Trauma system development in low- and middle-income countries: a review (original) (raw)
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Systematic Reviews
Background: Trauma represents a major global health problem projected to increase in importance over the next decade. The majority of deaths occur in low-and middle-income countries (LMICs) where survival rates are lower than their high-income country (HIC) counterparts. Health system level changes in care for injured patients have been attributed to significant improvements in care quality and outcomes in HIC settings. There is a need for further research to assess trauma care health systems in LMICs to inform health system strengthening for the care of the injured. This study aims to conduct a narrative synthesis of a systematic search of the literature on the assessment of trauma care health systems in LMICs in order to inform the further development of trauma care health system assessment. Methods: The review will include primary quantitative, qualitative or mixed method studies and secondary literature reviews. No restriction will be placed on language or date. Reports and publications identified from the grey literature including from relevant national and international health organisations will be included. Articles will be screened by two independent reviewers with a third reviewer resolving any persisting disagreement. The search will reveal heterogenous studies not suitable for meta-analysis. A narrative synthesis of the identified papers will be conducted to identify key methodological ideas and paradigms used to assess trauma care health systems. The analysis will consider how the differing methodological approaches could be adopted to understand barriers and delays to seeking, reaching and receiving care within a "Three Delays" framework. An iterative approach will be adopted to categorise identified articles, with the results presented as both within and across study analysis. Discussion: The results of the review will be disseminated through publication in a peer-reviewed academic journal. The study forms part of a PhD project. The results will inform the development of a trauma care health system assessment applicable to LMICs. As this is a review of secondary data, no formal ethical approval is required. Systematic review registration: PROSPERO CRD42018112990
Prehospital trauma systems reduce mortality in developing countries
Journal of Trauma and Acute Care Surgery, 2012
The majority of trauma deaths in the developing world occur outside of the hospital. In the mid-1990s, preliminary studies of prehospital trauma systems showed improvements in mortality. However, no empirical data are available to assess the overall benefit of these systems. We undertook a systematic review and meta-analysis to assess the effectiveness of prehospital trauma systems in developing countries. We conducted multiple database and bibliography searches (from inception until December 2010) to identify articles assessing the effectiveness of prehospital trauma systems in developing countries. The primary outcome was mortality. Secondary outcomes were physiologic severity score, Injury Severity Score, and prehospital time. We calculated relative risks (95% confidence intervals [CIs]), performed a sensitivity analysis, and pooled estimates using a fixed effects method. Fourteen studies met our inclusion criteria for qualitative analysis. Eight studies representing seven countries (n = 5,607) were included in the meta-analysis. Our pooled estimates show a 25% decreased risk of dying from trauma in areas that have prehospital trauma systems (relative risk [RR], 0.75; 95% CI, 0.66-0.85), with no significant heterogeneity (χ = 3.71, p = 0.72). Rural settings showed slightly enhanced treatment effect compared with urban settings (RR, rural 0.71; 95% CI, 0.59-0.86 vs. urban 0.79; 95% CI, 0.65-0.94). In-field response time was reduced in both rural (without an ambulance system, 66 minutes, 95% CI: 24-108) and urban (with an ambulance system, 6 minutes, 95% CI: 5.47 to 6.53, p < 0.0005) settings. Prehospital trauma systems in developing countries, particularly middle-income countries, reduce mortality. These data should inform and encourage developing countries to adopt prehospital trauma systems at the policy level. Meta-analysis, level III+.
African Journal of Emergency Medicine, 2019
Introduction: Injury and violence are neglected global health concerns, despite being largely predictable and therefor preventable. We conducted a small study to indirectly describe and compare the perception of availability of resources to manage major trauma in high-income, and low-and middle-income countries using evidence-based guidance (as per the 2016 National Institute of Clinical Excellence guidelines), as self-reported by delegates attending the 2016 International Conference on Emergency Medicine held in South Africa. Methods: A survey was distributed to delegates at the International Conference on Emergency Medicine 2016. The survey instrument captured responses from participants working in both pre-and in-hospital settings. Responses were grouped according to income group (either high-income, or low-and middle-income) based on the respondent's nationality (using the World Bank definition for income group). A Fisher's Exact test was conducted to compare responses between different income groups. Results: The survey was distributed to 980 delegates, and 392 (40%) responded. A total of 206 (53%) respondents were from high-income countries and 186 (47%) were from low-to middle-income countries. Respondents described significantly less access to resources and services for low-and middle-income countries to adequately care for major trauma patients both pre-and in-hospital when compared to high-income countries. Shortages ranged from consumables to analgesia, imaging to specialist services, and pre-hospital to in-hospital care. Conclusion: Major trauma care requires a chain of successful, evidence-based events for outcomes to benefit. This small study suggests that many of the links of this chain are either missing or broken within low-and middleincome countries. These settings simply do not benefit from the currently available evidence-base in major trauma care. It is important that this evidence-base also be evaluated within low-and middle-income countries. The capacity of low-and middle-income country emergency care systems also needs better describing. African relevance • Resource restriction is a major concern for major trauma care in low-and middle-income countries. • Current accepted reference standards provide little room for clinicians working in these countries. • More research is required to describe the problem of resource restrictions in LMICs.
World Journal of Surgery, 2006
Background: We sought to identify affordable and sustainable methods to strengthen trauma care capabilities globally, especially in developing countries, using the Guidelines for Essential Trauma Care. These guidelines were created by the World Health Organization (WHO) and the International Society of Surgery and provide recommendations on elements of trauma care that should be in place at the range of health facilities globally. Methods: The guidelines were used as a basis for needs assessments in 4 countries selected to represent the worldÕs range of geographic and economic conditions: Mexico (middle income; Latin America); Vietnam (low income; east Asia); India (low income; south Asia); and Ghana (low income; Africa). One hundred sites were assessed, including rural clinics (n = 51), small hospitals (n = 34), and large hospitals (n = 15). Site visits utilized direct inspection and interviews with administrative and clinical staff. Results: Resources were partly adequate or adequate at most large hospitals, but there were gaps that could be improved, especially in low-income settings, such as shortages of airway equipment, chest tubes, and trauma-related medications; and prolonged periods where critical equipment (e.g., X-ray, laboratory) were unavailable while awaiting repairs. Rural clinics everywhere had difficulties with basic supplies for resuscitation even though some received significant trauma volumes. In all settings, there was a dearth of administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and regular in-service training. Conclusions: This study identified several low-cost ways in which to strengthen trauma care globally. It also has demonstrated the usefulness of the Guidelines for Essential Trauma Care in providing an internationally applicable, standardized template by which to assess trauma care capabilities. T rauma is now a leading cause of death and disability globally, including in low-and middle-income countries (LMICs). Increased attention is being paid to this problem, especially from the viewpoints of road safety and injury prevention. 1 However, strategies to strengthen trauma care globally, especially in the setting of LMICs, have not been well worked out. Several studies have shown high rates of medically preventable trauma deaths in LMICs, many from conditions that could be treated well
Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 2016
Knowledge on the current trauma systems in Asian countries is limited. The objective of this study was to describe the emergency medical services (EMS) and trauma care systems among countries participating in the Pan-Asian Trauma Outcomes Study (PATOS) Clinical Research Network. The PATOS network consists of 33 participating sites from 14 countries. Standardized data was collected from each site using an EMS survey form and included general information (population, population density, urbanization, EMS service fee, etc.), dispatcher system, trauma care practice, trauma education program, existence of a trauma registry, and data on EMS transfers. Data is described with simple descriptive statistics. All countries included urban sites. Nine countries included rural sites and only one country included wilderness site. Of the 33 sties, 18 sites had physician-based EMS systems. EMS services were free in 9 countries. Twelve sites had dispatch centers operated by government health departme...
Trauma systems in Asian countries: challenges and recommendations
Critical care, 2024
Introduction Trauma burden is one of the leading causes of young human life and economic loss in low-and middle-income countries. Improved emergency and trauma care systems may save up to 2 million lives in these countries. Method This is a comprehensive expert opinion participated by 4 experts analyzing 6 Asian countries compiling the most pressing trauma care issues in Asia as well as goal directed solutions for uplifting of trauma care in these countries. Result Lack of legislation, stable funding under a dedicated lead agency is a major deterrent to development and sustainment of trauma systems in most Asian countries. While advocating trauma, critical care as a specialty is a key event in the system establishment, Trauma specialized training is challenging in low resource settings and can be circumvented by regional cooperation in creating trauma specialized academic centers of excellence. Trauma quality improvement process is integral to the system maturity but acquisition and analysis of quality data through trauma specific registries is the least developed in the Asian setting.
The VCU international trauma system development program in Central and South America
Background Injury is a major cause of death and disability in low- and middle-income countries (LMICs) where there is a paucity of injury data. We aimed to create information and communication infrastructure to evaluate injury patterns, identify areas for improvement and measure effectiveness of interventions at every level of health care facilities in LMICs. Methods We created an electronic trauma database in 3 languages (English, Spanish and Portuguese) with the ability to link hospital systems at a local, regional and national level. Access is through either a secure online website or software installation where internet is limited. The database consists of 50 essential elements, expandable up to 250 elements, per record, using the ICD-10 system and Injury Severity Scores. It can generate fixed or modifiable reports and import/export data for statistical analysis. We implemented this system in 3 countries as a pilot program for clinicians, administrators and data entry personnel,...
Maximizing the potential of trauma registries in low-income and middle-income countries
Trauma Surgery & Acute Care Open, 2020
Injury is a major global health issue, resulting in millions of deaths every year. For decades, trauma registries have been used in wealthier countries for injury surveillance and clinical governance, but their adoption has lagged in low-income and middle-income countries (LMICs). Paradoxically, LMICs face a disproportionately high burden of injury with few resources available to address this pandemic. Despite these resource constraints, several hospitals and regions in LMICs have managed to develop trauma registries to collect information related to the injury event, process of care, and outcome of the injured patient. While the implementation of these trauma registries is a positive step forward in addressing the injury burden in LMICs, numerous challenges still stand in the way of maximizing the potential of trauma registries to inform injury prevention, mitigation, and improve quality of trauma care. This paper outlines several of these challenges and identifies potential soluti...