Trauma care and capture rate of variables of World Health Organisation data set for injury at regional hospitals in Tanzania: first steps to a national trauma registry

Assessment and reassessment of injured patients at non-tertiary hospitals in Ghana: A stepped-wedge cluster randomized trial

Introduction

Frequent reassessment of injured patients is an important component of trauma and emergency care. How frequently such reassessment is done in African hospitals has been minimally addressed. We sought to address this gap, as well as to assess the effectiveness of a standardized trauma intake form (TIF) to improve assessment and reassessment rates.

Methods

We undertook a stepped-wedge cluster randomized trial with research assistants observing trauma care before and after introducing the TIF at emergency units of eight non-tertiary Ghanaian hospitals for 17.5 months. Differences in seven key performance indicators (KPIs) of assessment and reassessment were evaluated using generalized linear mixed regression. KPIs included: respiratory rate, heart rate, blood pressure, level of consciousness, mobility, temperature, and oxygen saturation.

Results

Management of 4077 patients was observed: 2067 before TIF initiation and 2010 after. In the before period, completion of KPIs of initial assessment ranged from 55% (oxygen saturation) to 88% (level of consciousness). KPIs for reassessment for patients still in the EU after 30 min (n = 1945, in before period) were much lower than for initial assessment, ranging from 10% (respiratory rate and oxygen saturation) to 13% (level of consciousness). The TIF did not significantly improve performance of any KPI of assessment or reassessment. Similar patterns pertained for the subgroup of seriously injured patients (Injury Severity Score ≥9).

Conclusion

At non-tertiary hospitals in Ghana, performance of KPIs of initial assessment were mostly adequate, but with room for improvement. Performance of KPIs for reassessment were very low, even for seriously injured patients. The intervention (trauma intake form) did not impact reassessment rates, despite previously having been shown to impact many other KPIs of trauma care. Potential avenues to pursue to improve reassessment rates include other quality improvement efforts and increased emphasis on reassessment in training courses.

Pulse oximetry training landscape for healthcare workers in low- and middle-income countries: A scoping review

Background

Pulse oximetry has been used in medical care for decades. Its use quickly became standard of care in high resource settings, with delayed widespread availability and use in lower resource settings. Pulse oximetry training initiatives have been ongoing for years, but a map of the literature describing such initiatives among health care workers in low- and middle-income countries (LMICs) has not previously been conducted. Additionally, the coronavirus disease 2019 (COVID-19) pandemic further highlighted the inequitable distribution of pulse oximetry use and training. We aimed to characterise the landscape of pulse oximetry training for health care workers in LMICs prior to the COVID-19 pandemic as described in the literature.

Methods

We systematically searched six databases to identify studies reporting pulse oximetry training among health care workers, broadly defined, in LMICs prior to the COVID-19 pandemic. Two reviewers independently assessed titles and abstracts and relevant full texts for eligibility. Data were charted by one author and reviewed for accuracy by a second. We synthesised the results using a narrative synthesis.

Results

A total of 7423 studies were identified and 182 screened in full. A total of 55 training initiatives in 42 countries met inclusion criteria, as described in 66 studies since some included studies reported on different aspects of the same training initiative. Five overarching reasons for conducting pulse oximetry training were identified: 1) anaesthesia and perioperative care, 2) respiratory support programme expansion, 3) perinatal assessment and monitoring, 4) assessment and monitoring of children and 5) assessment and monitoring of adults. Educational programmes varied in their purpose with respect to the types of patients being targeted, the health care workers being instructed, and the depth of pulse oximetry specific training.

Conclusions

Pulse oximetry training initiatives have been ongoing for decades for a variety of purposes, utilising a multitude of approaches to equip health care workers with tools to improve patient care. It is important that these initiatives continue as pulse oximetry availability and knowledge gaps remain. Neither pulse oximetry provision nor training alone is enough to bolster patient care, but sustainable solutions for both must be considered to meet the needs of both health care workers and patients.

Fall injuries in Sub-Saharan Africa: analysis of prospective injury registry from 23 health facilities in Malawi and Tanzania

BACKGROUND

Low-and middle-income countries account for over 80% of fall-related fatalities globally. However there is little emphasis on the issue and limited high quality data to understand the burden, and to inform preventive and management strategies. We characterise the burden of fall injuries in Malawi and Tanzania.

METHODS

This multi-centre prospective descriptive study utilized trauma registry data from 10 hospitals in Malawi and 13 hospitals in Tanzania. The study included twelve months of data in Tanzania (October 2019 to September 2020), and eighteen months of data from Malawi (September 2018 to March 2020). We describe patient demographics, the causes, location, and nature of injuries, timing of arrival to hospital, and final disposition. Regression analyses were performed to determine risk factors for serious injuries.

RESULTS

There were 93,178 trauma patients in the registries of both countries, of which 44,609 (47.9%) had fall related complaints. Fall injuries accounted for 55.3% and 17.4% of all trauma cases in Malawi and Tanzania respectively. Overall the median age was 16 years (Interquartile range (IQR) 8-31 years), and 62.8% were male. Most fall injuries (69.9%) occurred at home, were unintentional (98.1%), and were due to a ground level fall (74.9%). Nearly half of patients (47.9%) arrived at a facility using public transport, with median arrival time of 10 h (IQR 8-13 h) from initial injury. Extremities (87.0%) were the most commonly injured region, followed by head and neck (4.4%). Overall 3275 (7.4%) patients had potentially serious injuries. Age > 60 years was associated with two times odds of having serious injuries than those < 5 years, and those sustaining injury at work (adjusted Odds Ratio (aOR) 1.95 95% CI; 1.56-2.43) or recreational areas (aOR 3.47 95% CI; 2.93-4.10) had higher odds of serious injuries compared to those injured at home.

CONCLUSIONS

In these facilities in Sub-Saharan Africa, fall injuries accounted for a substantial fraction of all injuries. While most common in younger males, those aged 5-13 and over 60 years were more likely to have serious injuries. Most falls occurred at home, but serious injuries were more likely to occur at recreational and work areas. Future efforts should focus on preventive strategies to mitigate these injuries.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Purpose of Review

Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.

Recent Findings

A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.

Summary

Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

Achievement of Key Performance Indicators in Initial Assessment and Care of Injured Patients in Ghanaian Non-tertiary Hospitals: An Observational Study

INTRODUCTION

We aimed to determine the level of achievement of key performance indicators (KPIs) during initial assessment and management of injured persons, as assessed by independent observers, at district and regional hospitals in Ghana.

METHODS

Trained observers were stationed at emergency units of six district (first level) and two regional (referral) hospitals, from October 2020 to February 2021, to observe management of injured patients by health service providers. Achievement of KPIs was assessed for all injured patients and for seriously injured patients (admitted for ≥ 24 h, referred, or died).

RESULTS

Management of 1006 injured patients was observed. Road traffic crash was the most common mechanism (63%). Completion of initial triage ranged from 65% for oxygen saturation to 92% for mobility assessment. For primary survey, airway was assessed in 77% of patients, chest examination performed in 66%, and internal abdominal bleeding assessed in 43%. Reassessment rates were low, ranging from 16% for respiratory rate to 23% for level of consciousness. Thirty-one percent of patients were seriously injured. Completion of KPIs was higher for these patients, but reassessment remained low, ranging from 25% for respiratory rate to 33% for level of consciousness.

CONCLUSION

KPIs were performed at a high level, but several specific elements should be performed more frequently, such as oxygen saturation and assessment for internal abdominal bleeding. Reassessment needs to be performed more frequently, especially for seriously injured patients. Overall, care for the injured at non-tertiary hospitals in Ghana could be improved with a more systematic approach.

Pediatric trauma burden in Tanzania: analysis of prospective registry data from thirteen health facilities

Background

Trauma is among the leading causes of morbidity and mortality among pediatric and adolescent populations worldwide, with over ninety percent of childhood injuries occurring in low-income and middle-income countries. Lack of region-specific data on pediatric injuries is among the major challenges limiting the ability of health systems to implement interventions to prevent injuries and improve outcomes. We aim to characterize the burden of pediatric health injuries, initial healthcare interventions and outcomes seen in thirteen diverse healthcare facilities in Tanzania.

Methods

This was a prospective cohort study of children aged up to 18 years presenting to emergency units (EUs) of thirteen multi-level health facilities in Tanzania from 1^st October 2019 to 30^th September 2020. We describe injury patterns, mechanisms and early interventions performed at the emergency units of these health facilities.

Results

Among 18,553 trauma patients seen in all thirteen-health facilities, 4368 (23.5%) were children, of whom 2894 (66.7%) were male. The overall median age was 8 years (Interquartile range 4–12 years). Fall 1592 (36.5%) and road traffic crash (RTC) 840 (19.2%) were the top mechanisms of injury. Most patients 3748 (85.8%) arrived at EU directly from the injury site, using motorized (two or three) wheeled vehicles 2401 (55%). At EU, 651 (14.9%) were triaged as an emergency category. Multiple superficial injuries (14.4%), fracture of forearm (11.7%) and open wounds (11.1%) were the top EU diagnoses, while 223 (5.2%) had intracranial injuries. Children aged 0–4 years had the highest proportion (16.3%) of burn injuries. Being referred and being triaged as an emergency category were associated with high likelihood of serious injuries with adjusted odds ratio (AOR) 4.18 (95%CI 3.07–5.68) and 2.11 (95%CI 1.75–2.56), respectively. 1095 (25.1%) of patients were admitted to inpatient care, 14 (0.3%) taken to operation theatre, and 25 (0.6%) died in the EU.

Conclusions

In these multilevel health facilities in Tanzania, pediatric injuries accounted for nearly one-quarter of all injuries. Over half of injuries occurred at home. Fall from height was the leading mechanism of injury, followed by RTC. Most patients sustained fractures of extremities. Future studies of pediatric injuries should focus on evaluating various preventive strategies that can be instituted at home to reduce the incidence and associated impact of such injuries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-022-00369-7.

The burden of trauma in Tanzania: Analysis of prospective trauma registry data at regional hospitals in Tanzania

BACKGROUND

Trauma contributes significantly to the burden of disease and mortality in sub-Saharan Africa (SSA). Like most of SSA, Tanzania lacks prospective trauma registries (TRs), resulting in poor and inconsistent availability of injury data. A model TR was implemented at five representative regional hospitals in Tanzania; the TR incorporates the variables recommended by the World Health Organisation (WHO) Data Set for Injury. This study characterises the burden of trauma seen at five regional hospital Emergency Units (EUs) in Tanzania using data from this new TR.

METHODS

This prospective descriptive study used TR data from EUs of five regional Hospitals in Tanzania between February 2019 to September 2019. Descriptive statistics were calculated for mechanism of injury, injury severity, disposition and mortality. Injury severity scores were calculated. We determined relative risk for mortality by injury type.

RESULTS

Over a seven-month period, 6,302 (9.6%) patients presented to these EUs with trauma-related complaints. They had a median age of 27 (IQR: 19-37) years and 71.3% were male. Most patients (76.6%) were self-referred and presented to EU on motorized (two or three-wheeler) vehicle (55.9%). Road traffic accidents (RTAs) 3786 (60.3%) were the most common mechanism of injury. Most patients (63.3%) presented with injuries to the upper and lower extremities, while few (2.0%) had injuries to the chest. The overall mean Injury Severity Score (ISS) was 9 (Interquartile Range (IQR): 4-13], and varied by hospital. Total 24-hour mortality was 3.3% and 126 (2.1%) patients died while receiving care at the EU. Among those who died, 156 (81.7%) had an intracranial injury; relative risk of death was [13.3 (CI_95%: 9.3 -19.1), p<0.0001] for intracranial injuries compared to other injury patterns.

CONCLUSIONS

TR from these five Tanzanian regional hospitals has provided an opportunity to more accurately describe the country's burden of injury. Having sufficient data for ISS and other key trauma variables allows us to compare the burden and outcomes of trauma in Tanzania with other countries, which will help to quantify an accurate burden of injury, inform quality improvement initiatives, and suggest where to focus preventative measures.

Development and pilot implementation of a standardised trauma documentation form to inform a national trauma registry in a low-resource setting: lessons from Tanzania

OBJECTIVES

Trauma registries are an integral part of a well-organised trauma system. Tanzania, like many low and middle-income countries, does not have a trauma registry. We describe the development, structure, implementation and impact of a context appropriate standardised trauma form based on the adaptation of the WHO Data Set for Injury (DSI), for clinical documentation and use in a national trauma registry.

SETTING

Our study was conducted in emergency units of five regional referral hospitals in Tanzania.

PROCEDURES

Mixed methods participatory action research was employed. After an assessment of baseline trauma documentation, we conducted semi-structured interviews with a purposefully selected sample of 33 healthcare providers from all participating hospitals to understand, develop, pilot and implement a standardised trauma form. We compared the number and types of variables captured before and after the form was implemented.

OUTCOMES

Change in proportion of variables of DSI captured after implementation of a standardised trauma documentation form.

RESULTS

Piloting and feedback informed the development of a context appropriate standardised trauma documentation paper form with carbonless copy that could be used as both the clinical chart and data capture. Among 721 patients (seen by 21 clinicians) during the initial 30-day pilot, overall variable capture was 86.4% of required variables. After modifications of the form and training of healthcare providers, the form was implemented for 7 months, during which the capture improved to 96.3% among 6302 patients (seen by 31 clinicians). The providers reported the form was user-friendly, resulted in less time documenting, and served as a guide to managing trauma patients.

CONCLUSIONS

The development and implementation of a contextually appropriate, standardised trauma form were successful, yielding increased capture rates of injury variables. This system will facilitate expansion of the trauma registry across the country and inform similar initiatives in Sub-Saharan Africa.