The Impact of Quality Improvement Interventions in Improving Surgical Infections and Mortality in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

Jin J 1 , Akau Ola S 2 , Yip CH 3 , Nthumba P 4 , Ameh EA 5 , de Jonge S 6 Show all authors , Mehes M 7 , Waiqanabete HI 8 , Henry J 9 , Hill A 10 , International Society of Surgery (ISS) and the G4 Alliance International Standards and Guidelines for Quality Safe Surgery and Anesthesia (ISG-QSSA) Group

Affiliations 

  • 1 Department of Surgery, The University of Auckland, Auckland, 1010, New Zealand
  • 2 Surgery, Fiji National University, samabula fiji Lakeba Street Samabula, Suva, Fiji
  • 3 Surgery, University of Malaya, Subang Jaya Medical Centre, 50603, Kuala Lumpur, Malaysia
  • 4 AIC Kijabe Hospital Surgery, Kijabe Road Kijabe Lari Kiambu KE, Kijabe, Kenya
  • 5 Division of Paediatric Surgery, Northcentral University, 8667 E Hartford Dr Ste 100, Scottsdale, AZ, 85255, USA
  • 6 Department of Surgery, Amsterdam UMC Locatie AMC, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
  • 7 G4 Alliance, Chicago, IL, USA
  • 8 Fiji National University College of Medicine Nursing and Health Sciences, Suva, Fiji
  • 9 Department of Surgery, Florida Atlantic University, Boca Raton, USA. james.jin@auckland.ac.nz
  • 10 Department of Surgery, University of Auckland, Auckland, 1010, New Zealand
World J Surg, 2021 10;45(10):2993-3006.
PMID: 34218314 DOI: 10.1007/s00268-021-06208-y

Abstract

BACKGROUND: Morbidity and mortality in surgical systems in low- and middle-income countries (LMICs) remain high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to improve peri-operative outcomes.

METHODS: A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country surgical systems was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC, occurred in a surgical setting, and measured the effect of an implementation and its impact. The primary outcome was mortality, and secondary outcomes were rates of rates of hospital-acquired infection (HAI) and surgical site infections (SSI). Prospero Registration: CRD42020171542.

RESULT: Of 38,273 search results, 31 studies were included in a qualitative synthesis, and 28 articles were included in a meta-analysis. Implementation of multimodal bundled interventions reduced the incidence of HAI by a relative risk (RR) of 0.39 (95%CI 0.26 to 0.59), the effect of hand hygiene interventions on HAIs showed a non-significant effect of RR of 0.69 (0.46-1.05). The WHO Safe Surgery Checklist reduced mortality by RR 0.68 (0.49 to 0.95) and SSI by RR 0.50 (0.33 to 0.63) and antimicrobial stewardship interventions reduced SSI by RR 0.67 (0.48-0.93).

CONCLUSION: There is evidence that a number of quality improvement processes, interventions and structural changes can improve mortality, HAI and SSI outcomes in the peri-operative setting in LMICs.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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