Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BACKGROUND

Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

METHODS

Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported.

RESULTS

We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

CONCLUSION

Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Adult male involvement in maternity care in Enugu State, Nigeria: A cross-sectional study

INTRODUCTION

Men are the key decision makers in the family and play a crucial role in the reproductive health of partners, in Nigeria. This study assessed adult male involvement in maternity care in Enugu south local government area, Enugu State, Nigeria.

METHODS

This community-based study was conducted using a cross-sectional survey design. A total of 145 respondents were selected through multi-stage sampling and data were collected using a structured questionnaire developed by the researchers. Data generated were statistically analyzed based on the research objectives using descriptive statistics.

RESULTS

Major findings revealed that the respondents had moderate knowledge on the expected role of males in maternity care with the majority, assessed using a 4-point Likert scale, having a moderate (2.99) level of involvement in maternity care. Lack of facilities that encourage male participation in maternity care, work schedule of the male partner, and lack of knowledge on the role of the male partners during maternity care were identified as major barriers to male involvement in maternity care with means of 3.80, 3.58 and 3.48, respectively.

CONCLUSIONS

Involvement in maternity care among the respondents in this study was moderate. However, men may be restricted by some cultural beliefs such as maternity care being regarded as exclusively a woman's matter. Thus, men should be educated on the importance of their role as partners in maternity care and on the need to participate actively, regardless of existing cultural norms. Hospitals should also promote policies that encourage male presence during birth and delivery rooms need to be designed to allow bonding of partners during birth.

A study of the dosage and duration for levobupivacaine infusion by the caudal-epidural route in infants aged 3-6 months

BACKGROUND

The local anesthetic, levobupivacaine, is the safer enantiomer of racemic bupivacaine. Present protocols for levobupivacaine are based on studies and pharmacokinetic modeling with racemic bupivacaine.

AIMS

The aim is to investigate total serum levobupivacaine concentrations after a caudalepidural loading dose followed by a maintenance infusion over 48 hours in infants aged 3-6 months.

METHODS

The clinical trial was conducted in eight infants aged 3-6 months, undergoing bladder exstrophy repair. Pharmacokinetic modeling allowed optimization of clinical sampling to measure total levobupivacaine and α₁ -acid glycoprotein and prediction of the effect of α₁ -acid glycoprotein on levobupivacaine plasma protein binding.

RESULTS

The observed median total levobupivacaine serum concentration was 0.30 mg/L (range: 0.20-0.70 mg/L) at 1 hour after the loading dose of 2 mg/kg. The median total levobupivacaine concentration after 47 hours of infusion, at 0.2 mg/kg/h, was 1.21 mg/L (0.07-1.85 mg/L). Concentrations of α₁ -acid glycoprotein were found to rise throughout the study period. Pharmacokinetic modeling suggested that unbound levobupivacaine quickly reached steady state at a concentration of approximately 0.03 mg/L.

CONCLUSION

The study allows the development of a pharmacokinetic model, combining levobupivacaine and α₁ -acid glycoprotein data. Modeling indicates that unbound levobupivacaine quickly reaches steady state once the infusion is started. Simulations suggest that it may be possible to continue the infusion beyond 48 hours.