Annals of Global Health VOL. 83, NO. 2, 2017 ª 2017 Icahn School of Medicine at Mount Sinai. ISSN 2214-9996/$36.00 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.aogh.2017.04.002 ORIGINAL RESEARCH Assessment of Surgical and Trauma Capacity in Potosí, Bolivia Kevin J. Blair, BA, Marissa A. Boeck, MD, MPH, José Luis Gallardo Barrientos, MD, FACS, José Luis Hidalgo López, MD, Irene B. Helenowski, PhD, Benedict C. Nwomeh, MD, MPH, Michael B. Shapiro, MD, Mamta Swaroop, MD, FACS Chicago, Illinois; New York, New York; Boston, Massachusetts; Potosí, Bolivia; and Columbus, Ohio Abstract BACKGROUND Scaling up surgical and trauma care in low- and middle-income countries could prevent nearly 2 million annual deaths. Various survey instruments exist to measure surgical and trauma capacity, including Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) and Interna- tional Assessment of Capacity for Trauma (INTACT). OBJECTIVE We sought to evaluate surgical and trauma capacity in the Bolivian department of Potosí using a combined PIPES and INTACT tool, with additional questions to further inform intervention targets. METHODS In June and July 2014 a combined PIPES and INTACT survey was administered to 20 gov- ernment facilities in Potosí with a minimum of 1 operating room: 2 third-level, 10 second-level, and 8 first-level facilities. A surgeon, head physician, director, or obstetrician-gynecologist completed the survey. Additional personnel responded to 4 short-answer questions. Survey items were divided into subsections, and PIPES and INTACT indices calculated. Medians were compared via Wilcoxon rank sum and Kruskal-Wallis tests. FINDINGS Six of 20 facilities were located in the capital city and designated urban. Urban estab- lishments had higher median PIPES (8.5 vs 6.7, P ¼ .11) and INTACT (8.5 vs 6.9, P ¼ .16) indices compared with rural. More than half of surgeons and anesthesiologists worked in urban hospitals. Urban facilities had higher median infrastructure and procedure scores compared with rural. Fifty-three individuals completed short-answer questions. Training was most desired in laparoscopic surgery and trauma management; less than half of establishments reported staff with trauma training. CONCLUSIONS Surgical and trauma capacity in Potosí was most limited in personnel, infrastructure, and procedures at rural facilities, with greater personnel deficiencies than previously reported. Inter- ventions should focus on increasing the number of surgical and anesthesia personnel in rural areas, with a particular focus on the reported desire for trauma management training. Results have been made available to key stakeholders in Potosí to inform targeted quality improvement interventions. KEY WORDS Bolivia, Latin America, global surgery, essential surgery, trauma, surgical capacity Funding for this project came from the Global Health Initiative travel grant, through the Center for Global Health at Northwestern University’s Feinberg School of Medicine. There are no conflicts of interest to report. K.J.B, J.L.G.B., J.L.H.L., B.C.N., M.B.S., and M.S. contributed to the study design. K.J.B., and J.L.G.B., performed data collection. All authors had access to data. K.J.B., M.A.B., J.L.G.B., and M.S. performed the data analysis. K.J.B. and M.A.B. wrote the initial draft manuscript, and all authors participated in revision and final approval of the submitted manuscript. From the Northwestern University, Feinberg School of Medicine, Department of Surgery, Division of Trauma & Critical Care, Chicago, IL (KJB, MAB, MBS, MS); New York Presbyterian Hospital, Columbia University Medical Center, Department of Surgery, New York, NY (MAB); Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA (MAB); La Caja Nacional de SaluddPotosí, Departamento de Cirugía, Potosí, Boli- via (JLGB); Servicio Departamental de SaluddPotosí, Potosí, Bolivia (JLHL); Northwestern University, Feinberg School of Medicine, Department of Preventative Medicine, Chicago, IL (IBH); Nationwide Children’s Hospital, Department of Pediatric Surgery, Columbus, OH (BCN). Address corre- spondence to K.J.B. ([email protected]). Annals of Global Health, VOL. 83, NO. 2, 2017 Blair et al. 263 MarcheApril 2017: 262– 273 Surgical & Trauma Capacity in Potosí, Bolivia INTRODUCTION and trauma care capacity in the more rural, less developed regions of the country has yet to be An estimated 2 million lives could be saved annually performed.6 We sought to determine baseline surgi- through increased access to basic surgical care and cal and trauma care capacities at government health further development of trauma care systems in care facilities in Potosí through the application of low- and middle-income countries (LMICs).1-3 A the Personnel, Infrastructure, Procedures, Equip- critical step in the development of comprehensive ment, and Supplies (PIPES)14 and the International trauma care systems is for health care facilities to Assessment of Capacity for Trauma (INTACT)15 assess baseline surgical and trauma capacity survey instruments, with this study being the first strengths and weaknesses.4,5 Data from these known prospective application of the INTACT assessments can inform targeted, locally relevant tool. Collected capacity data will provide a more quality improvement interventions for surgical or comprehensive picture of the spectrum of surgical trauma care, as well as provide the ability to compare and trauma care available across Bolivia and can facility capabilities at departmental and national be used to inform targeted, locally relevant improve- levels. Multiple survey instruments have been used ment plans for the department of Potosí, with a for the assessment of these capacities in LMICs; particular focus on self-determined areas of need. however, few have been completed in Latin Amer- ica, with 2 focusing on the Plurinational State of Bolivia (Bolivia).6-8 MATERIALS AND METHODS Bolivia is a lower-middle income country in cen- tral South America with a population of 10.8 mil- Survey Instrument. Among the many survey instru- lion and a median age of 23.7 years.9,10 Among ments developed for the evaluation of surgical and Latin American countries, Bolivia ranks poorly on trauma care capacity in LMICs, the first to focus several health and development indicators, such as on surgical care was the WHO’s Tool for mortality (6.52 deaths per 1000) and life expectancy Situational Analysis to Assess Emergency and (68.86 years).10 Bolivia also has the highest income Essential Surgical Care (TSAAEESC).16 Sur- inequality in Latin America, with 45% of the pop- geons OverSeas (SOS) modified TSAAEESC to ulation living below the poverty line.10 Specifically create PIPES, which introduced a binary system of regarding injuries, Bolivia has one of the highest measurement by limiting respondents to the choice road traffic injury death rates in Latin America of whether resources or procedures were available/ (23.2 deaths per 100,000), behind only Brazil and performed or not available/not performed.14 PIPES Belize according to the World Health Organization contains 105 data points, organized into personnel, (WHO) 2015 Road Safety Report.11 infrastructure, procedures, equipment, and supply Potosí is 1 of 9 administrative departments sections. Evaluations of surgical care capacity have within Bolivia, covering 118,218 km2 in the south- been conducted in at least 12 countries using western corner of the country.12 In 2012, the popu- PIPES.8 PIPES was subsequently modified to focus lation was 823,517, with just over 20% living in the on trauma-specific surgical care via INTACT.15 capital city, also named Potosí. This department has The 40-question INTACT survey includes only the lowest percentage of urban inhabitants of all those PIPES items specific to trauma, with the Bolivian departments and is also distinct for its addition of cervical collars, which is not present in high level of poverty, prevalent mining community, PIPES. unsafe mountain roads, and high altitudes, with an In our evaluation of surgical and trauma care average elevation of 3,977 meters above sea capacity at facilities in Potosí, we used a combined level.12,13 Such factors limit not only access to PIPES and INTACT survey instrument of 106 health care but challenge the development of surgi- questions. For a separate inter-rater reliability cal and trauma care systems, which are vital in a assessment, the equipment and supplies sections country plagued by high rates of road traffic injuries were modified to include all equipment and supplies and a department where treacherous roads and items originally present in TSAAEESC, as well as labor-intensive jobs leave inhabitants particularly at the additional response option of sometimes risk for injury. available. For the purpose of the present study, A prior countrywide assessment of surgical only results from PIPES and INTACT items are capacity in Bolivia included 2 facilities in Potosí; included. To maintain the original PIPES and however, an in-depth evaluation of the surgical INTACT binary response system, the response of 264 Blair et al. AnnalsofGlobalHealth,VOL.83,NO.2,2017 MarcheApril 2017: 262– 273 Surgical & Trauma Capacity in Potosí, Bolivia sometimes available in the equipment and supplies designation used by the WHO.21 Lastly, third- sections was scored as not always available. level facilities are large, multispecialty hospitals Four additional short-answer questions not located in departmental capital cities across