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Whitaker J, Edem I, Amoah AS, Dube A, D'Ambruoso L, Rickard RF, Leather AJM, Davies J. Understanding the health system utilisation and reasons for avoidable mortality after fatal injury within a Three-Delays framework in Karonga, Northern Malawi: a retrospective analysis of verbal autopsy data. BMJ Open 2024; 14:e081652. [PMID: 38684258 PMCID: PMC11086451 DOI: 10.1136/bmjopen-2023-081652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care. DESIGN Retrospective analysis of existing VA data routinely collected by a demographic surveillance site. SETTING Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi. PARTICIPANTS Fatally injured members of the HDSS. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system. RESULTS Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49). CONCLUSIONS VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Idara Edem
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, USA
- Michigan State University, East Lansing, Michigan, USA
| | - Abena S Amoah
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health, National Health Service (NHS) Grampian, Grampian, Scotland
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andy J M Leather
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Rivera-Lara L, Videtta W, Calvillo E, Mejia-Mantilla J, March K, Ortega-Gutierrez S, Obrego GC, Paranhos JE, Suarez JI. Reducing the incidence and mortality of traumatic brain injury in Latin America. Eur J Trauma Emerg Surg 2023; 49:2381-2388. [PMID: 36637481 DOI: 10.1007/s00068-022-02214-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 12/26/2022] [Indexed: 01/14/2023]
Abstract
Traumatic brain injury (TBI) represents a considerable portion of the global injury burden. The incidence of TBI will continue to increase in view of an increase in population density, an aging population, and the increased use of motor vehicles, motorcycles, and bicycles. The most common causes of TBI are falls and road traffic injuries. Deaths related to road traffic injury are three times higher in low-and middle-income countries (LMIC) than in high-income countries (HIC). The Latin American Caribbean region has the highest incidence of TBI worldwide, primarily caused by road traffic injuries. Data from HIC indicates that road traffic injuries can be successfully prevented through concerted efforts at the national level, with coordinated and multisector responses to the problem. Such actions require implementation of proven measures to address the safety of road users and the vehicles themselves, road infrastructure, and post-crash care. In this review, we focus on the epidemiology of TBI in Latin America and the implementation of solutions and preventive measures to decrease mortality and long-term disability.
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Affiliation(s)
- Lucia Rivera-Lara
- Department of Neurology, School of Medicine, Center for Academic Medicine, Stanford University, 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Walter Videtta
- Department of National Hospital, Alejandro Posadas, Buenos Aires, Argentina
| | - Eusebia Calvillo
- Departments of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | | | - Karen March
- Clinical Development at Integra Life Sciences, Seattle, WA, USA
| | | | | | - Jorge E Paranhos
- Santa Casa da Misericordia de São João del Rey, Minas Gerais, Brazil
| | - Jose I Suarez
- Departments of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
- Departments of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
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Hughes M, Schmidt J, Svenson J. Emergency Services Capacity of a Rural Community in Guatemala. West J Emerg Med 2022; 23:746-753. [PMID: 36205672 PMCID: PMC9541976 DOI: 10.5811/westjem.2022.7.56258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 07/19/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Access to emergency care is an essential part of the health system. Improving access to emergency services in low- and middle-income countries (LMIC) decreases mortality and reduces global disparities; however, few studies have assessed emergency services resources in LMICs. To guide future improvements in care, we performed a comprehensive assessment of the emergency services capacity of a rural community in Guatemala serving a mostly indigenous population. Methods We performed an exhaustively sampled cross-sectional survey of all healthcare facilities providing urgent and emergent care in the four largest cities surrounding Lake Atitlán using the Emergency Services Resource Assessment Tool (ESRAT). Results Of 17 identified facilities, 16 agreed to participate and were surveyed: nine private hospitals; four public clinics; and three public hospitals, including the region’s public departmental hospital. All facilities provided emergency services 24/7, and a dedicated emergency unit was available at 67% of hospitals and 75% of clinics. A dedicated physician was present in the emergency unit during the day at 67% of hospitals and 75% of clinics. Hospitals had a significantly higher percentage of available equipment compared to clinics (85% vs 54%, mean difference 31%; 95% confidence interval (CI) 23–37%; P = 0.004). There was no difference in availability of laboratory tests between public and private hospitals or between cities. Private hospitals had access to a significantly higher percentage of medications compared to clinics (56% vs 27%, mean difference 29%; 95% CI 9–49%; P = 0.024). Conclusion We found a high availability of emergency services and universal availability of personal protective equipment but a severe shortage of critical medications in clinics, and widespread shortage of pediatric equipment.
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Affiliation(s)
- Matthew Hughes
- University of Wisconsin School of Medicine and Public Health Department of Emergency Medicine, Madison, Wisconsin
| | - Jessica Schmidt
- University of Wisconsin School of Medicine and Public Health Department of Emergency Medicine, Madison, Wisconsin
| | - James Svenson
- University of Wisconsin School of Medicine and Public Health Department of Emergency Medicine, Madison, Wisconsin
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Wang Z, Nguonly D, Du RY, Garcia RM, Lam SK. Pediatric traumatic brain injury prehospital guidelines: a systematic review and appraisal. Childs Nerv Syst 2022; 38:51-62. [PMID: 34557952 DOI: 10.1007/s00381-021-05364-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) disproportionately affects children within low- and middle-income countries (LMICs). Prehospital emergency care can mitigate secondary brain injury and improve outcomes. Here, we systematically review clinical practice guidelines (CPGs) for pediatric TBI with the goal to inform LMICs prehospital care. METHODS A systematic search was conducted in PubMed/Medline, Embase, and Web of Science databases. We appraised evidence-based CPGs addressing prehospital management of pediatric TBI using the Appraisal of Guidelines for Research & Evaluation (AGREE) tool. CPGs were rated as high-quality if ≥ 5 (out of 6) AGREE domains scored > 60%. RESULTS Of the 326 articles identified, 10 CPGs were included in analysis. All 10 were developed in HICs, and 4 were rated as high-quality. A total of 154 pediatric prehospital recommendations were grouped into three subcategories, initial assessment (35.7%), prehospital treatment (38.3%), and triage (26.0%). Of these, 79 (51.3%) were evidence-based with grading, and 31 (20.1%) were consensus-based without direct evidence. CONCLUSION Currently available CPGs for prehospital pediatric TBI management were all developed in HICs. Four CPGs have high-quality, and recommendations from these can serve as frameworks for LMICs or resource-limited settings. Context-specific evaluation and implementation of evidence-based recommendations allow LMIC settings to respond to the public health crisis of pediatric TBI and address gaps in trauma care systems.
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Affiliation(s)
- Zhe Wang
- Department of Neurological Surgery, Stony Brook University Renaissance School of Medicine, Health Science Center T12, Room 080, 100 Nicolls Rd, Stony Brook, NY, 11790, USA.
| | - Dellvin Nguonly
- Department of Emergency Medicine, Rocky Vista University College of Osteopathic Medicine, Parker, CO, USA
| | - Rebecca Y Du
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Roxanna M Garcia
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandi K Lam
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
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Hashmi Y, Ayyaz N, Umar H, Jawaid A, Ahmed Z. Are Trauma Surgery Simulation Courses Beneficial in Low- and Middle-Income Countries—A Systematic Review and Meta-Analysis. Trauma Care 2021; 1:130-42. [DOI: 10.3390/traumacare1030012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite trauma-related injuries being a leading cause of death worldwide, low- and middle-income countries (LMICs) lack the infrastructure and resources required to offer immediate surgical care, further perpetuating the risk of morbidity and mortality. In high-income countries, trauma surgery simulation courses are routinely delivered to surgeons, teaching the fundamental skills of operative trauma. This study aimed to assess whether similar courses are beneficial in LMICs and how they can be improved. We performed a systematic review and meta-analysis using MEDLINE, Embase and Google Scholar, analysing studies evaluating trauma surgery simulation in LMICs. The outcomes measured included clinical knowledge improvement, participant confidence and general course-feedback. The review was carried out in-line with PRISMA guidelines. Five studies were included, summating a population of 172 participants. In three studies, meta-analysis showed an overall significant weighted mean improvement of knowledge post-course by 22.91% (95%CI 19.53, 26.29; p < 0.00001; I2 = 0%). One study reported a significant increase in participant confidence for 20/22 of operative skills taught (p < 0.04). We conclude that these courses are beneficial in LMICs; however, further research is necessary to establish the optimum course design, and whether patient outcomes are improved following their implementation. Collaboration between international trauma institutions is essential for closing the educational resource inequality gap between higher- and lower-income countries.
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Kinder F, Mehmood S, Hodgson H, Giannoudis P, Howard A. Barriers to Trauma Care in South and Central America: a systematic review. Eur J Orthop Surg Traumatol 2021. [PMID: 34392445 DOI: 10.1007/s00590-021-03080-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
Introduction Trauma is widespread in Central and South America and is a significant cause of morbidity and mortality. Providing high quality emergency trauma care is of great importance. Understanding the barriers to care is challenging; this systematic review aims to establish current the current challenges and barriers in providing high-quality trauma care within the 21 countries in the region. Methods OVID Medline, Embase, EBM reviews and Global Health databases were systematically searched in October 2020. Records were screened by two independent researchers. Data were extracted according to a predetermined proforma. Studies of any type, published in the preceding decade were included, excluding grey literature and non-English records. Trauma was defined as blunt or penetrating injury from an external force. Studies were individually critically appraised and assessed for bias using the RTI item bank. Results 57 records met the inclusion criteria. 20 countries were covered at least once. Nine key barriers were identified: training (37/57), resources and equipment (33/57), protocols (29/57), staffing (17/57), transport and logistics (16/57), finance (15/57), socio-cultural (13/57), capacity (9/57), public education (4/57). Conclusion Nine key barriers negatively impact on the provision of high-quality trauma care and highlight potential areas for improving care in Central & South America. Many countries in the region, along with rural areas, are under-represented by the current literature and future research is urgently required to assess barriers to trauma management in these countries. No funding was received. Clinical Trial Registration: PROSPERO CRD42020220380.
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Whitaker J, O'Donohoe N, Denning M, Poenaru D, Guadagno E, Leather AJM, Davies JI. Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments. BMJ Glob Health 2021; 6:e004324. [PMID: 33975885 PMCID: PMC8118008 DOI: 10.1136/bmjgh-2020-004324] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/07/2021] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles. METHODS We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment. RESULTS Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment. CONCLUSIONS Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.
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Affiliation(s)
- John Whitaker
- King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - Max Denning
- Department of Surgery and Cancer, Imperial College London, London, UK
- Stanford Graduate School of Business, Stanford University, Stanford, California, USA
| | - Dan Poenaru
- Harvey E Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Elena Guadagno
- Harvey E Beardmore Division of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, Western Cape, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Sarmiento Altamirano D, Himmler A, Chango Sigüenza O, Pino Andrade R, Flores Lazo N, Reinoso Naranjo J, Sacoto Aguilar H, Fernández de Córdova L, Rodas E, Puyana JC, Salamea Molina JC. The Successful Implementation of a Trauma and Acute Care Surgery Model in Ecuador. World J Surg 2021; 44:1736-1744. [PMID: 32107595 DOI: 10.1007/s00268-020-05435-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND For years, surgical emergencies in Ecuador were managed on a case-by-case basis without significant standardization. To address these issues, the Regional Hospital Vicente Corral Moscoso adapted and implemented a model of "trauma and acute care surgery" (TACS) to the reality of Cuenca, Ecuador. METHODS A cohort study was carried out, comparing patients exposed to the traditional model and patients exposed to the TACS model. Variables assessed included number of surgical patients attended to in the emergency department, number of surgical interventions, number of surgeries performed per surgeon, surgical wait time, length of stay and in-hospital mortality. RESULTS The total number of surgical interventions increased (3919.6-5745.8, p ≤ 0.05); by extension, the total number of surgeries performed per surgeon also increased (5.37-223.68, p ≤ 0.05). We observed a statistically significant decrease in surgical wait time (10.6-3.2 h for emergency general surgery, 6.3-1.6 h for trauma, p ≤ 0.05). Length of stay decreased in trauma patients (9-6 days, p ≤ 0.05). Higher mortality was found in the traditional model (p ≤ 0.05) compared to the TACS model. CONCLUSIONS The implementation of TACS model in a resource-restrained hospital in Latin America had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients and length of stay in trauma patients. We also noted a statistically significant decrease in mortality. Savings to the overall system and patients can be inferred by decreased mortality, length of stay and surgical wait times. To our knowledge, this is the first implementation of a TACS model described in Latin America.
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Affiliation(s)
| | - Amber Himmler
- Division of Surgery, Medstar Georgetown University Hospital and Washington Hospital Center, Washington, DC, USA. .,University of Pittsburgh, Pittsburgh, PA, USA.
| | - Oscar Chango Sigüenza
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Raúl Pino Andrade
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Nube Flores Lazo
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Jeovanni Reinoso Naranjo
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad de Cuenca, Cuenca, Ecuador
| | - Hernán Sacoto Aguilar
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador.,Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Lenin Fernández de Córdova
- Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador.,Facultad de Medicina, Universidad Católica de Cuenca, Cuenca, Ecuador
| | - Edgar Rodas
- Division of Trauma and Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Juan Carlos Puyana
- Division of Trauma and Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juan Carlos Salamea Molina
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador.,Division of Trauma and Acute Care Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
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Uribe Buritica FL, Carvajal SM, Torres N, Bustamante Cristancho LA, García Marín AF. Equipos de trauma: realidad mundial e implementación en un país en desarrollo. Descripción narrativa. Rev Colomb Cir 2021. [DOI: 10.30944/20117582.650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El trauma es una de las entidades con mayor morbimortalidad en el mundo. Los equipos especializados en la atención del paciente traumatizado son llamados <<equipos de trauma>>. Dichos equipos surgieron de la necesidad de brindar tratamiento oportuno multidisciplinario a individuos con heridas que condicionan gran severidad en la guerra; sin embargo, con el paso del tiempo se trasladaron al ámbito civil, generando un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad.
El objetivo de este estudio fue describir el proceso de desarrollo de los equipos de trauma a nivel mundial y la experiencia en nuestra institución en el suroccidente colombiano.
Métodos. Se realizó una búsqueda en la base de datos PUBMED, que incluyó revisiones sistemáticas, metaanálisis, revisiones de Cochrane, ensayos clínicos y series de casos.
Resultados. Se incluyeron 41 estudios para esta revisión narrativa, y se observó que el tiempo de permanencia en el Emergencias, el tiempo de traslado a cirugía, la mortalidad y las complicaciones asociadas al trauma fueron menores cuando se implementan equipos de trauma.
Discusión. El diseño de un sistema de atención y valoración horizontal de un paciente con traumatismos severos produce un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad. Se hace necesario establecer los parámetros operativos necesarios en las instituciones de salud de alta y mediana complejidad en nuestro país para implementar dichos equipos de trabajo.
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Christie SA, Nwomeh BC, Krishnaswami S, Yang GP, Holterman AL, Charles A, Jayaraman S, Jawa RS, Rickard J, Swaroop M, Ziad SC, Etoundi Mballa GA, Monono ME, Chichom Mefire A, Juillard C. Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries. World J Surg 2019; 43:736-43. [PMID: 30443662 DOI: 10.1007/s00268-018-4854-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Global health is transitioning toward a focus on building strong and sustainable health systems in developing countries; however, resources, funding, and agendas continue to concentrate on "vertical" (disease-based) improvements in care. Surgical care in low- and middle-income countries (LMICs) requires the development of health systems infrastructure and can be considered an indicator of overall system readiness. Improving surgical care provides a scalable gateway to strengthen health systems in multiple domains. In this position paper by the Society of University Surgeons' Committee on Global Academic Surgery, we propose that health systems development appropriately falls within the purview of the academic surgeon. Partnerships between academic surgical institutions and societies from high-income and resource-constrained settings are needed to strengthen advocacy and funding efforts and support development of training and research in LMICs.
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Ramachandran A, Ranjit A, Zogg CK, Herrera-Escobar JP, Appelson JR, Pino LF, Aboutanous MB, Haider AH, Ordonez CA. Comparison of Epidemiology of the Injuries and Outcomes in Two First-Level Trauma Centers in Colombia Using the Pan-American Trauma Registry System. World J Surg 2018; 41:2224-2230. [PMID: 28417184 DOI: 10.1007/s00268-017-4013-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The aim of this study was to compare the epidemiology of traumatic injuries and mortality outcomes between two tertiary-care trauma centers in Colombia using data from Pan-American Trauma Registry (PATR). METHODS January 1-December 31, 2012, data from the Hospital Universitario del Valle (HUV, public) and Fundacion Valle del Lili (FVL, private) in Cali, Colombia, were considered. Differences in demographic and clinical information were compared using descriptive statistics. Propensity score matching was used to match patients on age, gender, and ISS. Within matched cohorts, multivariable logistic regression models were used to assess for differences in in-hospital mortality, further adjusting for insurance type, employment, heart rate, presence of hypotension (SBP < 90), and GCS score. RESULTS HUV (8539; 78% male) and FVL (10,456; 60% male) had a combined total of 18,995 trauma cases in 2012 with comparable mean ages of 29.7 years. There were significant differences in insurance status, injury severity, and mechanism of injury between patients at HUV and FLV. On risk-adjusted logistic regression analyses with propensity score matched cohorts, the odds of death in HUV was higher compared to patients presenting at FVL hospital (OR [95% CI]:4.93 [3.37-7.21], p < 0.001). CONCLUSION The study established the utility of the PATR and revealed important trends in patient demographics, injury epidemiology, and mortality outcomes, which can be used to target trauma initiatives throughout the region. It underscores the profound importance that differences in case mix play in the risk of trauma-related mortality, further emphasizing the need to monitor and evaluate unique aspects of trauma in LMIC. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Anju Ranjit
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA, USA
| | | | - Juan P Herrera-Escobar
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA, USA
| | - Jessica R Appelson
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA, USA
| | - Luis F Pino
- Department of Surgery from Division of Trauma and Acute Care Surgery, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Michel B Aboutanous
- Division of Acute Care Surgery, Virginia Commonwealth University Trauma Center, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA, USA.
| | - Carlos A Ordonez
- Department of Surgery from Division of Trauma and Acute Care Surgery, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
- Department of Surgery From Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
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Blair KJ, Paladino L, Shaw PL, Shapiro MB, Nwomeh BC, Swaroop M. Surgical and trauma care in low- and middle-income countries: a review of capacity assessments. J Surg Res 2016; 210:139-151. [PMID: 28457320 DOI: 10.1016/j.jss.2016.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/04/2016] [Accepted: 11/02/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical and trauma capacity assessments help guide resource allocation and plan interventions to improve care for the injured in low- and middle-income countries (LMICs). To forge expert consensus on conducting these assessments, we undertook a systematic review of studies using five tools: (1) World Health Organization's (WHO) Guidelines for Essential Trauma Care, (2) WHO's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, (3) Personnel, Infrastructure, Procedures, Equipment, and Supplies tool, (4) Harvard Humanitarian Initiative tool, and (5) Emergency and Critical Care tool. MATERIALS AND METHODS Publications describing utilization of survey instruments to assess surgical or trauma capacity in LMICs were reviewed. Included articles underwent thematic analysis to develop recommendations. A modified Delphi method was used to establish expert consensus. Experts rated recommendations on a Likert-type scale via online survey. Consensus was defined by Cronbach's α ≥ 0.80. Recommendations achieving agreement by ≥80% of experts were included. RESULTS Two hundred and ninety-eight publications were identified and 41 included, describing evaluation of 1170 facilities across 36 LMICs. Nine recommendations were agreed upon by expert consensus: (1) inclusion of district hospitals, (2) inclusion of highest level public hospital, (3) inclusion of private facilities, (4) facility visits for on-site completion, (5) direct inspections, (6) checking surgical logs, (7) adaptation of survey instrument, (8) repeat assessments, and (9) need for increased collaboration. CONCLUSIONS Expert recommendations developed in this review describe methodology to be employed when conducting assessments of surgical and trauma capacity in LMICs. Consensus has yet to be achieved for tool selection.
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Affiliation(s)
- Kevin J Blair
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Lorenzo Paladino
- Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Pamela L Shaw
- Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael B Shapiro
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Benedict C Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Mamta Swaroop
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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LaGrone L, Riggle K, Joshipura M, Quansah R, Reynolds T, Sherr K, Mock C. Uptake of the World Health Organization's trauma care guidelines: a systematic review. Bull World Health Organ 2016; 94:585-598C. [PMID: 27516636 PMCID: PMC4969985 DOI: 10.2471/blt.15.162214] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/29/2016] [Accepted: 02/15/2016] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To understand the degree to which the trauma care guidelines released by the World Health Organization (WHO) between 2004 and 2009 have been used, and to identify priorities for the future implementation and dissemination of such guidelines. METHODS We conducted a systematic review, across 19 databases, in which the titles of the three sets of guidelines - Guidelines for essential trauma care, Prehospital trauma care systems and Guidelines for trauma quality improvement programmes - were used as the search terms. Results were validated via citation analysis and expert consultation. Two authors independently reviewed each record of the guidelines' implementation. FINDINGS We identified 578 records that provided evidence of dissemination of WHO trauma care guidelines and 101 information sources that together described 140 implementation events. Implementation evidence could be found for 51 countries - 14 (40%) of the 35 low-income countries, 15 (32%) of the 47 lower-middle income, 15 (28%) of the 53 upper-middle-income and 7 (12%) of the 59 high-income. Of the 140 implementations, 63 (45%) could be categorized as needs assessments, 38 (27%) as endorsements by stakeholders, 20 (14%) as incorporations into policy and 19 (14%) as educational interventions. CONCLUSION Although WHO's trauma care guidelines have been widely implemented, no evidence was identified of their implementation in 143 countries. More serial needs assessments for the ongoing monitoring of capacity for trauma care in health systems and more incorporation of the guidelines into both the formal education of health-care providers and health policy are needed.
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Affiliation(s)
- Lacey LaGrone
- Harborview Injury Prevention and Research Center, Campus Box #356410, University of Washington, Seattle, WA 98104, United States of America (USA)
| | - Kevin Riggle
- Department of Surgery, University of Washington, Seattle, USA
| | | | - Robert Quansah
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, USA
| | - Charles Mock
- Harborview Injury Prevention and Research Center, Campus Box #356410, University of Washington, Seattle, WA 98104, United States of America (USA)
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Tabiri S, Nicks BA, Dykstra R, Hiestand B, Hildreth A. Assessing Trauma Care Capabilities of the Health Centers in Northern Ghana. World J Surg 2015; 39:2422-7. [PMID: 26159118 DOI: 10.1007/s00268-015-3124-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Traffic-related injury is a major and increasing cause of global mortality, especially in low- and middle-income countries (LMICs). However, trauma systems, personnel, resources, and infrastructure are frequently insufficient to meet the needs of the population in this at-risk population in LMICs. In addition, these resources are not uniformly distributed, coordinated, nor well described within most countries. Trauma care resources have not previously been characterized in the Northern Region of Ghana. METHODS We performed uniform site evaluations and interviews at 92 hospitals in Northern Ghana. Trauma systems, material resources, and human resources were quantified. Equipment was characterized as available in the Emergency Department (ED), in the hospital only, or unavailable. Hospitals were categorized as primary, district, or referral. RESULTS Forty-two primary hospitals, 48 district hospitals, 3 regional hospitals, and 1 teaching hospital were surveyed. Over 95 % of hospitals reported having no training or systems for the care of injured patients. Substantial clinical equipment deficits were found at most primary hospitals. In over 90 % of these hospitals, the majority of circulation and monitoring, airway and breathing, and diagnostic imagining resources were not available. Equipment was also frequently unavailable at district and regional hospitals. When available, these resources were infrequently present in the ED. CONCLUSIONS Although resources may be unavoidably constrained, there are substantial opportunities to improve the systematic management of trauma care and improve the education of the medical providers regarding care of injured patients in the region studied.
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Aaronson EL, Marsh RH, Guha M, Schuur JD, Rouhani SA. Emergency department quality and safety indicators in resource-limited settings: an environmental survey. Int J Emerg Med 2015; 8:39. [PMID: 26520848 PMCID: PMC4628609 DOI: 10.1186/s12245-015-0088-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 10/16/2015] [Indexed: 11/16/2022] Open
Abstract
Background As global emergency care grows, practical and effective performance measures are needed to ensure high quality care. Our objective was to systematically catalog and classify metrics that have been used to measure the quality of emergency care in resource-limited settings. Methods We searched MEDLINE, Embase, CINAHL, and the gray literature using standardized terms. The references of included articles were also reviewed. Two researchers screened titles and abstracts for relevance; full text was then reviewed by three researchers. A structured data extraction tool was used to identify and classify metrics into one of six Institute of Medicine (IOM) quality domains (safe, timely, efficient, effective, equitable, patient-centered) and one of three of Donabedian’s structure/process/outcome categories. A fourth expert reviewer blinded to the initial classifications re-classified all indicators, with a weighted kappa of 0.89. Results A total of 1705 articles were screened, 95 received full text review, and 34 met inclusion criteria. One hundred eighty unique metrics were identified, predominantly process (57 %) and structure measures (27 %); 16 % of metrics were related to outcomes. Most metrics evaluated the effectiveness (52 %) and timeliness (28 %) of care, with few addressing the patient centeredness (11 %), safety (4 %), resource-efficiency (3 %), or equitability (1 %) of care. Conclusions The published quality metrics in emergency care in resource-limited settings primarily focus on the effectiveness and timeliness of care. As global emergency care is built and strengthened, outcome-based measures and those focused on the safety, efficiency, and equitability of care need to be developed and studied to improve quality of care and resource utilization. Electronic supplementary material The online version of this article (doi:10.1186/s12245-015-0088-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
| | - Moytrayee Guha
- Center for Clinical Excellence, Brigham and Women's Hospital, Boston, MA, USA.
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
| | - Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA.
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Chichom-Mefire A, Mbarga-Essim NT, Monono ME, Ngowe MN. Compliance of district hospitals in the Center Region of Cameroon with WHO/IATSIC guidelines for the care of the injured: a cross-sectional analysis. World J Surg 2014; 38:2525-33. [PMID: 24838483 DOI: 10.1007/s00268-014-2609-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Injuries are a major cause of death and disability worldwide. Low-income countries, particularly in Africa, are disproportionately affected. The burden of injuries can be alleviated by preventive measures and appropriate management of injury cases. African countries generally lack trauma care systems based on reliable and affordable guidelines. The aim of this study was to assess the compliance of some district hospitals in Cameroon with World Health Organization/International Association for Trauma and Intensive Care (WHO/IATSIC) guidelines for care of the injured. METHODS This cross-sectional descriptive survey used items from the WHO/IATSIC "Guidelines for Essential Trauma Care" to develop a checklist for inspection of physical equipment and a questionnaire assessing human resources and organizational capabilities in 25 district hospitals of the Center Region of Cameroon. RESULTS All hospitals surveyed had at least one doctor available. Each reported treating a mean of 338 ± 214 injury cases every year. Most hospitals (n = 22) were globally either not compliant or partly compliant with the guidelines. Staff generally had received the appropriate basic training but had no additional training specifically directed toward trauma management. Skills for managing specific injuries (e.g., chest injuries) were poor. Availability and utilization of equipment was globally inadequate, and organizational capabilities were almost nonexistent. CONCLUSIONS District hospitals of the Center Region of Cameroon still lack compliance with the WHO/IATSIC guidelines for essential trauma care but have significant potential for improvement. It seems possible to optimize the utilization of existing facilities.
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Shah MT, Bhattarai S, Lamichhane N, Joshi A, LaBarre P, Joshipura M, Mock C. Assessment of the availability of technology for trauma care in Nepal. Injury 2015; 46:1712-9. [PMID: 26140742 DOI: 10.1016/j.injury.2015.06.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/03/2015] [Accepted: 06/05/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND We sought to assess the availability of technology-related equipment for trauma care in Nepal and to identify factors leading to optimal availability as well as deficiencies. We also sought to identify potential solutions addressing the deficits in terms of health systems management and product development. METHODS Thirty-two items for large hospitals and sixteen items for small hospitals related to the technological aspect of trauma care were selected from the World Health Organization's Guidelines for Essential Trauma Care for the current study. Fifty-six small and 29 large hospitals were assessed for availability of these items in the study area. Site visits included direct inspection and interviews with administrative, clinical, and bioengineering staff. RESULTS Deficiencies of many specific items were noted, including many that were inexpensive and which could have been easily supplied. Shortage of electricity was identified as a major infrastructural deficiency present in all parts of the country. Deficiencies of pulse oximetry and ventilators were observed in most hospitals, attributed in most part to frequent breakdowns and long downtimes because of lack of vendor-based service contracts or in-house maintenance staff. Sub-optimal oxygen supply was identified as a major and frequent deficiency contributing to disruption of services. All equipment was imported except for a small percent of suction machines and haemoglobinometers. CONCLUSIONS The study identified a range of items which were deficient and whose availability could be improved cost-effectively and sustainably by better planning and organisation. The electricity deficit has been dealt with successfully in a few hospitals via direct feeder lines and installation of solar panels; wider implementation of these methods would help solve a large portion of the technological deficiencies. From a health systems management view-point, strengthening procurement and stocking of low cost items especially in remote parts of the country is needed. From a product development view-point, there is a need for robust pulse-oximeters and ventilators that are lower cost and which have longer durability and less need for repairs. Increasing capabilities for local manufacture is another potential method to increase availability of a range of equipment and spare parts.
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Affiliation(s)
- Mihir Tejanshu Shah
- Academy of Traumatology (India), Ahmedabad, India; Smt NHL Municipal Medical College, Ahmedabad, India.
| | | | | | - Arpita Joshi
- Smt NHL Municipal Medical College, Ahmedabad, India
| | | | | | - Charles Mock
- Department of Surgery, University of Washington, Seattle, USA
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Kesinger MR, Puyana JC, Rubiano AM. Improving trauma care in low- and middle-income countries by implementing a standardized trauma protocol. World J Surg 2014; 38:1869-74. [PMID: 24682314 DOI: 10.1007/s00268-014-2534-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Standardized trauma protocols (STPs) have reduced morbidity and mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not yet implemented such protocols, often due to financial and logistic limitations. We report preliminary findings from a trauma quality improvement (QI) initiative, using and evaluating the impact of a low-cost STP in an LMIC university hospital. METHODS We developed an STP based on generally accepted best practices and damage control resuscitation. It was designed for the resources available at the test institution. The Neiva University Hospital (NUH) is a tertiary care hospital and level I trauma center in Neiva, Colombia. As in most LMIC hospitals, there was no trauma information data system at NUH. Therefore, we adapted an administrative electronic database to capture clinically relevant information of adult patients who were hospitalized or died in the emergency department (ED) between August 2010 and June 2012 with an International Classification of Diseases, 10th revision (ICD-10) diagnoses indicating trauma (S00-Y98). Interventions that were recommended in the STP were compared in these two groups. Length of hospital stay (LOS) and mortality were also examined. RESULTS A total of 4,324 patients were included, of whom, 2,457 patients were in the pre-protocol period and 1,867 were in the post-protocol period. The use of several interventions increased: blood product transfusions in the ED (1.0 vs. 2.7%; p < 0.001), use of hypertonic fluids in hypotensive patients (3.2 vs. 8.9 %; p < 0.001), placement of Foley catheters (11.1 vs. 13.8%; p = 0.007), arterial blood gas draws (16.6 vs. 26.4%; p < 0.001), tetanus vaccinations (19.3 vs. 26.0%; p < 0.001), placement of multiple large bore peripheral catheters (29.5 vs. 34.7%; p < 0.001), prophylactic antibiotics (34.9 vs. 38.0%; p = 0.035), and the use of analgesics (64.5 vs. 68.0%; p = 0.016). Other interventions also trended upwards. Length of stay (LOS) decreased for both surgical and non-surgical patients (surgical 13.4 vs. 11.8 days; p = 0.017; non-surgical 4.4 vs. 3.8 days; p = 0.059). All-cause mortality of trauma patients decreased (3.9 vs. 2.9%; p = 0.088). CONCLUSIONS The institution of an STP at a university hospital in an LMIC has increased the use of vital interventions while decreasing overall LOS for all-cause trauma patients.
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Remick KN, Wong EG, Chuot Chep C, Morton RT, Monsour A, Fisher D, Oh JS, Wilson R, Malone DL, Branas C, Elster E, Gross KR, Kushner AL. Development of a novel Global Trauma System Evaluation Tool and initial results of implementation in the Republic of South Sudan. Injury 2014; 45:1731-5. [PMID: 25192865 DOI: 10.1016/j.injury.2014.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/01/2014] [Accepted: 08/03/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma remains a leading cause of death and disability in the world, and trauma systems decrease mortality from trauma. We developed the Global Trauma System Evaluation Tool (G-TSET) specifically for use in low- and middle-income countries (LMICs). The Sudan People's Liberation Army (SPLA) in the Republic of South Sudan (RSS) desires a military trauma system (MTS) which allowed us to pilot the G-TSET. METHODS The G-TSET was developed by modifying key components of a trauma system applicable to LMICs. We partnered with the SPLA Medical Corps using clinical collaboration, direct observation, and discussion groups. Benchmarks and indicators were scored with 5 indicating "full capability" and 1 meaning "not present" and were used to develop a SPLA MTS plan. RESULTS The overall MTS score was 1.15 indicating an urgent need for system development. The assessment highlighted the need for SPLA Command support. Battlefield care, transport to a trauma facility, and inter-facility communication were identified for improvement. After essential battlefield care, consisting primarily of bandaging and splinting, transport times for injured SPLA soldiers were 12h to 3 days by truck. Based on our findings, we collaborated with SPLA medical leadership to develop a plan to develop a formal MTS. CONCLUSION We piloted a novel trauma system assessment tool for the MTS in the RSS. Qualitatively, we identified gaps in the MTS and provided the medical leadership with a plan for improvement. We anticipate a short-term follow-up to quantify improvement, and we seek to validate this tool for use in other countries.
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Affiliation(s)
- Kyle N Remick
- Trauma and Acute Care Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, United States; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Evan G Wong
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States.
| | - Chep Chuot Chep
- SPLA Medical Corps, SPLA Military Hospital, Juba, South Sudan.
| | | | | | - Dane Fisher
- Uniformed Services University of the Health Sciences School of Medicine, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - John S Oh
- Trauma and Acute Care Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, United States; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Ramey Wilson
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Debra L Malone
- Trauma and Acute Care Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, United States; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Charles Branas
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 8th Floor, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - Eric Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States.
| | - Kirby R Gross
- Joint Trauma System, US Army Institute of Surgical Research, 3698 Chambers Pass Ste B, JBSA Ft Sam Houston, TX 78234, United States.
| | - Adam L Kushner
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States; Surgeons OverSeas (SOS), 504 E. 5th Street, Suite 3E, New York, NY 10009, United States; Columbia University, Department of Surgery, New York, NY, United States.
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Wong EG, Gupta S, Deckelbaum DL, Razek T, Kushner AL. Prioritizing injury care: a review of trauma capacity in low and middle-income countries. J Surg Res 2014; 193:217-22. [PMID: 25277355 DOI: 10.1016/j.jss.2014.08.055] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/18/2014] [Accepted: 08/28/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Trauma is a large contributor to the global burden of disease, particularly in low and middle-income countries (LMICs). This study aimed to summarize the literature assessing surgical capacity in LMICs to provide a current assessment of trauma capacity, which will help guide future efforts. MATERIALS AND METHODS The MEDLINE database was queried via PubMed to identify studies assessing baseline surgical capacity in individual LMICs. Data were collected from each study by extracting the relevant information from the full-published text or tables. Trauma capacity was evaluated using 12 surrogate criteria of trauma care, including laparotomy, cricothyroidotomy and chest tube insertion capabilities, and accessibility to a blood bank. RESULTS Seventeen studies were reviewed, documenting data from 531 hospitals in seventeen countries. None of the countries had access to all twelve trauma criteria in all their hospitals. Endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. Bag mask valves were available at 61% (234/383) of the institutions. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. A third or less of district hospitals had access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97), blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95). CONCLUSIONS Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs.
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Affiliation(s)
- Evan G Wong
- Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada; Surgeons OverSeas (SOS), New York, New York.
| | - Shailvi Gupta
- Surgeons OverSeas (SOS), New York, New York; Department of Surgery, University of California, San Francisco - East Bay, Oakland, California
| | - Dan L Deckelbaum
- Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tarek Razek
- Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Adam L Kushner
- Surgeons OverSeas (SOS), New York, New York; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Surgery, Columbia University, New York, New York
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Kesinger MR, Nagy LR, Sequeira DJ, Charry JD, Puyana JC, Rubiano AM. A standardized trauma care protocol decreased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country. Injury 2014; 45:1350-4. [PMID: 24861416 DOI: 10.1016/j.injury.2014.04.037] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 04/08/2014] [Accepted: 04/18/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Standardized trauma protocols (STP) have reduced morbidity and in-hospital mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not implemented STPs, often because of financial and logistic limitations. We report the impact of an STP designed for the care of trauma patients in the emergency department (ED) at an LMIC hospital on patients with severe traumatic brain injury (STBI). METHODS We developed an STP based on generally accepted best practices and damage control resuscitation for a level I trauma centre in Colombia. Without a pre-existing trauma registry, we adapted an administrative electronic database to capture clinical information of adult patients with TBI, a head abbreviated injury score (AIS) ≥3, and who presented ≤12h from injury. Demographics, mechanisms of injury, and injury severity were compared. Primary outcome was in-hospital mortality. Secondary outcomes were Glasgow Coma Score (GCS), length of hospital and ICU stay, and prevalence of ED interventions recommended in the STP. Logistic regression was used to control for potential confounders. RESULTS The pre-STP group was hospitalized between August 2010 and August 2011, the post-STP group between September 2011 and June 2012. There were 108 patients meeting inclusion criteria, 68 pre-STP implementation and 40 post-STP. The pre- and post-STP groups were similar in age (mean 37.1 vs. 38.6, p=0.644), head AIS (median 4.5 vs. 4.0, p=0.857), Injury Severity Scale (median 25 vs. 25, p=0.757), and initial GCS (median 7 vs. 7, p=0.384). Post-STP in-hospital mortality decreased (38% vs. 18%, p=0.024), and discharge GCS increased (median 10 vs. 14, p=0.034). After controlling for potential confounders, odds of in-hospital mortality post-STP compared to pre-STP were 0.248 (95%CI: 0.074-0.838, p=0.025). Hospital and ICU stay did not significantly change. The use of many ED interventions increased post-STP, including bladder catheterization (49% vs. 73%, p=0.015), hypertonic saline (38% vs. 63%, p=0.014), arterial blood gas draws (25% vs. 43%, p=0.059), and blood transfusions (3% vs. 18%, p=0.008). CONCLUSIONS An STP in an LMIC decreased in-hospital mortality, increased discharge GCS, and increased use of vital ED interventions for patients with STBI. An STP in an LMIC can be implemented and measured without a pre-existing trauma registry.
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Affiliation(s)
| | - Lisa R Nagy
- University of Pittsburgh School of Nursing, United States.
| | | | | | - Juan C Puyana
- University of Pittsburgh School of Nursing, United States.
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Wong EG, Gupta S, Deckelbaum DL, Razek T, Kamara TB, Nwomeh BC, Haider AH, Kushner AL. The International Assessment of Capacity for Trauma (INTACT): an index for trauma capacity in low-income countries. J Surg Res 2014; 190:522-7. [PMID: 24594216 DOI: 10.1016/j.jss.2014.01.060] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/30/2014] [Accepted: 01/31/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Injury remains a leading cause of death worldwide with a disproportionate impact in the developing world. Capabilities for trauma care remain limited in these settings. We propose the implementation of the International Assessment of Capacity for Trauma (INTACT) index to provide a standardized way of assessing a health care facility's capacity to provide adequate trauma care. MATERIALS AND METHODS A retrospective review of the trauma capacity of 10 government hospitals (district, secondary, regional, maternity, and tertiary facilities) in Sierra Leone was performed using data collected during on-site visits in August 2011. The index incorporates 40 key elements, including resuscitation, laparotomy, chest tube insertion, fracture repair, and burn management capabilities. The INTACT index was calculated on a scale of 0-10 and compared with a previously published index of surgical capacity, the personnel, infrastructure, equipment, and supplies (PIPES) index. RESULTS Connaught Hospital, the only tertiary referral center, had the highest index (9.0), consistent with it being the best equipped and staffed of the country. The three district hospitals assessed had the lowest scores from 3.5 to 4.3. INTACT and PIPES scores were correlated overall (r = 0.88). The proportionate difference compared with the PIPES survey was 30% for the maternity hospital and 1% for the tertiary center, suggesting that the INTACT index may be specific for trauma. Deficiencies are especially prominent in personnel, imaging, fracture repair, and burn management. CONCLUSIONS The INTACT index is a simple tool designed to specifically assess trauma capacity from initial resuscitation to definitive care. Shortcomings in trauma capacity remain prominent and the INTACT index could be used to assess trauma care deficiencies in developing countries.
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Affiliation(s)
- Evan G Wong
- Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Surgeons OverSeas, New York, New York.
| | - Shailvi Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Surgeons OverSeas, New York, New York; Department of Surgery, University of California, San Francisco, East Bay
| | - Dan L Deckelbaum
- Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tarek Razek
- Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Thaim B Kamara
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone; College of Medicine and Allied Health Science, Freetown, Sierra Leone
| | - Benedict C Nwomeh
- Surgeons OverSeas, New York, New York; Nationwide Children's Hospital, Ohio State University, Columbus, Ohio
| | - Adil H Haider
- Center for Surgical Trials and Outcomes Research (CSTOR), Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adam L Kushner
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Surgeons OverSeas, New York, New York; Department of Surgery, Columbia University, New York, New York
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Parra MW, Castillo RC, Rodas EB, Suarez-Becerra JM, Puentes-Manosalva FE, Wendt LM. International trauma teleconference: evaluating trauma care and facilitating quality improvement. Telemed J E Health 2013; 19:699-703. [PMID: 23841490 DOI: 10.1089/tmj.2012.0254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evaluation, development, and implementation of trauma systems in Latin America are challenging undertakings as no model is currently in place that can be easily replicated throughout the region. The use of teleconferencing has been essential in overcoming other challenges in the medical field and improving medical care. This article describes the use of international videoconferencing in the field of trauma and critical care as a tool to evaluate differences in care based on local resources, as well as facilitating quality improvement and system development in Latin America. MATERIALS AND METHODS In February 2009, the International Trauma and Critical Care Improvement Project was created and held monthly teleconferences between U.S. trauma surgeons and Latin American general surgeons, emergency physicians, and intensivists. In-depth discussions and prospective evaluations of each case presented were conducted by all participants based on resources available. Care rendered was divided in four stages: (1) pre-hospital setting, (2) emergency room or trauma room, (3) operating room, and (4) subsequent postoperative care. Furthermore, the participating institutions completed an electronic survey of trauma resources based on World Health Organization/International Association for Trauma and Surgical Intensive Care guidelines. RESULTS During a 17-month period, 15 cases in total were presented from a Level I and a Level II U.S. hospital (n=3) and five Latin American hospitals (n=12). Presentations followed the Advanced Trauma Life Support sequence in all U.S. cases but in only 3 of the 12 Latin American cases. The following deficiencies were observed in cases presented from Latin America: pre-hospital communication was nonexistent in all cases; pre-hospital services were absent in 60% of cases presented; lack of trauma team structure was evident in the emergency departments; during the initial evaluation and resuscitation, the Advanced Trauma Life Support protocol was followed one time and the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage protocol on two occasions; it was determined that imaging resources were adequately used in half of the cases; the initial care was mostly provided by emergency room physicians; and a surgeon, operating room, and intensive care unit were not readily available 83% of the time. The ease of patient flow was cumbersome because of a lack of a structured system for trauma care except for one academic urban center. Adequate trauma resources are present in less than 50% of the time. Multidisciplinary resources, quality improvement programs, protocols, and guidelines were deficient. CONCLUSIONS A well-structured international teleconference can be used as a dynamic window of observation to evaluate and identify deficiencies in trauma care in the Latin American region. These findings can be used to formulate specific recommendations based on local resources. Furthermore, by raising local awareness, leaders could be identified to become the executors of more efficient healthcare policies that can potentially affect trauma care.
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Ordóñez CA, Pino LF, Tejada JW, Badiel M, Loaiza JH, Mata LV, Aboutanos MB. Experiencia en dos hospitales de tercer nivel de atención del suroccidente de Colombia en la aplicación del Registro Internacional de Trauma de la Sociedad Panamericana de Trauma. Rev Col Bras Cir 2012; 39:255-62. [DOI: 10.1590/s0100-69912012000400003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 03/31/2012] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Describir la experiencia en la implementación de un Sistema de Registro de Trauma (SRT) en dos hospitales en Cali, Colombia. MÉTODOS: El SRT incluye información prehospitalaria, hospitalaria y estatus de egreso del paciente. Cada hospital tiene una estrategia para la captura electrónica de datos. Se presenta un análisis descriptivo exploratorio durante un piloto de tres meses. RESULTADOS: Se han registrado 3293 pacientes, 1626(49.4%) del Hospital Público y 1613(50.6%) en el Privado. 67.2% fueron hombres; edad promedio 30,5±20 años, 30,5% menores de 18 años. Mortalidad global 3,52 %. Causa más frecuente de consulta fueron las caídas (33,7%); 11.6% fueron heridas por arma de fuego, la mortalidad en este grupo fue del 44.7%. CONCLUSIÓN: Se determinaron las necesidades para la implementación del SRT y los mecanismos para darle continuidad. El registro se convierte en una fuente de información para el desarrollo de la investigación. Se identificaron las causas de consulta, morbilidad y muerte por trauma que permitirá una mejor planeación de los servicios de urgencias y del sistema regional de trauma con el fin de optimizar y de reducir los costos de atención. A partir de este sistema de información de trauma se podrán plantear los ajustes indispensables para rediseñar el sistema de trauma y emergencias del suroccidente colombiano.
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Hanche-Olsen TP, Alemu L, Viste A, Wisborg T, Hansen KS. Trauma care in Africa: a status report from Botswana, guided by the World Health Organization's "Guidelines for Essential Trauma Care". World J Surg 2012; 36:2371-83. [PMID: 22678165 DOI: 10.1007/s00268-012-1659-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Trauma represents a significant and increasing challenge to health care systems all over the world. This study aimed to evaluate the trauma care capabilities of Botswana, a middle-income African country, by applying the World Health Organization's Guidelines for Essential Trauma Care. METHODS All 27 government (16 primary, 9 district, 2 referral) hospitals were surveyed. A questionnaire and checklist, based on "Guidelines for Essential Trauma Care" and locally adapted, were developed as situation analysis tools. The questionnaire assessed local trauma organization, capacity, and the presence of quality improvement activity. The checklist assessed physical availability of equipment and timely availability of trauma-related skills. Information was collected by interviews with hospital administrators, key personnel within trauma care, and through on-site physical inspection. RESULTS Hospitals in Botswana are reasonably well supplied with human and physical resources for trauma care, although deficiencies were noted. At the primary and district levels, both capacity and equipment for airway/breathing management and vascular access was limited. Trauma administrative functions were largely absent at all levels. No hospital in Botswana had any plans for trauma education, separate from or incorporated into other improvement activities. Team organization was nonexistent, and training activities in the emergency room were limited. CONCLUSIONS This study draws a picture of trauma care capabilities of an entire African country. Despite good organizational structures, Botswana has room for substantial improvement. Administrative functions, training, and human and physical resources could be improved. By applying the guidelines, this study creates an objective foundation for improved trauma care in Botswana.
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Abstract
BACKGROUND Reducing the global burden of injury requires both injury prevention and improved trauma care. We sought to provide an estimate of the number of lives that could be saved by improvements in trauma care, especially in low income and middle income countries. METHODS Prior data showed differences in case fatality rates for seriously injured persons (Injury Severity Score ≥ 9) in three separate locations: Seattle, WA (high income; case fatality 35%); Monterrey, Mexico (middle income; case fatality 55%); and Kumasi, Ghana (low income; case fatality 63%). For the present study, total numbers of injury deaths in all countries in different economic strata were obtained from the Global Burden of Disease study. The number of lives that could potentially be saved from improvements in trauma care globally was calculated as the difference in current number of deaths from trauma in low income and middle income countries minus the number of deaths that would have occurred if case fatality rates in these locations were decreased to the case fatality rate in high income countries. RESULTS Between 1,730,000 and 1,965,000 lives could be saved in low income and middle income countries if case fatality rates among seriously injured persons could be reduced to those in high income countries. This amounts to 34-38% of all injury deaths. CONCLUSIONS A significant number of lives could be saved by improvements in trauma care globally. This is another piece of evidence in support of investment in and greater attention to strengthening trauma care services globally.
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Affiliation(s)
- Charles Mock
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, 325 Ninth Avenue, P.O. Box 359960, Seattle, WA, 98104, USA.
| | - Manjul Joshipura
- Department of Violence and Injury Prevention and Disability, World Health Organization, Geneva, Switzerland
| | | | - Robert Quansah
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Abstract
Injury and violence rank among the leading causes of death worldwide, with more than 5 million deaths annually, representing a significant portion of the global burden of disease. This article examines how injury and violence relate to global health using recent global burden of disease data and selected key studies and databases, and further explores risk factors and intervention initiatives that address unintentional and intentional injuries. The article serves as a call to action to enhance understanding of the growing burden of injury and violence, especially in low-income and middle-income countries, where more than 90% of injuries occur.
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