Monday, September 28, 2015

Mbarara part I

J. Reisel

My time in Mbarara in March-April of 2015 was a really exciting one.  It is always great to be back in Mbarara and to reconnect with old friends and colleagues.  

During my month in Mbarara, I was able to continue work on 2 research projects that had been paused while working on research in Boston.  I will discuss the Typhoid project in the next blog entry.  

My other research project focussed on quality and safety in the surgery department at Mbarara Regional Referral Hospital (MRRH).  In Mbarara, similar to many resource constrained settings, medical records are maintained on paper charts.  There's no distinct filing system, and no standardized forms, so the admission notes and hospital records may vary from a succinct synopsis to a detailed account.  The records are papers held together by twine strung through ripped holes, and commonly pages (documenting days worth of treatment) are lost.  Similarly charts have a habit of "walking away" either with the patient who takes it with them in a pile of their belongings after discharges, or with a resident who needs to present the patient's case at conference.  

As a result, it becomes exceedingly difficult to assess what is actually taking place on the surgical service on a large scale.  While providers most certainly know that head injuries from road traffic accidents tend to do poorly, they may not know that children under the age of 5 do the worst and therefore need additional care and focus.  Or that in the dry season, cases of Typhoid perforations spike - and therefore suspicions for this disease should be raised when I patient presents with abdominal pain and fever.  

For this reason, I got involved with a quality assurance database built by faculty from MGH and MRRH.  This database provides a secure, electronic forum for documenting all surgical cases, their hospital course, and their outcomes at MRRH, making quality assurance not only easier but feasible.  We have learned a lot from this database - but one of the most salient lessons has been quite simply how to run such a database.  One of the most important elements of this has been transitioning from "free text entry" (for example:  "Admission Diagnosis: mild head injury") to standardized coded entries (e.g. ICD-10 codes) so that areas of interest can be easily queried and assessed.  

As a spin off of this project, I worked with a Harvard Medical Student and 3 Ugandan physicians to develop a project that would allow us to better understand what happens in the operating theaters so that we can better report what equipment is needed from the government in order to provide adequate surgical care.  During my month in Mbarara we were able to put our heads together and design a research project that will allow use to identify a condensed list of ICD-9 codes for procedures performed in the operating theater.  Recognizing that the same list of procedures performed in the US and elsewhere is not necessarily applicable in the resource-constrained setting (e.g.Laparoscopic gastric bypass surgery is not in high demand in Uganda), we wanted to create a condensed list that applies to directly to a setting like MRRH, but still uses a standardized and widely applicable set of codes such that cross country and continent data can be compared.  

It has been a wonderful process working through these ideas together and to develop a project that is important to everyone involved.  I am eager to see the end result

Peter Kayima, MRRH Surgical Resident and one of our partners in the condensed operative coding project, and I at the MGH Guest House in Mbarara, Uganda.   

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