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Reducing Infections Among Women Undergoing Cesarean Section in Colombia by Means of Continuous Quality Improvement Methods
Michelle Weinberg, MD, MPH;
Jose Maria Fuentes, MD;
Ariel I. Ruiz, MD;
Fred Wilson Lozano, MD;
Edith Angel, MD;
Hernando Gaitan, MD;
Brunhilde Goethe, RN;
Sonia Parra, RN;
Susan Hellerstein, MD, MPH;
Dennis Ross-Degnan, ScD;
Donald A. Goldmann, MD;
W. Charles Huskins, MD, MS
Arch Intern Med. 2001;161:2357-2365.
Background Improving obstetric care in resource-limited countries is a major international
health priority.
Objective To reduce infection rates after cesarean section by optimizing systems
of obstetric care for low-income women in Colombia by means of quality improvement
methods.
Methods Multidisciplinary teams in 2 hospitals used simple methods to improve
their systems for prescribing and administering perioperative antibiotic prophylaxis.
Process indicators were the percentage of women in whom prophylaxis was administered
and the percentage of these women in whom it was administered in a timely
fashion. The outcome indicator was the surgical site infection rate.
Results Before improvement, prophylaxis was administered to 71% of women in
hospital A; 24% received prophylaxis in a timely fashion. Corresponding figures
in hospital B were 36% and 50%. Systems improvements included implementing
protocols to administer prophylaxis to all women and increasing the availability
of the antibiotic in the operating room. These improvements were associated
with increases in overall and timely administration of prophylaxis (P<.001) in both hospitals by time series analysis, with
adjustment for volume and case mix. After improvement, overall and timely
administration of prophylaxis was 95% and 96% in hospital A and 89% and 96%
in hospital B. In hospital A, the surgical site infection rate decreased immediately
after the improvements (P<.001). In hospital B,
the infection rate began a downward trend before the improvements that continued
after their implementation (P = .04).
Conclusion Simple quality improvement methods can be used to optimize obstetric
services and improve outcomes of care in resource-limited settings.
From the Division of Infectious Diseases, Children's Hospital, Boston,
Mass (Drs Weinberg, Goldmann, and Huskins); Department of Medicine, Hospital
Simón Bolívar (Drs Fuentes and Lozano and Ms Goethe), Escuela
Colombiana de Medicina (Drs Fuentes and Lozano), Instituto Materno Infantil
(Drs Ruiz, Angel, and Gaitan and Ms Parra), and Departamento de Ginecologia
y Obstetricia, Universidad Nacional de Colombia (Drs Ruiz, Angel, and Gaitan),
Santafé de Bogotá, Colombia; Department of Obstetrics and Gynecology,
Beth Israel Deaconess Medical Center and Department of Obstetrics, Gynecology,
and Reproductive Biology, Harvard Medical School, Boston (Dr Hellerstein);
Department of Ambulatory Care and Prevention Drug Policy Research Group, Harvard
Medical School and Harvard Pilgrim Health Care, Boston (Dr Ross-Degnan); and
Department of Pediatrics, Harvard Medical School, Boston (Drs Goldmann and
Huskins). Dr Weinberg is now with the Division of Quarantine, National Center
for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta,
Ga. Dr Huskins is now with the Department of Pediatrics and Adolescent Medicine,
Mayo Clinic, Rochester, Minn.
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