation of QI methods in multiple countries. For example, a basic trauma QI programme in Khon Kaen, Thailand is highlighted which led to a decrease in overall mortality among all admitted trauma patients from 6.1% to 4.4%, using techniques that are eminently applicable in hospitals in all countries worldwide. Finally, several case examples are provided in the annexes for practice in scrutinising clinical data, identifying problems in care, and deriving practical and effective corrective strategies.

The guidelines are intended to provide guidance on specific QI techniques and, more broadly, to stimulate interest in this topic and to catalyse greater implementation of QI programmes for trauma care globally.

In summary, this document provides how-to-do guidance on a range of different trauma QI methods. These are broadly applicable to all healthcare institutions that care for the injured in countries at all economic levels. One or more of the methods described in this document will be directly applicable to any given institution and will enable that institution to upgrade the level of function of its existing trauma QI activities. In so doing, the quality of trauma care can be strengthened and the lives of many injured persons saved.