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MIXED METHODS STUDY PROTOCOL FOR COMBINING STAKEHOLDER-LED RAPID EVALUATION WITH NEAR REAL-TIME CONTINUOUS REGISTRY DATA TO FACILITATE EVALUATIONS OF QUALITY OF CARE IN INTENSIVE CARE UNITS
Quality of Care
Intensive Care
Critical Illness
Lowand Middle-Income Countries
Learning Health Systems
Author
Rashan, Aasiyah
Beane, Abi
Ghose, Aniruddha
Dondorp, Arjen M.
Kwizera, Arthur
Vijayaraghavan, Bharath Kumar Tirupakuzhi
Biccard, Bruce
Righy, Cassia
Thwaites, C. Louise
Pell, Christopher
Sendagire, Cornelius
Thomson, David
Done, Dilanthi Gamage
Aryal, Diptesh
Wagstaff, Duncan
Nadia, Farah
Putoto, Giovanni
Panaru, Hem
Udayanga, Ishara
Amuasi, John
Salluh, Jorge
Gokhale, Krishna
Nirantharakumar, Krishnarajah
Pisani, Luigi
Hashmi, Madiha
Schultz, Marcus
Ghalib, Maryam Shamal
Mukaka, Mavuto
Mat-Nor, Mohammed Basri
Siaw-Frimpong, Moses
Surenthirakumaran, Rajendra
Haniffa, Rashan
Kaddu, Ronnie P.
Pereira, Snehal Pinto
Murthy, Srinivas
Harris, Steve
Moonesinghe, Suneetha Ramani
Vengadasalam, Sutharshan
Tripathy, Swagata
Gooden, Tiffany E.
Tolppa, Timo
Pari, Vrindha
Waweru-Siika, Wangari
Minh, Yen Lam
Beane, Abi
Ghose, Aniruddha
Dondorp, Arjen M.
Kwizera, Arthur
Vijayaraghavan, Bharath Kumar Tirupakuzhi
Biccard, Bruce
Righy, Cassia
Thwaites, C. Louise
Pell, Christopher
Sendagire, Cornelius
Thomson, David
Done, Dilanthi Gamage
Aryal, Diptesh
Wagstaff, Duncan
Nadia, Farah
Putoto, Giovanni
Panaru, Hem
Udayanga, Ishara
Amuasi, John
Salluh, Jorge
Gokhale, Krishna
Nirantharakumar, Krishnarajah
Pisani, Luigi
Hashmi, Madiha
Schultz, Marcus
Ghalib, Maryam Shamal
Mukaka, Mavuto
Mat-Nor, Mohammed Basri
Siaw-Frimpong, Moses
Surenthirakumaran, Rajendra
Haniffa, Rashan
Kaddu, Ronnie P.
Pereira, Snehal Pinto
Murthy, Srinivas
Harris, Steve
Moonesinghe, Suneetha Ramani
Vengadasalam, Sutharshan
Tripathy, Swagata
Gooden, Tiffany E.
Tolppa, Timo
Pari, Vrindha
Waweru-Siika, Wangari
Minh, Yen Lam
Affilliation
University College London. Institute of Health Informatics. London, UK.
University of Edinburgh. Centre for Inflammation Research. Edinburgh, UK / Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Amsterdam Institute for Global Health and Development. Amsterdam, The Netherlands.
Chittagong Medical College Hospital. Department of Medicine. Chattogram, Bangladesh.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Amsterdam Institute for Global Health and Development. Amsterdam, The Netherlands / University of Oxford. Nuffield Department of Medicine. Oxford, UK.
Makerere University. Department of Anaesthesia and Intensive Care Medicine. Kampala, Uganda.
Apollo Hospitals Educational and Research Foundation. Department of Critical Care Medicine. Chennai, India.
University of Cape Town. Department of Anaesthesia and Perioperative Medicine. Cape Town, South Africa.
Oswaldo Cruz Foundation. Evandro Chagas National Institute of Infectious Diseases. Rio de Janeiro, RJ, Brazil.
University of Oxford. Nuffield Department of Medicine. Oxford, UK / Oxford University Clinical Research Unit. University of Oxford. Ho Chi Minh City, Vietnam.
Amsterdam Institute for Global Health and Development. Amsterdam, The Netherlands.
University of Makerere. Uganda Heart Institute. Makerere, Uganda / D'Or Institute for Research and Education. São Paulo, SP, Brazil.
University of Cape Town. Department of Anaesthesia and Perioperative Medicine. Cape Town, South Africa.
Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka / University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / D'Or Institute for Research and Education. São Paulo, SP, Brazil / Nepal Intensive Care Research Foundation. Department of Critical Care. Kathmandu, Nepal.
University of Cape Town. Department of Anaesthesia and Perioperative Medicine. Cape Town, South Africa / University College London. Centre for Preoperative Medicine. London, UK.
International Islamic University Malaysia. Department of Intensive Care Anaesthesiology. Kuala Lumpur, Malaysia.
Department of Planning and Operational Research. Doctors with Africa CUAMM. Padova, Italy.
Nepal Intensive Care Research Foundation. Department of Critical Care. Kathmandu, Nepal.
Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka.
Kwame Nkrumah University of Science and Technology. Department of Global Health. Kumasi, Ghana.
D'Or Institute for Research and Education. São Paulo, SP, Brazil.
University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Ziauddin University. Department of Critical Care Medicine. Karachi, Pakistan.
University of Amsterdam. Intensive Care Medicine. Amsterdam, The Netherlands.
Wazir Akbar Khan Hospital. General Surgery. Kabul, Afghanistan.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / University of Oxford. Nuffield Department of Medicine. Oxford, UK.
International Islamic University Malaysia. Department of Intensive Care Anaesthesiology. Kuala Lumpur, Malaysia.
Komfo Anokye Teaching Hospital. Department of Anaesthesiology and Intensive care. Kumasi, Ghana.
University of Jaffna. Department of Community and Family Medicine. Jaffna, Sri Lanka.
University of Edinburgh. Centre for Inflammation Research. Edinburgh, UK / Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka.
The Aga Khan University. Department of Anaesthesia. Nairobi, Kenya.
University College London. Department of Targeted Intervention. London, UK.
University of British Columbia. Faculty of Medicine. Department of Pediatrics. Vancouver, Canada.
University College London Hospitals NHS Foundation Trust. Department of Critical Care. London, UK.
University College London. Department of Targeted Intervention. London, UK.
Teaching Hospital Jaffna. Jaffna, Sri Lanka.
University of Edinburgh. Centre for Inflammation Research. Edinburgh, UK / AII India Institute of Medical Sciences. New Delhi, India.
University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka.
Chennai Critical Care Consultants Private Limited. Chennai, India.
The Aga Khan University. Department of Anaesthesia. Nairobi, Kenya.
Oxford University Clinical Research Unit. University of Oxford. Ho Chi Minh City, Vietnam.
University of Edinburgh. Centre for Inflammation Research. Edinburgh, UK / Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Amsterdam Institute for Global Health and Development. Amsterdam, The Netherlands.
Chittagong Medical College Hospital. Department of Medicine. Chattogram, Bangladesh.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Amsterdam Institute for Global Health and Development. Amsterdam, The Netherlands / University of Oxford. Nuffield Department of Medicine. Oxford, UK.
Makerere University. Department of Anaesthesia and Intensive Care Medicine. Kampala, Uganda.
Apollo Hospitals Educational and Research Foundation. Department of Critical Care Medicine. Chennai, India.
University of Cape Town. Department of Anaesthesia and Perioperative Medicine. Cape Town, South Africa.
Oswaldo Cruz Foundation. Evandro Chagas National Institute of Infectious Diseases. Rio de Janeiro, RJ, Brazil.
University of Oxford. Nuffield Department of Medicine. Oxford, UK / Oxford University Clinical Research Unit. University of Oxford. Ho Chi Minh City, Vietnam.
Amsterdam Institute for Global Health and Development. Amsterdam, The Netherlands.
University of Makerere. Uganda Heart Institute. Makerere, Uganda / D'Or Institute for Research and Education. São Paulo, SP, Brazil.
University of Cape Town. Department of Anaesthesia and Perioperative Medicine. Cape Town, South Africa.
Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka / University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / D'Or Institute for Research and Education. São Paulo, SP, Brazil / Nepal Intensive Care Research Foundation. Department of Critical Care. Kathmandu, Nepal.
University of Cape Town. Department of Anaesthesia and Perioperative Medicine. Cape Town, South Africa / University College London. Centre for Preoperative Medicine. London, UK.
International Islamic University Malaysia. Department of Intensive Care Anaesthesiology. Kuala Lumpur, Malaysia.
Department of Planning and Operational Research. Doctors with Africa CUAMM. Padova, Italy.
Nepal Intensive Care Research Foundation. Department of Critical Care. Kathmandu, Nepal.
Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka.
Kwame Nkrumah University of Science and Technology. Department of Global Health. Kumasi, Ghana.
D'Or Institute for Research and Education. São Paulo, SP, Brazil.
University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Ziauddin University. Department of Critical Care Medicine. Karachi, Pakistan.
University of Amsterdam. Intensive Care Medicine. Amsterdam, The Netherlands.
Wazir Akbar Khan Hospital. General Surgery. Kabul, Afghanistan.
Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / University of Oxford. Nuffield Department of Medicine. Oxford, UK.
International Islamic University Malaysia. Department of Intensive Care Anaesthesiology. Kuala Lumpur, Malaysia.
Komfo Anokye Teaching Hospital. Department of Anaesthesiology and Intensive care. Kumasi, Ghana.
University of Jaffna. Department of Community and Family Medicine. Jaffna, Sri Lanka.
University of Edinburgh. Centre for Inflammation Research. Edinburgh, UK / Mahidol Oxford Tropical Medicine Research Unit. Bangkok, Thailand / Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka.
The Aga Khan University. Department of Anaesthesia. Nairobi, Kenya.
University College London. Department of Targeted Intervention. London, UK.
University of British Columbia. Faculty of Medicine. Department of Pediatrics. Vancouver, Canada.
University College London Hospitals NHS Foundation Trust. Department of Critical Care. London, UK.
University College London. Department of Targeted Intervention. London, UK.
Teaching Hospital Jaffna. Jaffna, Sri Lanka.
University of Edinburgh. Centre for Inflammation Research. Edinburgh, UK / AII India Institute of Medical Sciences. New Delhi, India.
University of Birmingham. Institute of Applied Health Research. Birmingham, UK.
Nat-Intensive Care Surveillance. Mahidol Oxford Tropical Medicine Research Unit. Colombo, Sri Lanka.
Chennai Critical Care Consultants Private Limited. Chennai, India.
The Aga Khan University. Department of Anaesthesia. Nairobi, Kenya.
Oxford University Clinical Research Unit. University of Oxford. Ho Chi Minh City, Vietnam.
Abstract
Background: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be led by local stakeholders, performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.
Keywords
Rapid EvaluationQuality of Care
Intensive Care
Critical Illness
Lowand Middle-Income Countries
Learning Health Systems
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