Hospital inspection

All countries have some mechanism, however rudimentary, for monitoring the functioning of their hospitals. This is especially true in locations in which a significant portion of health care is provided by government-run hospitals. It also comes in the form of accreditation of hospitals, whether they be private or public.

Hospital inspection and related accreditation has proven to be an important part of the development of systems for trauma management in high-income coun tries. A brief review of this process is instructive. However, any process of hospital inspection and review related to the implementation of the Guidelines for essential trauma care in low- and middle-income countries would be quite different in both form and substance. Usually, some political jurisdiction is responsible for designating which hospitals should play what roles in an organized system for trauma management, varying from large urban trauma centres to small rural hospitals. For example, a choice may have to be made between several large urban hospitals as to which one should be the level-1 (highest level) trauma centre for a given city. This would imply that it would receive the necessary resources to function at this level. It would also include the establishment of pre-hospital triage guidelines so that the most seriously injured patients in that particular city are taken by preference to this hospital. Similar considerations would apply to choosing among several potential medium-sized hospitals in suburban areas or larger towns.

In terms of rural hospitals, such planning of systems for trauma management would also imply choosing between potential alternatives in widely dispersed rural areas, as well as assuring that smaller hospitals that do provide a certain minimal level of trauma care are brought up to an expected minimum standard. Such "designation" is accompanied by a process of inspection and verification or accreditation. This may be performed by a governmental body. However, it is usually performed by an independent, qualified, professional organization. For example, in the United States, the individual states designate the level of capability at which hospitals are to function in a system for trauma management. However, it is the American College of Surgeons (ACS) that performs the actual hospital inspection and verification. The criteria that hospitals must meet to be designated at various levels of trauma care are laid out in detail in the publication Resources for optimal care of the patient, to which we have alluded in the earlier parts of these Guidelines for essential trauma care. Similar situations exist in Canada and Australia, where the Trauma Association of Canada (22) and the Royal Australasian College of Surgeons (RACS), respectively, provide such inspection.

One note on terminology is warranted here. The term "trauma centre" verification is often used. However, it is really the trauma service of a given hospital that is inspected and verified. This is true no matter the size of the hospital. Hence, the concept of inspection and verification should not be construed as pertaining only to large urban hospitals providing primarily trauma care. It pertains to hospitals of all sizes that provide trauma care among other services.

Typically, a verification review of a hospital lasts two days. It is usually carried out by a team consisting of two general surgeons or one general surgeon with an emergency physician, neurosurgeon, orthopaedic surgeon, anaesthesiologist, hospital administrator or trauma nurse coordinator. Before the visit, a questionnaire has been administered to the hospital administrator and/or chief of the trauma service. This is reviewed by the team with key personnel from the hospital. The actual site visit occurs the following day and usually takes six hours. The team makes a one- to two-hour tour of the whole hospital, emphasizing the emergency department (casualty ward or wherever else trauma patients are first seen and evaluated), trauma resuscitation areas, radiology department, laboratory, blood bank, operating theatre and intensive care units. Following this, a review lasting three to four hours is made of randomly selected patient records, as well as all trauma deaths from the preceding year. This is utilized to make an assessment of the quality of care rendered and the functioning of quality improvement programmes for trauma. Specific cases are tracked through the quality improvement programmes to see how potential problems are identified and dealt with. During the review, approximately 100 criteria are used. Most apply to all levels of hospitals. However, there are several criteria, such as sub-specialized clinical services and research, which apply only to level-one trauma centres (77, 78).

A review of verification visits of 179 hospitals showed that the leading factor associated with unsuccessful review was absence or deficiencies in programmes for performance improvement. The second leading item was lack of an organized trauma service, including a trauma service director. The third most common deficiency was lack of documentation for the presence of a general surgeon in the emergency department for the resuscitation of critically injured patients (77, 78).

The authors of the summary of verification reviews felt that programmes for performance improvement were not well understood and that more emphasis on these was needed in the development of systems for trauma management. Examples of deficiencies in performance improvement included failure to correct problems that had been identified, lack of documentation of physician response times in particular, failure to adhere to protocols, failure to attend a regular mul-tidisciplinary performance improvement conference and failure to utilize an existing trauma registry to support a performance improvement programme. The next major criterion associated with unsuccessful reviews was the lack of an organized trauma service. In most such cases, there were groups of surgeons caring for trauma patients independently, without any oversight by a trauma director, nor any coordination between the surgeons (77, 78).

The third most common deficiency was the lack of documentation of a trauma surgeon's presence in the emergency department at the time of arrival of a critically injured patient. This was felt to arise most often from inadequate trauma alert protocols, with a lack of coordination between surgical services and doctors in the emergency department. It was also felt to reflect a general lack of commitment by the surgical staff to trauma care.

It was interesting to note that actual deficiencies in hospital facilities, such as personnel, equipment and supplies, were rarely identified (at least in the higher-

income setting) and were rarely the cause of unsuccessful verification reviews. It was rather organization, performance and appropriate utilization of the resources that constituted the problem.

The accreditation process itself has been shown to improve the functioning of a trauma centre. This has been demonstrated through an improved process of medical care, with fewer deficiencies being noted after completion of a review process. It has also been shown by a decrease in mortality of seriously injured patients (79). Such verification of trauma centres has been identified as an integral part of the overall development of systems for trauma management (22).

It would be reasonable to adapt the trauma centre verification process, as described above, to efforts to promote the Guidelines for essential trauma care. This would be conceptually similar to the trauma centre verification process in high-income countries. However, it would need to be significantly amended to suit the system of accreditation, management and supervision of hospitals and health facilities already existing in a given country. For example, EsTC criteria, especially those of high importance and impact, might be added to existing review processes. On the other hand, specific review of trauma treatment facilities might be reasonable for hospitals with large numbers of trauma patients.

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