Reducing infections among women undergoing cesarean section in Colombia by means of continuous quality improvement methods.

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.

Concealment of neonatal cerebral infarction on MRI by normal brain water.

Magnetic resonance imaging (MRI) is highly sensitive in detecting cerebral infarction in adults, both in the acute and chronic stages. Cytotoxic and vasogenic edema produce an increase in the water content of acutely ischemic brain, resulting in good tissue contrast from adjacent normal brain on spin density, T1 and T2 weighted MR images. Gliosis and other chronic brain changes are well seen in later stages. We recently encountered a case of remote cerebral infarction in an infant, however, which was not evident on the initial MR examination at 7 weeks of age but which was clearly seen on a follow-up scan at 9 1/2 months. Our contention is that the infarct was masked by the known increased water content of the neonatal brain, which results in lengthened spin density and relaxation times; edema and gliosis may thus be obscured. This age-related concealment of ischemic brain changes on MR has not to our knowledge been reported, and we present this case as a caveat in the detection of cerebral infarction in neonates.