# Improving Surgical Outcomes in Resource-Limited Settings: A Quality Improvement Approach to Unplanned Returns to Theater

## TL;DR

A quality improvement program in two Iraqi hospitals reduced unplanned returns to surgery by improving surgical techniques and checklist compliance.

## Contribution

Demonstrates the effectiveness of low-cost quality improvement strategies in reducing surgical complications in resource-limited settings.

## Key findings

- RTT rates dropped from 7.9% to 3.7% after implementing the quality improvement program.
- Surgical technique training and checklist compliance were key to reducing preventable complications.
- Most RTTs were due to sepsis, wound dehiscence, and hemorrhage, with incomplete checklists and urgent surgeries as significant risk factors.

## Abstract

Background: Unplanned return to theater (RTT) is a major concern in surgical care, often reflecting preventable complications that impact patient safety and health system efficiency. While quality improvement strategies are well-established in high-resource settings, their implementation in low-resource environments remains underexplored.

Objectives: This study aims to evaluate the impact of a multi-modal quality improvement program on RTT rates in general surgery and obstetrics and gynecology at two tertiary hospitals in Iraq.

Materials and methods: This two-center, quasi-experimental study included 1,133 surgical cases over two cycles: a retrospective baseline (January 2021-January 2022) and a prospective post-intervention phase (March 2022-March 2023). Interventions included staff training on secure surgical knot techniques, enhancing adherence to the WHO surgical safety checklist, and mandatory supervision by consultants during high-risk operations. Key outcomes included RTT rates, causes, preventability, intensive care unit admissions, and hospital stays.

Results: The overall RTT rate decreased significantly from 7.9% in the first cycle to 3.7% in the second (p = 0.004). Reductions were observed in both general surgery (6.3% to 3.0%, p = 0.048) and obstetrics and gynecology (10.5% to 4.8%, p = 0.037). Sepsis (40.0%), wound dehiscence (34.3%), and hemorrhage (25.7%) were the leading causes of RTTs. Incomplete WHO checklist documentation and urgent surgeries were significantly associated with RTTs (p < 0.001). Most RTT cases (58.6%) were deemed non-preventable, but 32.9% were potentially preventable, and 8.5% were preventable.

Conclusions: A structured, low-cost quality improvement program effectively reduced RTT rates in two Iraqi hospitals. Interventions such as surgical technique training, checklist compliance, and consultant supervision may help improve surgical outcomes in resource-limited settings.