Inter-rater reliability of the PIPES tool: validation of a surgical capacity index for use in resource-limited settings.

INTRODUCTION: In response to the need for simple, rapid means of quantifying surgical capacity in low resource settings, Surgeons OverSeas (SOS) developed the personnel, infrastructure, procedures, equipment and supplies (PIPES) tool. The present investigation assessed the inter-rater reliability of the PIPES tool. METHODS: As part of a government assessment of surgical services in Santa Cruz, Bolivia, the PIPES tool was translated into Spanish and applied in interviews with physicians at 31 public hospitals. An additional interview was conducted with nurses at a convenience sample of 25 of these hospitals. Physician and nurse responses were then compared to generate an estimate of reliability. For dichotomous survey items, inter-rater reliability between physicians and nurses was assessed using the Cohen's kappa statistic and percent agreement. The Pearson correlation coefficient was used to assess agreement for continuous items. RESULTS: Cohen's kappa was 0.46 for infrastructure, 0.43 for procedures, 0.26 for equipment, and 0 for supplies sections. The median correlation coefficient was 0.91 for continuous items. Correlation was 0.79 for the PIPES index, and ranged from 0.32 to 0.98 for continuous response items. CONCLUSIONS: Reliability of the PIPES tool was moderate for the infrastructure and procedures sections, fair for the equipment section, and poor for supplies section when comparing surgeons' responses to nurses' responses-an extremely rigorous test of reliability. These results indicate that the PIPES tool is an effective measure of surgical capacity but that the equipment and supplies sections may need to be revised.

A quantitative analysis of surgical capacity in Santa Cruz, Bolivia.

OBJECTIVES: This investigation aimed to document surgical capacity at public medical centers in a middle-income Latin American country using the Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) survey tool. MATERIALS AND METHODS: We applied the PIPES tool at six urban and 25 rural facilities in Santa Cruz, Bolivia. Outcome measures included the availability of items in five domains (Personnel, Infrastructure, Procedures, Equipment, and Supplies) and the PIPES index. PIPES indices were calculated by summing scores from each domain, dividing by the total number of survey items, and multiplying by 10. RESULTS: Thirty-one of the 32 public facilities that provide surgical care in Santa Cruz were assessed. Santa Cruz had at least 7.8 surgeons and 2.8 anesthesiologists per 100,000 population. However, these providers were unequally distributed, such that nine rural sites had no anesthesiologist. Few rural facilities had blood banking (4/25), anesthesia machines (11/25), postoperative care (11/25), or intensive care units (1/25). PIPES indices ranged from 5.7-13.2, and were significantly higher in urban (median 12.6) than rural (median 7.8) areas (P < 0.01). CONCLUSIONS: This investigation is novel in its application of a Spanish-language version of the PIPES tool in a middle-income Latin American country. These data document substantially greater surgical capacity in Santa Cruz than has been reported for Sierra Leone or Rwanda, consistent with Bolivia's development status. Unfortunately, surgeons are limited in rural areas by deficits in anesthesia and perioperative services. These results are currently being used to target local quality improvement initiatives.

What is an hour-lecture worth?

BACKGROUND: Although there are many ways to convey knowledge, attitudes, and techniques when teaching residents and students, the most optimal method (lecture, online lecture, online tutorial, simulator practice, and so on) is yet to be determined. METHODS: This study was designed to be a prospective analysis of change in resident behavior, and the model chosen was resident compliance with alcohol screening during admissions to the trauma service. Baseline values were determined the month before the educational "intervention," which was planned to be a 1-hour lecture during Grand Rounds on the importance of screening for alcohol disuse syndromes. After the "intervention," results were analyzed at 3 points in time: during the first month after the lecture and then at 3 and 12 months. RESULTS: Resident compliance with alcohol usage screening rose from 53% at baseline to 80% at 1 year. CONCLUSIONS: This straightforward model of utility of a lecture showed a significant change in resident behavior.

Cervical spine fractures in patients 65 years or older: a 3-year experience at a level I trauma center.

BACKGROUND: Cervical spine fractures in the elderly carry a mortality as high as 26%. We reviewed our experience to define the level of injury, prevalence of neurologic deficits, treatments employed, and the correlation between patients' pre- and posthospital residences. Also, we correlated the prevalence of advanced directives with length of stay. METHODS: We queried the data collected prospectively at an American College of Surgeons verified Level I hospital (National TRACS, American College of Surgeons) regarding patients aged 65 years or older presenting with cervical spine fractures (International Classification of Diseases-9 code 805.X) in calendar years 2000 through 2003. RESULTS: We identified 58 patients (ages 65-94). Mortality was 24%. Twelve patients had quadriplegia or paraplegia and seven of these patients died. Respiratory failure was the primary cause of death. Application of rigid collars and a halo brace were the most commonly employed therapies. Mortality rates for halo stabilization and rigid collar and halo stabilization were similar (23% vs. 29%). Despite having a higher mean Injury Severity Score, the 16 patients with advanced directives had an intensive care unit length of stay similar to that of patients without advanced directives but a statistically significant shorter overall length of stay (13 vs. 6.9 days). Eighteen of 45 patients living at home at the time of injury returned home. CONCLUSIONS: Cervical spine injury in the elderly does not inevitably relegate patients to a setting of more acute nursing care. The health and social factors that allowed many to return to living at home warrant investigation, as support of these factors may assist others with this injury.

Assessing the competencies in general surgery residency training.

BACKGROUND: Accreditation Council for Graduate Medical Education (ACGME) competencies have increased the focus on education. A 1-year study of observational assessments was conducted. METHODS: "Point of Observation" evaluations were completed by faculty for postgraduate year (PGY) I and II surgery residents. Resident procedures and patient office visits were rated in 9 categories, using a Likert scale. Interns were expected to perform at a novice level (0-30%) and PGY II residents at an advanced level, with improvements expected. RESULTS: PGY I and II residents showed overall improved scores (12% and 6%, respectively) over 1 year. Intern improvements in 9 categories were linear, ranging from 0% to 48%. PGY II resident scores were more variable, with improvements noted in 6 categories ranging from 10% to 30%. Three categories declined in scores, ranging from 2% to 18%. CONCLUSIONS: Competencies bring emphasis to education and measurable outcomes. Early efforts have proven valuable in identifying curriculum and learning needs.