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Goel R, Tiwari G, Varghese M, Bhalla K, Agrawal G, Saini G, Jha A, John D, Saran A, White H, Mohan D. Effectiveness of road safety interventions: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1367. [PMID: 38188231 PMCID: PMC10765170 DOI: 10.1002/cl2.1367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Background Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge. Objectives The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels. Search Methods The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019. Selection Criteria The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes. Data Collection and Analysis The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2. Main Results The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality. Authors' Conclusions The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.
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Affiliation(s)
- Rahul Goel
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Geetam Tiwari
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Kavi Bhalla
- Department of Public Health SciencesUniversity of ChicagoChicagoIllinoisUSA
| | - Girish Agrawal
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | | | - Abhaya Jha
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
| | - Denny John
- Faculty of Life and Allied Health SciencesM S Ramaiah University of Applied Sciences, BangaloreKarnatakaIndia
| | | | | | - Dinesh Mohan
- Transportation Research and Injury Prevention CentreIndian Institute of Technology DelhiNew DelhiIndia
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Hansda U, Mishra TS, Topno N, Sahoo S, Mohan S, Chakola S. Prehospital care and interfacility transfer of trauma patients before reaching the emergency of a level-1 trauma care center. J Family Med Prim Care 2024; 13:656-659. [PMID: 38605763 PMCID: PMC11006027 DOI: 10.4103/jfmpc.jfmpc_1271_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/28/2023] [Accepted: 10/09/2023] [Indexed: 04/13/2024] Open
Abstract
Background Management of trauma patients includes prevention, prehospital care, appropriate resuscitation at a hospital, definitive treatment, and rehabilitation. Timely and adequate care for a trauma patient is paramount, which can dramatically impact survival. This study was planned to assess the proportion of patients who failed to receive adequate prehospital care before reaching our institute. Materials and Methods A retrospective study was conducted in the trauma and emergency department of a level-1 trauma center in eastern India from February to April 2022. The demographic profile, vital parameters, injury, mode of transport, travel duration, referring hospital, and any interventions as per airway/breathing/circulation/hypothermia were collected. Results The records of a hundred-two patients who were brought to the trauma and emergency department in the study period were reviewed. Road traffic accident involving two wheelers was the leading cause of injury. Eighty-three percent of the patients were referred from other health centers, of which 49 were referred from district headquarters hospitals. Only three patients out of 14 had been provided with an oropharyngeal airway for whom endotracheal intubation was indicated. Only one among the 41 patients needing Philadelphia collar actually received. Sixteen patients were provided supplemental oxygen out of the 35 for whom it was indicated. Out of 68 patients in whom intravenous cannulation and fluid administration were indicated, only 35 patients had received it. Out of 31 patients with fractures, none were provided immobilization. Conclusion The care of the trauma patients with respect to airway, breathing, circulation, and fracture immobilization was found to be grossly inadequate, emphasizing the need of structured and protocol based prehospital trauma care.
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Affiliation(s)
- Upendra Hansda
- Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
| | - Tushar S. Mishra
- Department of General Surgery, AIIMS, Bhubaneswar, Odisha, India
| | - Nitish Topno
- Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
| | - Sangeeta Sahoo
- Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
| | - Sreshtaa Mohan
- Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
| | - Sebastian Chakola
- Department of Trauma and Emergency, AIIMS, Bhubaneswar, Odisha, India
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Mamalelala TT, Holzemer W, Seloilwe ES, Iwu E, Kamienski M. Experiences of rural nurses with emergency patient transport in a resource limited setting. Int Emerg Nurs 2023; 71:101379. [PMID: 37951060 DOI: 10.1016/j.ienj.2023.101379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/05/2023] [Accepted: 10/25/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Registered nurses are primary care providers during most patient transfers from rural areas. Various local conditions and circumstances impact the provision of nursing care prior to and during transportation. These include clinic staffing, uneven access to functioning equipment and other necessary infrastructure across settings, the wide-ranging clinical need for specialty care, and complex social and interpersonal circumstances that play a role in care-seeking and transport decision-making. This study explored the experiences of nurses with emergency patient transport in rural health facilities in Botswana. METHOD A qualitative descriptive approach was used using a semi structured interview. Twenty-six registered nurses from four remote, isolated rural health districts in Botswana participated in this study. Purposive convenience sampling technique was employed. RESULTS The ten main themes under transporter were infringement of scope of practice, inadequate knowledge and skills, distressful practice, restriction from making decisions, challenges with staffing, Ineffective facilities clustering, lack of support from the managers, shortage of technology and tools, non-enabling infrastructure, and transport related tasks. DISCUSSION AND CONCLUSION The perceived ineffective emergency transfer of patients was associated with work system shortfalls. The work system needs to be balanced and consider the requirements of the various stakeholders involved in the processes for optimal performance of patient transport.
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Affiliation(s)
- Tebogo T Mamalelala
- School of Nursing, Rutgers, The State University of New Jersey, United States; School of Nursing, University of Botswana, Botswana.
| | - William Holzemer
- School of Nursing, Rutgers, The State University of New Jersey, United States
| | - Esther S Seloilwe
- Faculty of Health Sciences, School of Nursing, University of Botswana, Gaborone, Botswana
| | - Emilia Iwu
- School of Nursing, Rutgers, The State University of New Jersey, United States
| | - Mary Kamienski
- School of Nursing, Rutgers, The State University of New Jersey, United States
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Metelmann I, Nagel M, Schneider B, Krämer B, Kraemer S. Lasting Effects of COVID-19 Pandemic on Prehospital Emergency Medical Service Missions. Open Access Emerg Med 2023; 15:325-332. [PMID: 37745834 PMCID: PMC10516217 DOI: 10.2147/oaem.s425272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023] Open
Abstract
Purpose The COVID-19 pandemic confronted prehospital emergency medical services (PHEMS) with immense challenges. This study aimed to investigate the development of PHEMS mission numbers and times in the COVID-affected region of Southwest Saxony (SWS). Patients and Methods This was a retrospective analysis of PHEMS in SWS during lockdown periods and equal time spans in the previous and following years. Differences were tested for statistical significance using the chi-squared test and one-way analysis of variance (ANOVA). Results The total number of missions showed a substantial drop during the first (-16.6%) and the second (-4.5%) lockdown period compared with the previous year. Next-year periods showed a recovery that was nearly equivalent to the starting point. The first lockdown period was not associated with longer overall mission times. The minutes spent at the scene differed significantly between the first lockdown period (31.1 ± 3.52 min), previous year (28.4 ± 4.84 min), and follow-up period (31.8 ± 0.98 min). During the second lockdown, the overall mission times (71.6 ± 2.91 min), response times in minutes (8.9 ± 0.49 min), and minutes spent at the scene (31.4 ± 2.99 min) were significantly longer. The minutes spent at the scene (32.3 ± 18.68 min) and the overall mission time (69.6 ± 1.92 min) remained significantly longer during the control period. Conclusion Our data confirm the impact of the SARS-CoV-2 pandemic on German PHEMS. It can be concluded that nationwide lockdown measures led to lasting effects regarding a reduction in the total mission number, transport-on-site released-ratio, and emergency time intervals in the following year, without lockdown restrictions. The lasting effects on the transport-on-site released-ratio and emergency time intervals call for a re-evaluation of the delivery of emergency services during pandemics. These findings can inform future policy decisions and resource allocations to ensure optimal emergency medical services.
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Affiliation(s)
- Isabella Metelmann
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Saxony, 04103, Germany
| | | | | | - Bernd Krämer
- Rettungszweckverband Südwestsachsen, Plauen, Saxony, 08529, Germany
| | - Sebastian Kraemer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Saxony, 04103, Germany
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Bhattarai HK, Bhusal S, Barone-Adesi F, Hubloue I. Prehospital Emergency Care in Low- and Middle-Income Countries: A Systematic Review. Prehosp Disaster Med 2023; 38:495-512. [PMID: 37492946 PMCID: PMC10445116 DOI: 10.1017/s1049023x23006088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/08/2023] [Accepted: 06/17/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs. METHODS This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle-Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies. CONCLUSIONS The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.
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Affiliation(s)
- Hari Krishna Bhattarai
- Program in Global Health, Humanitarian Aid and Disaster Medicine, Università del Piemonte Orientale, Novara, Italy, and Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Francesco Barone-Adesi
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Ives Hubloue
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium Research Group on Emergency and Disaster Medicine, Medical School, Vrije Universiteit Brussel, Brussels, Belgium
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Patterns and Predictors of Timely Presentation and Outcomes of Polytrauma Patients Referred to the Emergency Department of a Tertiary Hospital in Tanzania. Emerg Med Int 2022; 2022:9611602. [PMID: 36387014 PMCID: PMC9652091 DOI: 10.1155/2022/9611602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Polytrauma patients require special facilities to care for their injuries. In HICs, these patients are rapidly transferred from the scene or the first-health facility directly to a trauma center. However, in many LMICs, prehospital systems do not exist and there are long delays between arrivals at the first-health facility and the trauma center. We aimed to quantify the delay and determine the predictors of mortality among polytrauma patients. Methodology. We consecutively enrolled adult polytrauma patients (≥18 years) with ISS >15 referred to the Emergency Medicine Department of Muhimbili National Hospital, a major trauma center in Tanzania between August 2019 and January 2020. Based on a pilot study, the arrival of >6 hours after injury was considered a delay. The outcome of interest was factors associated with delayed presentation and the association of timeliness with 7-day mortality. Results We enrolled 120 (4.5%) referred polytrauma adult patients. The median age was 30 years (IQR 25–39) and the ISS was 29 (IQR 24–34). The majority (85%) were males. While the median time from injury to first-health facility was 40 minutes (IQR 33–50), the median time from injury to arrival at EMD-MNH, was 377 minutes (IQR 314–469). Delayed presentation was noted in more than half (54.2%) of participants, with the odds of dying being 1.4 times higher in the delayed group (95% CI 0.3–5.6). Having a GCS <8 (AOR 16.3 (95% CI 3.1–86.3), hypoxia <92% (AOR 8.3 (95% CI 1.4–50.9), and hypotension <90 mmHg (R 7.3 (95% CI 1.6–33.6) were all independent predictors of mortality. Conclusion The majority of polytrauma patients arrive at the tertiary facilities delayed for more than 6 hours and a distance of more than 8 km between facilities is associated with delay. Hypotension, hypoxia, and GCS of less than 8 are independent predictors of poor outcome. In the interim, there is a need to expedite the transfer of polytrauma patients to trauma care capable centers.
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De los Ríos-Pérez A, García A, Cuello L, Rebolledo S, Fandiño-Losada A. Performance of the Paediatric Trauma Score on survival prediction of injured children at a major trauma centre: A retrospective Colombian cohort, 2011-2019. LANCET REGIONAL HEALTH. AMERICAS 2022; 13:100312. [PMID: 36777320 PMCID: PMC9903890 DOI: 10.1016/j.lana.2022.100312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Despite improvements in children's health due to a reduction in infections, trauma continues to cause many deaths among adolescents. Strategies to mitigate morbidity and mortality from trauma include severity scores to classify and refer patients to the appropriate hospitals to provide better management; however, these strategies have not been assessed in Colombian children. This study aimed to describe the characteristics and outcomes of injured children and evaluate the performance of the Pediatric Trauma Score (PTS) in predicting survival at a major trauma centre in a Colombian city. Methods This was a retrospective cohort study of children aged <18 years who were treated for injuries at a hospital in Colombia. The primary outcome was 30-day mortality. A simple logistic regression model was used with PTS as the predictor variable and vital status at discharge as the outcome variable. PTS performance was assessed by discrimination using the area under the receiver-operating characteristic (AUROC) curve and by calibration using the Hosmer-Lemeshow (HL) goodness-of-fit test. Findings A total of 1047 children were admitted. The median age was 12 years (interquartile range [IQR]=5-15); 73·7% were male, and 66·1% had blunt trauma. The most frequent cause of injury was traffic accident (31·5%) followed by assaults (29%). Mortality was 5·9%; 61·3% of these deaths occurred in adolescents between 15 and 17 years of age and 71% of deaths in this age group were due to injuries from a firearm. The PTS had a median of 7 (IQR=5-9), an AUROC of 0·93, and good calibration (HL=7·97, p = 0·33). Interpretation The highest proportion of trauma and death occurred among adolescents. Interpersonal violence was the most frequent cause of death in this age group. The PTS showed good predictive power for survival, with excellent discrimination and good calibration. Funding None.
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Affiliation(s)
- Ana De los Ríos-Pérez
- Program in Methodology of Biomedical Research and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
- Fundación Valle del Lili University Hospital, Cali, Colombia
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
- Corresponding author.
| | - Alberto García
- Fundación Valle del Lili University Hospital, Cali, Colombia
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
- Faculty of Health, Universidad del Valle, Cali, Colombia
- Cisalva Institute, Faculty of Health, Universidad del Valle, Cali, Colombia
| | - Laura Cuello
- Fundación Valle del Lili University Hospital, Cali, Colombia
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Sara Rebolledo
- Fundación Valle del Lili University Hospital, Cali, Colombia
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Andrés Fandiño-Losada
- Faculty of Health, Universidad del Valle, Cali, Colombia
- Cisalva Institute, Faculty of Health, Universidad del Valle, Cali, Colombia
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Yohann A, Kratzke I, Williams B, Charles A. The effect of transfer status on trauma outcomes in low- and middle-income countries: A systematic review and meta-analysis. Injury 2022; 53:885-894. [PMID: 34689985 PMCID: PMC9176640 DOI: 10.1016/j.injury.2021.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Injuries are a leading cause of disability and death worldwide, and low- and middle-income countries (LMICs) are disproportionately burdened by trauma. Prior studies have shown that transfer status (direct transfer from injury scene to a referral hospital versus indirect transfer from another facility to a referral hospital) may affect patient outcomes. The purpose of this study is to evaluate the relationship between transfer status and trauma patient outcomes in LMICs by conducting a systematic review and meta-analysis. METHODS We performed a systematic search to identify studies from LMICs that evaluated the relationship between transfer status and trauma patient outcomes. We extracted data on study country, design, patient characteristics, and outcomes. We report results in the form of a narrative summary stratified by type of outcome. We also performed a meta-analysis of studies that reported mortality by transfer status. We calculated a pooled odds ratio of mortality among indirectly transferred (IT) versus directly transferred (DT) patients using random-effects modeling. RESULTS We included 17 observational studies from 9 LMICs in this systematic review. Outcomes assessed were time from injury to arrival at a referral hospital, post-trauma functional status, hospital length of stay, and mortality. IT patients took between 0.6 and 37.9 h longer to arrive at referral hospitals than DT patients. Hospital length of stay was up to 6 days longer for IT patients than DT patients. The pooled odds ratio of mortality among IT patients compared to DT patients was 1.55 (95% CI 1.12 - 2.15; p = 0.009). CONCLUSION Trauma patients in LMICs who are indirectly transferred to referral hospitals have significantly higher mortality rates than patients who present directly to referral hospitals. These results conflict with findings from HICs and reflect the relative immaturity of trauma systems in LMICs. Strategies to narrow the mortality gap between IT and DT patients include improving prehospital and primary hospital care and developing more efficient transfer protocols.
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Affiliation(s)
- Avital Yohann
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Ian Kratzke
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Brittney Williams
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, United States; Kamuzu Central Hospital, Lilongwe, Malawi.
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Relationship Between Prehospital Time and 24-h Mortality in Road Traffic-Injured Patients in Laos. World J Surg 2022; 46:800-806. [PMID: 35041060 PMCID: PMC8885552 DOI: 10.1007/s00268-022-06445-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
Background Road traffic injury has long been regarded as a “time-dependent disease.” However, shortening the prehospital time might not improve the outcome in developing countries given the current quality of in-hospital care. We aimed to examine the relationship between the prehospital time and 24-h mortality among road traffic victims in Laos. Methods A prospective observational study was conducted using the trauma registry data on traffic-injured patients who were transported by ambulance to a trauma center in the capital city of Laos from May 2018 to April 2019. The analysis focused on patients with non-mild conditions, whose outcomes could be affected by the prehospital time. To examine the relationship between a prehospital time of <60 min and 24-h mortality, a generalized estimating equation model was used incorporating the inverse probability weights utilizing the propensity score for the prehospital time. Results Of 701 patients, 73% were men, 91% were riding 2- or 3-wheel motor vehicles during the crash, and 68% had a prehospital time of <60 min. A total of 35 patients died within 24 h after the crash. Compared with those who survived, individuals who died tended to have head and torso injuries. The proportions of 24-h mortality were 4.7% and 5.4% in patients whose prehospital time was <60 min and ≥60 min, respectively. No significant relationship was found between the prehospital time and 24-h mortality. Conclusion A shorter prehospital time was not associated with the 24-h survival among road traffic victims in Laos. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06445-9.
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Yohann A, Kayange L, Purcell LN, Gallaher J, Charles A. Direct Transfer to a Tertiary Care Hospital After Traumatic Injury is Associated with a Survival Benefit in a Resource-Limited Setting. World J Surg 2022; 46:504-511. [PMID: 34989834 DOI: 10.1007/s00268-021-06415-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Trauma is a leading cause of morbidity and mortality worldwide, and patients in low- and middle-income countries are disproportionately affected. Organized trauma systems, including appropriate transfer to a higher level of care, improve trauma outcomes. We sought to evaluate the relationship between transfer status and trauma mortality in Malawi. METHODS We performed a retrospective analysis of trauma patients admitted to Kamuzu Central Hospital (KCH), a trauma center in Lilongwe, Malawi, between January 1, 2013, and May 30, 2018. Transfer status was categorized as direct if a patient arrives at KCH from the injury scene and indirect if a patient comes to KCH from another health care facility. We used logistic regression modeling to evaluate the relationship between transfer status and in-hospital mortality. RESULTS A total of 8369 patients were included in the study. The mean age was 34.6 years (SD 15.8), and 81% of patients were male. The most common mechanism of injury was motor vehicle collision. Injury severity did not significantly differ between the two groups. Crude mortality was 4.8% for indirect and 2.6% for direct transfers. After adjusting for relevant covariates, odds ratio of mortality was 2.12 (1.49-3.02, p < 0.001) for indirect versus direct transfers. CONCLUSION Trauma patients indirectly transferred to a trauma center have nearly double the risk of mortality compared to direct transfers. Trauma outcome improvement efforts must focus on strengthening prehospital care, improving district hospital capacity, and developing protocols for early assessment, treatment, and transfer of trauma patients to a trauma center.
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Affiliation(s)
- Avital Yohann
- Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA
| | | | - Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA. .,Kamuzu Central Hospital, Lilongwe, Malawi.
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Motsumi MJ, Ayane G, Kwati M, Panzirah-Mabaka K, Walsh M. Preventable deaths following road traffic collisions in Botswana: A retrospective review. Injury 2021; 52:2665-2671. [PMID: 33888332 DOI: 10.1016/j.injury.2021.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 03/27/2021] [Accepted: 04/01/2021] [Indexed: 02/02/2023]
Abstract
Road traffic collisions (RTC) are a major cause of mortality and morbidity in Botswana. To our knowledge no research has been conducted in Botswana to investigate preventable deaths that occur as a result of RTCs. The aim of this study is to establish the rate of preventable deaths from RTCs in the greater Gaborone area in Botswana. This was a 5-year retrospective study conducted at the forensic pathology department for the greater Gaborone area, in Botswana. Nine hundred and nine (909) forensic pathology reports were retrieved. Sixty-eight percent (68.2%) of RTC deaths were considered preventable. Head injury in isolation and in combination with other injuries accounted for 87.6% (796/909) of deaths. Haemorrhagic shock was present in 70.2% (638) of all documented injuries. Another documented injury contributing to fatal RTCs was high spinal cord injury. This injury was documented in 13.1% (119/909) of all deaths. We recommend the implementation of a comprehensive trauma system in Botswana to reduce the number of deaths from RTCs.
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Affiliation(s)
- Mpapho Joseph Motsumi
- Department of Surgery, Faculty of Medicine, University of Botswana, P.O. Box 37 Mogoditshane, Botswana.
| | - Gezahen Ayane
- Department of Surgery, Faculty of Medicine, University of Botswana, P.O. Box 37 Mogoditshane, Botswana
| | - Morapedi Kwati
- Department of Surgery, Princess Marina hospital, Botswana
| | | | - Michael Walsh
- Department of Surgery, Bokamoso private hospital, Botswana
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Yilmaz S, Ak R, Hokenek NM, Yilmaz E, Tataroglu O. Comparison of trauma scores and total prehospital time in the prediction of clinical course in a plane crash: Does timing matter? Am J Emerg Med 2021; 50:301-308. [PMID: 34425323 DOI: 10.1016/j.ajem.2021.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/10/2021] [Accepted: 08/10/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate how the total prehospital time (TPT), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and Trauma Score-Injury Severity Score (TRISS) affect the outcome of plane crash victims from anatomical, physiological and psychological perspectives. The accuracy or strength of these scores and TPT in predicting hospitalization and surgery, sequelae development and psychiatric complications [permanent temporary disability (PoTDs)] and PTSD can allow medical professionals to direct and prioritize management efforts of the victims of mass casualties in general. METHODS The study was designed as a single-center retrospective study. By examining the records of victims of a plane crash transferred to the ED, AIS, ISS, TRISS and TPT were calculated on admission. The clinical severity of the patients was determined by a joint decision of five clinicians. The performances of the trauma scores on hospitalization, surgery, PTSD and PoTDs were compared. The study data were analyzed via the Mann-Whitney U test and descriptive statistical methods. Pearson's chi-square test was used for the comparison of qualitative data, and ROC analyses were employed to determine cutoff levels. RESULTS The AIS, ISS, and TRISS scores of the victims with an indication for hospitalization, calculated on admission to the ED, were significantly higher than those of the other victims (p = 0.001). In addition, TPT, AIS, ISS, and TRISS scores were significantly higher in hospitalized patients than in outpatients (p < 0.05). The cutoff levels for AIS and ISS were ≥ 1.50 and ≥ 4.50, respectively, while they were ≥ 123.5 min for TPT with regard to hospitalization decisions. The AIS, ISS, and TRISS scores calculated on admission for the patients who underwent surgery were significantly higher than those who did not (p = 0.001). Cutoff levels for AIS and ISS were ≥ 2.50 and ≥ 11.50, respectively, while they were ≥ 135.5 min for TPT with respect to the decision to operate on the victims. CONCLUSIONS It is expected that everyone who practices medicine be equipped to handle multiple casualties. As the number of people involved in mass casualties increases, diagnostic tools, workups such as laboratory and radiological studies, and prognostic markers such as trauma scores should be simpler and more user-friendly.
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Affiliation(s)
- Sarper Yilmaz
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Rohat Ak
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Nihat Mujdat Hokenek
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey.
| | - Erdal Yilmaz
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Ozlem Tataroglu
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
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Cirocchi R, Popivanov G, Konaktchieva M, Chipeva S, Tellan G, Mingoli A, Zago M, Chiarugi M, Binda GA, Kafka R, Anania G, Donini A, Nascimbeni R, Edilbe M, Afshar S. The role of damage control surgery in the treatment of perforated colonic diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:867-879. [PMID: 33089382 PMCID: PMC8026449 DOI: 10.1007/s00384-020-03784-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II-IV complicated acute diverticulitis (CAD). METHODS A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953). RESULTS Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%]. CONCLUSIONS The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach.
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Affiliation(s)
- Roberto Cirocchi
- Department of General Surgery, University of Perugia, 06123 Perugia, Italy
| | - Georgi Popivanov
- Department of Surgery, Military Medical Academy, ul. “Sv. Georgi Sofiyski” 3, 1606 Sofia, Bulgaria
| | - Marina Konaktchieva
- Department of Gastroenterology and Hepatology, Military Medical Academy, ul. “Sv. Georgi Sofiyski” 3, 1606 Sofia, Bulgaria
| | - Sonia Chipeva
- Department of Statistics and Econometrics, University of National and World Economy, Sofia, Bulgaria
| | - Guglielmo Tellan
- Department of Emergency and Acceptance, Critical Areas and Trauma, “Umberto I” University Hospital, Sapienza University of Rome, 00161 Rome, Italy
| | - Andrea Mingoli
- Dipartimento di Chirurgia “P. Valdoni”, Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Mauro Zago
- Department of Emergency and Robotic Surgery - A.Manzoni Hospital, Lecco, Italy
| | - Massimo Chiarugi
- Emergency Surgery & Trauma Center, Cisanello University Hospital, 56124 Pisa, Italy
| | | | - Reinhold Kafka
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Gabriele Anania
- Department of Medical Science, University of Ferrara, 4121 Ferrara, Italy
| | - Annibale Donini
- Department of General Surgery, University of Perugia, 06123 Perugia, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy
| | - Mohammed Edilbe
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - Sorena Afshar
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
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Krishna G, Aggarwal V, Singh I. Prospective Analysis of Coagulopathy Associated with Isolated Traumatic Brain Injury and Clinical Outcome. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1728989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Introduction Traumatic brain injury (TBI) affects the coagulation pathway in a distinct way than does extracranial trauma. The extent of coagulation abnormalities varies from bleeding diathesis to disseminated thrombosis.
Design Prospective study.
Methods The study included 50 patients of isolated TBI with cohorts of moderate (MHI) and severe head injury (SHI). Coagulopathy was graded according to the values of parameters in single laboratory. The incidence of coagulopathy according to the severity of TBI and correlation with disseminated intravascular coagulation (DIC) score, platelets, prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, and fibrinogen was observed. The comparison was also made between expired and discharged patients within each group. It also compared coagulation derailments with clinical presentation (Glasgow Coma Scale [GCS]) and outcome (Glasgow Outcome Scale [GOS]).
Results Road traffic accident was the primary (72%) mode of injury. Fifty-two percent had MHI and rest had SHI. Eighty-four percent of cases were managed conservatively. The mean GCS was 12.23 and 5.75 in MHI and SHI, respectively. Sixty-two percent of MHI and 96% of the patients with SHI had coagulation abnormalities. On statistical analysis, DIC score (p < 0.001) strongly correlated with the severity of head injury and GOS. PT and APTT were also significantly associated with the severity of TBI. In patients with moderate TBI, D-dimer and platelet counts showed association with clinical outcome. Fibrinogen levels did not show any statistical significance. The mean platelet counts remained normal in both the groups of TBI. The mean GOS was 1.54 and 4.62 in SHI and MHI, respectively.
Conclusion Coagulopathy is common in isolated TBI. The basic laboratory parameters are reliable predictors of coagulation abnormalities in TBI. Coagulopathy is directly associated with the severity of TBI, GCS, and poor outcome.
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Affiliation(s)
- Gopal Krishna
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Varun Aggarwal
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Ishwar Singh
- Department of Neurosurgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
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Hosseinzadeh A, Kluger R. Do EMS times associate with injury severity? ACCIDENT; ANALYSIS AND PREVENTION 2021; 153:106053. [PMID: 33636435 DOI: 10.1016/j.aap.2021.106053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 06/12/2023]
Abstract
In this study, emergency medical services times, along with other crash-related explanatory variables, have been used to investigate influential factors on injury severity. To overcome the complexity of emergency medical services times impact on crash outcome, the interaction effects of EMS times and injury location on the body were also investigated in a separate model. This study utilized the linked data of police-reported crash data and emergency medical services runs, including 2192 crash injuries that transferred to hospital. A random-effects ordered probit approach was implemented to identify effective factors on crash injury severity. Three models of (1) crash-related variables, (2) crash-related and emergency medical services times and (3) crash-related, emergency medical services times and interaction effects of EMS times and injury location on the body were developed. Although the outcome could not find the impact of faster emergency medical services times on injury severity in the second model, in the third model, faster response time and slower on-scene time were associated with decreasing the severity of entire-body injuries. We discuss why this may be the case.
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Affiliation(s)
- Aryan Hosseinzadeh
- Department of Civil and Environmental Engineering, University of Louisville, W.S. Speed, Louisville, KY, 40292, USA
| | - Robert Kluger
- Department of Civil and Environmental Engineering, University of Louisville, W.S. Speed, Louisville, KY, 40292, USA.
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Babu SV. The Golden Hour Trauma Care. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0040-1718479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractGlobally the road accidents had become a great burden and claiming lot of precious lives today. However, the initial treatment within the first hour of the injury indeed had proven the high chance of survival after the trauma. This article updates and signifies the systematic emergency approach and current principles in saving lives after injury.
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Affiliation(s)
- Subbiah Venkatesh Babu
- Department of Orthopaedic & Trauma, Sri Sakthi Hospital, Tirunelveli City, Tamil Nadu, India
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17
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Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study. PLoS Med 2020; 17:e1003360. [PMID: 33022018 PMCID: PMC7537901 DOI: 10.1371/journal.pmed.1003360] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/31/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Whether rapid transportation can benefit patients with trauma remains controversial. We determined the association between prehospital time and outcome to explore the concept of the "golden hour" for injured patients. METHODS AND FINDINGS We conducted a retrospective cohort study of trauma patients transported from the scene to hospitals by emergency medical service (EMS) from January 1, 2016, to November 30, 2018, using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital time intervals were categorized into response time (RT), scene to hospital time (SH), and total prehospital time (TPT). The outcomes were 30-day mortality and functional status at hospital discharge. Multivariable logistic regression was used to investigate the association of prehospital time and outcomes to adjust for factors including age, sex, mechanism and type of injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and prehospital interventions. Overall, 24,365 patients from 4 countries (645 patients from Japan, 16,476 patients from Korea, 5,358 patients from Malaysia, and 1,886 patients from Taiwan) were included in the analysis. Among included patients, the median age was 45 years (lower quartile [Q1]-upper quartile [Q3]: 25-62), and 15,498 (63.6%) patients were male. Median (Q1-Q3) RT, SH, and TPT were 20 (Q1-Q3: 12-39), 21 (Q1-Q3: 16-29), and 47 (Q1-Q3: 32-60) minutes, respectively. In all, 280 patients (1.1%) died within 30 days after injury. Prehospital time intervals were not associated with 30-day mortality. The adjusted odds ratios (aORs) per 10 minutes of RT, SH, and TPT were 0.99 (95% CI 0.92-1.06, p = 0.740), 1.08 (95% CI 1.00-1.17, p = 0.065), and 1.03 (95% CI 0.98-1.09, p = 0.236), respectively. However, long prehospital time was detrimental to functional survival. The aORs of RT, SH, and TPT per 10-minute delay were 1.06 (95% CI 1.04-1.08, p < 0.001), 1.05 (95% CI 1.01-1.08, p = 0.007), and 1.06 (95% CI 1.04-1.08, p < 0.001), respectively. The key limitation of our study is the missing data inherent to the retrospective design. Another major limitation is the aggregate nature of the data from different countries and unaccounted confounders such as in-hospital management. CONCLUSIONS Longer prehospital time was not associated with an increased risk of 30-day mortality, but it may be associated with increased risk of poor functional outcomes in injured patients. This finding supports the concept of the "golden hour" for trauma patients during prehospital care in the countries studied.
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Koome G, Atela M, Thuita F, Egondi T. Health system factors associated with post-trauma mortality at the prehospital care level in Africa: a scoping review. Trauma Surg Acute Care Open 2020; 5:e000530. [PMID: 33083557 PMCID: PMC7528423 DOI: 10.1136/tsaco-2020-000530] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/30/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Africa accounts forabout 90% of the global trauma burden. Mapping evidence on health systemfactors associated with post-trauma mortality is essential in definingpre-hospital care research priorities and mitigation of the burden. The studyaimed to map and synthesize existing evidence and research gaps on healthsystem factors associated with post-trauma mortality at the pre-hospital carelevel in Africa. METHODS A scoping review of published studies and grey literature was conducted. The search strategy utilized electronic databases comprising of Medline, Google Scholar, Pub-Med, Hinari and Cochrane Library. Screening and extraction of eligible studies was done independently and in duplicate. RESULTS A total of 782 study titles and or abstracts were screened. Of these, 32 underwent full text review. Out of the 32, 17 met the inclusion criteria for final review. The majority of studies were literature reviews (24%) and retrospective studies (23%). Retrospective and qualitative studies comprised 6% of the included studies, systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%), systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%). Reported post-trauma mortality ranged from 13% in Ghana to 40% in Nigeria. Reported preventable mortality is as high as 70% in South Africa, 60% in Ghana and 40% in Nigeria. Transport mode is the most studied health system factor (reported in 76% of the papers). Only two studies (12%) included access to pre-hospital care interventions aspects, nine studies (53%) included care providers aspects and three studies (18%) included aspects of referral pathways. The types of transport mode and referral pathway are the only factors significantly associated with post-trauma mortality, though the findings were mixed. None of the included studies reported significant associations between pre-hospital care interventions, care providers and post-trauma mortality. DISCUSSION Although research on health system factors and its influence on post-trauma mortality at the pre-hospital care level in Africa are limited, anecdotal evidence suggests that access to pre-hospital care interventions, the level of provider skills and referral pathways are important determinants of mortality outcomes. The strength of their influence will require well designed studies that could incorporate mixed method approaches. Moreover, similar reviews incorporating other LMICs are also warranted. Key Words: Health System Factors, Emergency Medical Services [EMS], Pre-hospital Care, Post-Trauma mortality, Africa.
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Affiliation(s)
- Gilbert Koome
- School of Public Health, University of Nairobi, Nairobi, Kenya
| | - Martin Atela
- Peterhouse, University of Cambridge, Cambridge, UK
| | - Faith Thuita
- School of Public Health, University of Nairobi, Nairobi, Kenya
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19
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Early Surgery in Trauma Patients Is a Key Performance Indicator of Outcome—A Case Series Analysis. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02371-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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20
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Feldhaus I, Carvalho M, Waiz G, Igu J, Matthay Z, Dicker R, Juillard C. Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review. Trauma Surg Acute Care Open 2020; 5:e000424. [PMID: 32420451 PMCID: PMC7223475 DOI: 10.1136/tsaco-2019-000424] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/27/2020] [Accepted: 04/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings. Materials and methods This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized. Results Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility. Conclusions The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective. PROSPERO registration number CRD42017064600.
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Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Melissa Carvalho
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Ghazel Waiz
- Department of Surgery, Center for Global Surgical Studies, University of California San Francisco, San Francisco, California, USA
| | - Joel Igu
- Johns Hopkins University Carey Business School, Baltimore, Maryland, USA
| | - Zachary Matthay
- Department of Surgery, Center for Global Surgical Studies, University of California San Francisco, San Francisco, California, USA
| | - Rochelle Dicker
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Catherine Juillard
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
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Dharap S. Trauma and General Surgeon. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02103-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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22
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Soni KD, Mahindrakar S, Kaushik G, Kumar S, Sagar S, Gupta A. Do the Care Process and Survival Chances Differ in Patients Arriving to a Level 1 Indian Trauma Center, during-Hours and after-Hours? J Emerg Trauma Shock 2019; 12:128-134. [PMID: 31198280 PMCID: PMC6557059 DOI: 10.4103/jets.jets_76_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country. Methodology Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded. Results Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan-Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST. Conclusions Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.
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Affiliation(s)
- Kapil Dev Soni
- Department of Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Santosh Mahindrakar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Gaurav Kaushik
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Landreau F, Valcarcel O, Noir J, Pernía G, Orzábal ML, Martínez S, Tobar A, Isola M, Núñez M, Martínez P, Cuellar C, Villagrán F, Crescenti A. Helicopter Emergency Medical Services in Buenos Aires: An Operational Overview. Air Med J 2018; 37:367-370. [PMID: 30424854 DOI: 10.1016/j.amj.2018.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 06/12/2018] [Accepted: 07/22/2018] [Indexed: 06/09/2023]
Abstract
As part of the emergency medical care system, helicopter emergency medical services (HEMS) have a different crew composition from the traditional team. HEMS consist of a pilot, doctor, and firefighter with rescue skills and training in basic life support on board an air ambulance. This allows the adaptation to different environments and increases the varieties of air procedures normally performed. HEMS began operating relatively recently in Buenos Aires. Yet, in 3 years, its use grew to such an extent that in 2015 it tripled, and by 2016 the number of medical assists was 4 times greater than in 2014. Furthermore, over the 3-year study period, 92% to 95% of assisted victims were traffic accident casualties requiring primary care. The HEMS crew is informed about the availability of resources in the acute care general hospitals and can therefore transfer patients to the most appropriate trauma center in the shortest time. However, 75% to 85% of the time, the choice of destination is strongly influenced by the availability of a helipad and the operational safety that it provides.
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Affiliation(s)
- Fernando Landreau
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dalmacio Velez Sarsfield, Buenos Aires.
| | - Oscar Valcarcel
- Dirección General Emergency Medical Care System, Buenos Aires
| | - Juan Noir
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dr. Cosme Argerich, Buenos Aires
| | - Guadalupe Pernía
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dr. Ramos Mejía, Buenos Aires
| | - María L Orzábal
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dalmacio Velez Sarsfield, Buenos Aires
| | - Sergio Martínez
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dr. Juan A. Fernandez, Buenos Aires
| | - Alejandro Tobar
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dalmacio Velez Sarsfield, Buenos Aires
| | - Mariana Isola
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dr. Ramos Mejía, Buenos Aires
| | - Mariano Núñez
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dr. Juan A. Fernandez, Buenos Aires
| | - Pablo Martínez
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Donación Francisco Santojanni, Buenos Aires
| | - Cristian Cuellar
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Dr. Cosme Argerich, Buenos Aires
| | - Federico Villagrán
- Escuadrón Aéreo del Emergency Medical Care System, Buenos Aires; HGA (Hospital General de Agudos) Donación Francisco Santojanni, Buenos Aires
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Balhara KS, Bustamante ND, Selvam A, Winders WT, Coker A, Trehan I, Becker TK, Levine AC. Bystander Assistance for Trauma Victims in Low- and Middle-Income Countries: A Systematic Review of Prevalence and Training Interventions. PREHOSP EMERG CARE 2018; 23:389-410. [PMID: 30141702 DOI: 10.1080/10903127.2018.1513104] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Lack of organized prehospital care may contribute to the disproportionate burden of trauma-related deaths in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends bystander training in basic principles of first aid and victim transport; however, prevalence of bystander or layperson assistance to trauma victims in LMICs has not been well-described, and organized reviews of existing evidence for bystander training are lacking. This systematic review aims to 1) describe the prevalence of bystander or layperson aid or transport for trauma victims in the prehospital setting in LMICs and 2) ascertain impacts of bystander training interventions in these settings. METHODS A systematic search of OVID Medline, Cochrane Library, and relevant gray literature was conducted. We included 1) all studies detailing prevalence of bystander-administered aid or transport for trauma victims in LMICs and 2) all randomized controlled trials and observational studies evaluating bystander training interventions. We extracted study characteristics, interventions, and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS Sixty-two studies detailed prevalence of bystander transport and aid. Family members, police, and bus or taxi drivers commonly transported patients; a majority of patients, up to >94%, received aid from bystanders. Twenty-four studies examined impacts of training interventions. Only one study looked at transport interventions; the remainder addressed first aid training. Interventions varied in content, duration, and target learners. Evidence was generally of low quality, but all studies demonstrated improvements in layperson knowledge and skills. Five studies reported a mortality reduction. CONCLUSIONS Heterogeneity in data reporting and outcomes limited formal meta-analysis. However, this review shows high rates of bystander involvement in prehospital trauma care and transport in LMICs and highlights the need for bystander training. Bystander training in these settings is feasible and may have an important impact on meaningful outcomes such as mortality. Categories of involved bystanders varied by region and training interventions should be targeted at relevant groups. "Train the trainer" models appear promising in securing community engagement and maximizing participation. Further research is needed to examine the value of bystander transport networks in trauma.
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Möller A, Hunter L, Kurland L, Lahri S, van Hoving DJ. The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town. Afr J Emerg Med 2018; 8:89-94. [PMID: 30456155 PMCID: PMC6223589 DOI: 10.1016/j.afjem.2018.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/22/2017] [Accepted: 01/21/2018] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa. METHODS The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients' folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher's Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant. RESULTS The majority of patients were 19-44 year old males (n = 427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n = 343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n = 18, 3.4%) was not significantly affected by transport method (p = 0.26), hospital arrival time (p = 0.22) or prehospital transport time intervals (all p-values >0.09). DISCUSSION Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate.
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Affiliation(s)
- Anders Möller
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83 Stockholm, Sweden
| | - Luke Hunter
- Khayelitsha Hospital, Private Bag X6, Khayelitsha, 7784 Cape Town, South Africa
| | - Lisa Kurland
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83 Stockholm, Sweden
- Department of Medical Sciences, Örebro University, School of Medical Sciences, Campus USÖ, S-701 82 Örebro, Sweden
- Department of Emergency Medicine, Örebro University Hospital, School of Medical Sciences, Campus USÖ, S-701 82 Örebro, Sweden
| | - Sa'ad Lahri
- Khayelitsha Hospital, Private Bag X6, Khayelitsha, 7784 Cape Town, South Africa
| | - Daniël J. van Hoving
- Division of Emergency Medicine, Stellenbosch University, Private Bag X1, Matieland, 7602 Stellenbosch, Cape Town, South Africa
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Foster JC, Sappenfield JW, Smith RS, Kiley SP. Initiation and Termination of Massive Transfusion Protocols: Current Strategies and Future Prospects. Anesth Analg 2017; 125:2045-2055. [PMID: 28857793 DOI: 10.1213/ane.0000000000002436] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The advent of massive transfusion protocols (MTP) has had a significant positive impact on hemorrhaging trauma patient morbidity and mortality. Nevertheless, societal MTP guidelines and individual MTPs at academic institutions continue to circulate opposing recommendations on topics critical to MTPs. This narrative review discusses up-to-date information on 2 such topics, the initiation and termination of an MTP. The discussion for each begins with a review of the recommendations and supporting literature presented by MTP guidelines from 3 prominent societies, the American Society of Anesthesiologists, the American College of Surgeons, and the task force for Advanced Bleeding Care in Trauma. This is followed by an in-depth analysis of the main components within those recommendations. Societal recommendations on MTP initiation in hemorrhaging trauma patients emphasize the use of retrospectively validated massive transfusion (MT) prediction score, specifically, the Assessment of Blood Consumption and Trauma-Associated Severe Hemorrhage scores. Validation studies have shown that both scoring systems perform similarly. Both scores reliably identify patients that will not require an MT, while simultaneously overpredicting MT requirements. However, each scoring system has its unique advantages and disadvantages, and this review discusses how specific aspects of each scoring system can affect widespread applicability and statistical performance. In addition, we discuss the often overlooked topic of initiating MT in nontrauma patients and the specific tools physicians have to guide the MT initiation decision in this unique setting. Despite the serious complications that can arise with transfusion of large volumes of blood products, there is considerably less research pertinent to the topic of MTP termination. Societal recommendations on MTP termination emphasize applying clinical reasoning to identify patients who have bleeding source control and are adequately resuscitated. This review, however, focuses primarily on the recommendations presented by the Advanced Bleeding Care in Trauma's MTP guidelines that call for prompt termination of the algorithm-guided model of resuscitation and rapidly transitioning into a resuscitation model guided by laboratory test results. We also discuss the evidence in support of laboratory result-guided resuscitation and how recent literature on viscoelastic hemostatic assays, although limited, highlights the potential to achieve additional benefits from this method of resuscitation.
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Affiliation(s)
- John C Foster
- From the University of Florida College of Medicine, Gainesville, Florida
| | - Joshua W Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Robert S Smith
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Sean P Kiley
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
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27
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Valentino TP. Major trauma: What is important for the best outcome and survival? J Postgrad Med 2017; 63:149-150. [PMID: 28695868 PMCID: PMC5525477 DOI: 10.4103/jpgm.jpgm_752_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- T P Valentino
- Emergency Department, Polyclinic Ospedali Riuniti University Hospital, Foggia, Apulia, Italy
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