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Gyedu A, Issaka A, Donkor P, Mock C. Assessment and reassessment of injured patients at non-tertiary hospitals in Ghana: A stepped-wedge cluster randomized trial. Afr J Emerg Med 2024; 14:122-127. [PMID: 38799078 PMCID: PMC11127473 DOI: 10.1016/j.afjem.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Frequent reassessment of injured patients is an important component of trauma and emergency care. How frequently such reassessment is done in African hospitals has been minimally addressed. We sought to address this gap, as well as to assess the effectiveness of a standardized trauma intake form (TIF) to improve assessment and reassessment rates. Methods We undertook a stepped-wedge cluster randomized trial with research assistants observing trauma care before and after introducing the TIF at emergency units of eight non-tertiary Ghanaian hospitals for 17.5 months. Differences in seven key performance indicators (KPIs) of assessment and reassessment were evaluated using generalized linear mixed regression. KPIs included: respiratory rate, heart rate, blood pressure, level of consciousness, mobility, temperature, and oxygen saturation. Results Management of 4077 patients was observed: 2067 before TIF initiation and 2010 after. In the before period, completion of KPIs of initial assessment ranged from 55% (oxygen saturation) to 88% (level of consciousness). KPIs for reassessment for patients still in the EU after 30 min (n = 1945, in before period) were much lower than for initial assessment, ranging from 10% (respiratory rate and oxygen saturation) to 13% (level of consciousness). The TIF did not significantly improve performance of any KPI of assessment or reassessment. Similar patterns pertained for the subgroup of seriously injured patients (Injury Severity Score ≥9). Conclusion At non-tertiary hospitals in Ghana, performance of KPIs of initial assessment were mostly adequate, but with room for improvement. Performance of KPIs for reassessment were very low, even for seriously injured patients. The intervention (trauma intake form) did not impact reassessment rates, despite previously having been shown to impact many other KPIs of trauma care. Potential avenues to pursue to improve reassessment rates include other quality improvement efforts and increased emphasis on reassessment in training courses.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Adamu Issaka
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, United States
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Gyedu A, Issaka A, Appiah AB, Donkor P, Mock C. Care of Injured Children Compared to Adults at District and Regional Hospitals in Ghana and the Impact of a Trauma Intake Form: A Stepped-Wedge Cluster Randomized Trial. J Pediatr Surg 2024; 59:1210-1218. [PMID: 38154994 PMCID: PMC11105994 DOI: 10.1016/j.jpedsurg.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/16/2023] [Accepted: 12/03/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND This study aimed to determine the effectiveness of a standardized trauma intake form (TIF) to improve achievement of key performance indicators (KPIs) of initial trauma care among injured children, compared to adults, at non-tertiary hospitals in Ghana. METHODS A stepped-wedge cluster randomized trial was performed with research assistants directly observing the management of injured patients before and after introducing the TIF at emergency units of 8 non-tertiary hospitals for 17.5 months. Differences in outcomes between children and adults in periods before and after TIF introduction were determined with multivariable logistic regression. Differences in outcomes among children after TIF introduction were determined using generalized linear mixed regression. RESULTS Management of 3889 injured patients was observed; 757 (19%) were children <18 years. Trauma care KPIs at baseline were lower for children compared to adults. Improvements in primary survey KPIs were observed among children after TIF introduction. Examples include airway assessment [279 (71%) to 359 (98%); adjusted odds ratio (AOR): 74.42, p = 0.005)] and chest examination [225 (58%) to 349 (95%); AOR 53.80, p = 0.002)]. However, despite these improvements, achievement of KPIs was still lower compared to adults. Examples are pelvic fracture evaluation [children: 295 (80%) vs adults: 1416 (88%), AOR: 0.56, p = 0.001] and respiratory rate assessment (children: 310 (84%) vs adults: 1458 (91%), AOR: 058, p = 0.030). CONCLUSIONS While the TIF was effective in improving most KPIs of pediatric trauma care, more targeted education is needed to bridge the gap in quality between pediatric and adult trauma care at non-tertiary hospitals in Ghana and other low- and middle-income countries. TYPE OF STUDY Stepped-wedged cluster randomized controlled trial. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Adamu Issaka
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Anthony Baffour Appiah
- Ghana Field Epidemiology and Laboratory Training Program, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA; Harborview Injury Prevention and Research Center, Seattle, WA, USA
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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] [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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Gyedu A, Loglo L, Ablorh K, Brobbey-Kyei IA, Donkor P, Mock C. Improvement in quality of trauma care at non-tertiary hospitals in Ghana during on-hours and off-hours with a trauma intake form: A stepped-wedge cluster randomized trial. Injury 2024:111569. [PMID: 38679559 DOI: 10.1016/j.injury.2024.111569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/22/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at non-tertiary hospitals in Ghana during on-hours (8AM-5PM weekdays) compared to off-hours (nights, weekends, and holidays). We also sought to assess the effectiveness of a standardized trauma intake form (TIF) with built-in decision support prompts to improve care and to assess whether this effectiveness varied between on-hours and off-hours. METHODS A stepped-wedge cluster randomized trial was performed with research assistants directly observing trauma care before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs and mortality were assessed using multivariable logistic regression and generalized linear mixed regression. RESULTS Management of 4,077 patients was observed; 1,126 (28 %) during on-hours and 2,951(72 %) during off-hours. At baseline, four of 20 KPIs were performed significantly more often during off-hours. TIF improved care during both on- and off-hours. Seventeen KPIs improved during on-hours and 18 KPIs improved during off-hours. After TIF, six KPIs were performed more often during on-hours, but differences, though significant, were small (1-5 %). Examples of KPIs which were performed more often during on-hours after TIF included: airway assessment (99 % for on-hours vs. 98 % for off-hours), evaluation for intra-abdominal bleeding (91 % vs. 87 %), and spine immobilization for blunt trauma (90 % vs. 85 %) (all p < 0.05). At baseline, mortality among seriously injured patients (Injury Severity Score >9) was higher during on-hours (27 %) compared to off-hours (17 %, p = 0.047). TIF lowered mortality for seriously injured patients during both on-hours (27 % before TIF, 8 % after, p = 0.027) and during off-hours (17 % before, 7 % after, p = 0.004). After TIF, mortality among seriously injured patients was equal between on- and off-hours (8 % vs. 7 %, NS). CONCLUSIONS At baseline, KPIs of trauma care were slightly better during off-hours compared with on-hours, and mortality was lower among seriously injured patient during off-hours. A quality improvement initiative (the TIF) using built-in decision support prompts improved care strongly in both on- and off-hours and eliminated the mortality difference between on- and off-hours. Use of similar decision support prompts during initial trauma care should be promoted widely in other low- and middle-income countries.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Lord Loglo
- Konongo-Odumase Government Hospital, Konongo, Ghana
| | | | | | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
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Jamshidi Z, Norouzi Tabrizi K, Khankeh H, Zeraati Nasrabadi M, Sadeghi H, Eghbali M. Design and psychometric properties of the acute care quality in trauma emergency units scale. Eur J Trauma Emerg Surg 2024; 50:447-453. [PMID: 37728635 DOI: 10.1007/s00068-023-02360-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/27/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Systematic trauma care scale could be designed and used by nurses to completely and adequately fulfill a complex care to improve trauma care quality. The purpose of this study was to design and evaluate the psychometric property of the Nursing Care Quality in Trauma Emergency Units and trauma care promotion. METHODS This methodological study was conducted in 2022. The process of designing and psychometric assessment of the scale was performed in two steps such as Generating an Item Pool and Validity and Reliability evaluation (Item reduction). The construct validity was determined using the experimental intervention; for determining the reliability of the scale and internal consistency, we measured the inter-rater reliability (IRR). Data were analyzed using the SPSS software, version 22. RESULTS Based on our findings, the CVI and CVR of the scale were 1 and 0.83-1, respectively. A significant difference between the pre- and post-intervention scores in group 1 supports the inference that the construct has been appropriately represented, and the instrument has construct validity (p < 0.001). We found that there was a significant difference in the scores of Patient assessment, Planning and Implementations, and Evaluation of the care plan. The inter-rater reliability method allows the optimal reliability assessment of observational instruments, which was used in this study, and the results confirmed excellent reliability of the instrument. CONCLUSIONS The validity and reliability of the Nursing Care Quality in Trauma Emergency Units Scale were confirmed. The instrument could successfully assess the process of nursing care in the trauma emergency ward. The use of this checklist is recommended as a valid observational tool for other researchers. STUDY TYPE Therapeutic/care management.
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Affiliation(s)
- Zahra Jamshidi
- Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Kian Norouzi Tabrizi
- School of Behavioral Sciences and Mental Health, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Hamidreza Khankeh
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
- Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
| | | | - Hajar Sadeghi
- Department of Nursing Education, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mohammad Eghbali
- School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
- Health Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
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Gyedu A, Stewart BT, Nakua E, Donkor P. Standardized trauma intake form with clinical decision support prompts improves care and reduces mortality for seriously injured patients in non-tertiary hospitals in Ghana: stepped-wedge cluster randomized trial. Br J Surg 2023; 110:1473-1481. [PMID: 37612450 PMCID: PMC10564400 DOI: 10.1093/bjs/znad253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/22/2023] [Accepted: 07/23/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND The WHO Trauma Care Checklist improved key performance indicators (KPIs) of trauma care at tertiary hospitals. A standardized trauma intake form (TIF) with real-time clinical decision support prompts was developed by adapting the WHO Trauma Care Checklist for use in smaller low- and middle-income country hospitals, where care is delivered by non-specialized providers and without trauma teams. This study aimed to determine the effectiveness of the TIF for improving KPIs in initial trauma care and reducing mortality at non-tertiary hospitals in Ghana. METHODS A stepped-wedge cluster randomized trial was conducted by stationing research assistants at emergency units of eight non-tertiary hospitals for 17.5 months to observe management of injured patients before and after introduction of the TIF. Differences in performance of KPIs in trauma care (primary outcomes) and mortality (secondary outcome) were estimated using generalized linear mixed regression models. RESULTS Management of 4077 injured patients was observed (2067 before TIF introduction, 2010 after). There was improvement in 14 of 16 primary survey and initial care KPIs after TIF introduction. Airway assessment increased from 72.9 to 98.4 per cent (adjusted OR 25.27, 95 per cent c.i. 2.47 to 258.94; P = 0.006) and breathing assessment from 62.1 to 96.8 per cent (adjusted OR 38.38, 4.84 to 304.69; P = 0.001). Documentation of important clinical data improved from 52.4 to 76.7 per cent (adjusted OR 2.14, 1.17 to 3.89; P = 0.013). The mortality rate decreased from 17.7 to 12.1 per cent among 302 patients (186 before, 116 after) with impaired physiology on arrival (hypotension or decreased level of consciousness) (adjusted OR 0.10, 0.02 to 0.56; P = 0.009). CONCLUSION The TIF improved overall initial trauma care and reduced mortality for more seriously injured patients. REGISTRATION NUMBER NCT04547192 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Surgery Unit, University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Emmanuel Nakua
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Bijok B, Jaulin F, Picard J, Michelet D, Fuzier R, Arzalier-Daret S, Basquin C, Blanié A, Chauveau L, Cros J, Delmas V, Dupanloup D, Gauss T, Hamada S, Le Guen Y, Lopes T, Robinson N, Vacher A, Valot C, Pasquier P, Blet A. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med 2023; 42:101262. [PMID: 37290697 DOI: 10.1016/j.accpm.2023.101262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care. DESIGN A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based. METHODS We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology. RESULTS The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions. CONCLUSION Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.
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Affiliation(s)
- Benjamin Bijok
- Pôle Anesthésie-Réanimation, Bloc des Urgences/Déchocage, CHU de Lille, Lille, France; Pôle de l'Urgence, Bloc des Urgences/Déchocage, CHU de Lille, Lille, France.
| | - François Jaulin
- Président du Groupe Facteurs Humains en Santé, France; Directeur Général et Cofondateur Patient Safety Database, France; Directeur Général et Cofondateur Safe Team Academy, France.
| | - Julien Picard
- Pôle Anesthésie-Réanimation, Réanimation Chirurgicale Polyvalente - CHU Grenoble Alpes, Grenoble, France; Centre d'Evaluation et Simulation Alpes Recherche (CESAR) - ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble Alpes, Grenoble, France; Comité Analyse et Maîtrise du Risque (CAMR) de la Société Française d'Anesthésie Réanimation (SFAR), France
| | - Daphné Michelet
- Département d'Anesthésie-Réanimation du CHU de Reims, France; Laboratoire Cognition, Santé, Société - Université Reims-Champagne Ardenne, France
| | - Régis Fuzier
- Unité d'Anesthésiologie, Institut Claudius Regaud. IUCT-Oncopole de Toulouse, France
| | - Ségolène Arzalier-Daret
- Département d'Anesthésie-Réanimation, CHU de Caen Normandie, Avenue de la Côte de Nacre, 14000 Caen, France; Comité Vie Professionnelle-Santé au Travail (CVP-ST) de la Société Française d'Anesthésie-Réanimation (SFAR), France
| | - Cédric Basquin
- Département Anesthésie-Réanimation, CHU de Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; CHP Saint-Grégoire, Groupe Vivalto-Santé, 6 Bd de la Boutière CS 56816, 35760 Saint-Grégoire, France
| | - Antonia Blanié
- Département d'Anesthésie-Réanimation Médecine Périopératoire, CHU Bicêtre, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France; Laboratoire de Formation par la Simulation et l'Image en Médecine et en Santé (LabForSIMS) - Faculté de Médecine Paris Saclay - UR CIAMS - Université Paris Saclay, France
| | - Lucille Chauveau
- Service des Urgences, SMUR et EVASAN, Centre Hospitalier de la Polynésie Française, France; Maison des Sciences de l'Homme du Pacifique, C9FV+855, Puna'auia, Polynésie Française, France
| | - Jérôme Cros
- Service d'Anesthésie et Réanimation, Polyclinique de Limoges Site Emailleurs Colombier, 1 Rue Victor-Schoelcher, 87038 Limoges Cedex 1, France; Membre Co-Fondateur Groupe Facteurs Humains en Santé, France
| | - Véronique Delmas
- Service d'Accueil des Urgences, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France; CAp'Sim, Centre d'Apprentissage par la Simulation, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France
| | - Danièle Dupanloup
- IADE, Cadre de Bloc, CHU de Nancy, 29 Avenue du Maréchal de Lattre de Tassigny, 54000 Nancy, France; Comité IADE de la Société Française d'Anesthésie Réanimation (SFAR), France
| | - Tobias Gauss
- Pôle Anesthésie-Réanimation, Bloc des Urgences/Déchocage, CHU Grenoble Alpes, Grenoble, France
| | - Sophie Hamada
- Université Paris Cité, APHP, Hôpital Européen Georges Pompidou, Service d'Anesthésie Réanimation, F-75015, Paris, France; CESP, INSERM U 10-18, Université Paris-Saclay, France
| | - Yann Le Guen
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Thomas Lopes
- Service d'Anesthésie-Réanimation, Hôpital Privé de Versailles, 78000 Versailles, France
| | | | - Anthony Vacher
- Unité Recherche et Expertise Aéromédicales, Institut de Recherche Biomédicale des Armées, Brétigny Sur Orge, France
| | | | - Pierre Pasquier
- 1ère Chefferie du Service de Santé, Villacoublay, France; Département d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France; École du Val-de-Grâce, Paris, France
| | - Alice Blet
- Lyon University Hospital, Department of Anaesthesiology and Critical Care, Croix Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; INSERM U1052, Cancer Research Center of Lyon, Lyon, France
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Werner K, Kak M, Herbst CH, Lin TK. Emergency care in post-conflict settings: a systematic literature review. BMC Emerg Med 2023; 23:37. [PMID: 37005602 PMCID: PMC10068156 DOI: 10.1186/s12873-023-00775-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 01/09/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Emergency care systems (ECS) organize and provide access to life-saving care both during transport and at health facilities. Not enough is known about ECS in uncertain contexts such as post-conflict settings. This review aims to systematically identify and summarize the published evidence on the delivery of emergency care in post-conflict settings and to guide health sector planning. METHODS We searched five databases (PubMed MEDLINE, Web of Science, Embase, Scopus, and Cochrane) in September 2021 to identify relevant articles on ECS in post-conflict settings. Included studies (1) described a context that is post-conflict, conflict-affected, or was impacted by war or crisis; (2) examined the delivery of an emergency care system function; (3) were available in English, Spanish, or French; and (4) were published between 1 and 2000 and 9 September 2021. Data were extracted and mapped using the essential system functions identified in the World Health Organization (WHO) ECS Framework to capture findings on essential emergency care functions at the scene of injury or illness, during transport, and through to the emergency unit and early inpatient care. RESULTS We identified studies that describe the unique burden of disease and challenges in delivering to the populations in these states, pointing to particular gaps in prehospital care delivery (both during scene response and during transport). Common barriers include poor infrastructure, lingering social distrust, scarce formal emergency care training, and lack of resources and supplies. CONCLUSION To our knowledge, this is the first study to systematically identify the evidence on ECS in fragile and conflict-affected settings. Aligning ECS with existing global health priorities would ensure access to these critical life-saving interventions, yet there is concern over the lack of investments in frontline emergency care. An understanding of the state of ECS in post-conflict settings is emerging, although current evidence related to best practices and interventions is extremely limited. Careful attention should be paid to addressing the common barriers and context-relevant priorities in ECS, such as strengthening prehospital care delivery, triage, and referral systems and training the health workforce in emergency care principles.
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Affiliation(s)
- Kalin Werner
- Department of Social and Behavioral Sciences, Institute for Health & Aging, University of California, San Francisco, CA, San Francisco, USA.
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
| | - Mohini Kak
- Health, Nutrition and Population Global Practice, The World Bank, Washington, DC, USA
| | - Christopher H Herbst
- Health, Nutrition and Population Global Practice, The World Bank, Washington, DC, USA
| | - Tracy Kuo Lin
- Department of Social and Behavioral Sciences, Institute for Health & Aging, University of California, San Francisco, CA, San Francisco, USA
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Amato S, Culbreath K, Dunne E, Sarathy A, Siroonian O, Sartorelli K, Roy N, Malhotra A. Pediatric trauma mortality in India and the United States: A comparison and risk-adjusted analysis. J Pediatr Surg 2023; 58:99-105. [PMID: 36328820 DOI: 10.1016/j.jpedsurg.2022.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is a paucity of research comparing pediatric risk-adjusted trauma mortality between high-income and low- and middle-income countries. This limits identification of populations and injury patterns for targeted interventions. We aim to compare independent predictors of pediatric trauma mortality between India and the United States (US). METHODS A retrospective cohort study was conducted for pediatric patients (age <18 years) in India's Towards Improved Trauma Care Outcomes (TITCO) project database and the US National Trauma Data Bank (NTDB) from 2013 to 2015. Demographic, injury, physiologic, anatomic and outcome data were analyzed. Multivariable regressions were used to determine independent predictors of mortality. RESULTS 126,678 pediatric trauma patients were included (India 3,373; US 123,305). Pediatric patients in India were on average significantly younger, with a higher median injury severity score (ISS), had lower systolic blood pressure, and suffered a higher case fatality rate (13.0% vs. 1.0%). When controlling for demographic, mechanism, physiologic, and anatomic injury characteristics, sustaining an injury in India was the strongest predictor of mortality (OR 22.70, 95% CI 18.70-27.56). On subgroup analysis, the highest relative odds of mortality in India was seen in children with lower injury and physiologic severity. CONCLUSIONS Risk-adjusted pediatric trauma-related mortality is significantly higher in India compared to the US. The comparative odds of mortality are highest among children with lower injury and physiologic severity. This suggests that low-cost targeted interventions focused on standard timely trauma care, protocols, training and early imaging could improve pediatric injury mortality in India. TYPE OF STUDY Retrospective Prognosis Study LEVEL OF EVIDENCE: II.
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Affiliation(s)
- Stas Amato
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA.
| | - Katherine Culbreath
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA; Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Emma Dunne
- University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Ashwini Sarathy
- University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Olivia Siroonian
- Department of Pharmacology, University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Kennith Sartorelli
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA
| | - Nobhojit Roy
- The George Institute for Global Health, 308, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India; WHO Collaborating Centre for Research in Surgical Care Delivery, Anushakti Nagar, Mumbai, MH 400094, India
| | - Ajai Malhotra
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA
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Werner K, Risko N, Kalanzi J, Wallis LA, Reynolds TA. Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda. PLoS One 2022; 17:e0279074. [PMID: 36516176 PMCID: PMC9750003 DOI: 10.1371/journal.pone.0279074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level. METHODS A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%. RESULTS Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters. CONCLUSION Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.
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Affiliation(s)
- Kalin Werner
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | | | - Lee A. Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Teri A. Reynolds
- Department for Clinical Services and Systems, Integrated Health Services, World Health Organization (WHO), Geneva, Switzerland
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11
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Tilahun M. Multi-Drug Resistance Profile, Prevalence of Extended-Spectrum Beta-Lactamase and Carbapenemase-Producing Gram Negative Bacilli Among Admitted Patients After Surgery with Suspected of Surgical Site Nosocomial Infection North East Ethiopia. Infect Drug Resist 2022; 15:3949-3965. [PMID: 35924020 PMCID: PMC9341454 DOI: 10.2147/idr.s376622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mihret Tilahun
- Department of Medical Laboratory Sciences, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
- Correspondence: Mihret Tilahun, Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wollo University, Dessie and Borumeda, PO.BOX 1145, Ethiopia, Tel +251 920988307, Fax +251 333115250, Email
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Gyedu A, Quainoo E, Nakua E, Donkor P, Mock C. Achievement of Key Performance Indicators in Initial Assessment and Care of Injured Patients in Ghanaian Non-tertiary Hospitals: An Observational Study. World J Surg 2022; 46:1288-1299. [PMID: 35286419 PMCID: PMC9058212 DOI: 10.1007/s00268-022-06507-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We aimed to determine the level of achievement of key performance indicators (KPIs) during initial assessment and management of injured persons, as assessed by independent observers, at district and regional hospitals in Ghana. METHODS Trained observers were stationed at emergency units of six district (first level) and two regional (referral) hospitals, from October 2020 to February 2021, to observe management of injured patients by health service providers. Achievement of KPIs was assessed for all injured patients and for seriously injured patients (admitted for ≥ 24 h, referred, or died). RESULTS Management of 1006 injured patients was observed. Road traffic crash was the most common mechanism (63%). Completion of initial triage ranged from 65% for oxygen saturation to 92% for mobility assessment. For primary survey, airway was assessed in 77% of patients, chest examination performed in 66%, and internal abdominal bleeding assessed in 43%. Reassessment rates were low, ranging from 16% for respiratory rate to 23% for level of consciousness. Thirty-one percent of patients were seriously injured. Completion of KPIs was higher for these patients, but reassessment remained low, ranging from 25% for respiratory rate to 33% for level of consciousness. CONCLUSION KPIs were performed at a high level, but several specific elements should be performed more frequently, such as oxygen saturation and assessment for internal abdominal bleeding. Reassessment needs to be performed more frequently, especially for seriously injured patients. Overall, care for the injured at non-tertiary hospitals in Ghana could be improved with a more systematic approach.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, KNUST, Private Mail Bag, University Post Office, Kumasi, Ghana.
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Emmanuel Quainoo
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Emmanuel Nakua
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah, Kumasi, Ghana
| | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, KNUST, Private Mail Bag, University Post Office, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
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Designing and conducting initial application of a performance assessment model for in-hospital trauma care. BMC Health Serv Res 2022; 22:273. [PMID: 35232439 PMCID: PMC8887084 DOI: 10.1186/s12913-022-07578-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/01/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Trauma is a major cause of death worldwide, especially in Low and Middle-Income Countries (LMIC). The increase in health care costs and the differences in the quality of provided services indicates the need for trauma care evaluation. This study was done to develop and use a performance assessment model for in-hospital trauma care focusing on traffic injures. METHODS This multi-method study was conducted in three main phases of determining indicators, model development, and model application. Trauma care performance indicators were extracted through literature review and confirmed using a two-round Delphi survey and experts' perspectives. Two focus group discussions and 16 semi-structured interviews were conducted to design the prototype. In the next step, components and the final form of the model were confirmed following pre-determined factors, including importance and necessity, simplicity, clarity, and relevance. Finally, the model was tested by applying it in a trauma center. RESULTS A total of 50 trauma care indicators were approved after reviewing the literature and obtaining the experts' views. The final model consisted of six components of assessment level, teams, methods, scheduling, frequency, and data source. The model application revealed problems of a selected trauma center in terms of information recording, patient deposition, some clinical services, waiting time for deposit, recording medical errors and complications, patient follow-up, and patient satisfaction. CONCLUSION Performance assessment with an appropriate model can identify deficiencies and failures of services provided in trauma centers. Understanding the current situation is one of the main requirements for designing any quality improvement programs.
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14
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O’Brien N, Shaw A, Flott K, Leatherman S, Durkin M. Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions. J Glob Health 2022; 12:04018. [PMID: 35265329 PMCID: PMC8876158 DOI: 10.7189/jogh.12.04018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The number of people living in fragile, conflict-affected, and vulnerable (FCV) settings is growing rapidly and attention to achieving universal health coverage must be accompanied by sufficient focus on the safety of care for universal access to be meaningful. Healthcare workers in these settings are working under extreme conditions, often with insufficient contextualized evidence to support decision-making. Recognising the relative paucity of, and methodological issues in gathering evidence from these settings, the evidence scanning described in this paper considered which patient safety interventions might offer the ‘better bet’, eg, the most effective and appropriate intervention in FCV settings. Methods An evidence scanning approach was used to examine the literature. The search was limited to FCV settings and low-income settings as defined by the World Bank, but if a systematic review included a mix of evidence from FCV/low income settings, as well as low-middle income settings, it was included. The search was conducted in English and limited to studies published from 2003 onwards, utilising Google Scholar as a publicly accessible database and further review of the grey literature, with specific attention to the outputs of non-governmental organisations. The search and subsequent analysis were completed between April and June 2020. Results The majority of studies identified related to strengthening infection prevention and control which was also found to be the ‘better bet’ intervention that could generalise to other settings, be most feasible to implement, and most effective for improving patient care and associated outcomes. Other prioritized interventions include risk management, with contributing elements such as reporting, audits, and death review processes. Conclusions Infection prevention and control interventions dominate in the literature for multiple reasons including strength of evidence, acceptability, feasibility, and impact on patient and health worker well-being. However, there is an urgent need to further develop the evidence base, specialist knowledge, and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions, and risk management.
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Affiliation(s)
- Niki O’Brien
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Alexandra Shaw
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Kelsey Flott
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sheila Leatherman
- UNC Gillings School of Global Public Health, University of North Carolina, North Carolina, USA
| | - Mike Durkin
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
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15
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Amato S, Bonnell L, Mohan M, Roy N, Malhotra A. Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis. Trauma Surg Acute Care Open 2021; 6:e000719. [PMID: 34869908 PMCID: PMC8603298 DOI: 10.1136/tsaco-2021-000719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives Comparisons of risk-adjusted trauma mortality between high-income countries and low and middle-income countries (LMICs) can be used to identify specific patient populations and injury patterns for targeted interventions. Due to a paucity of granular patient and injury data from LMICs, there is a lack of such comparisons. This study aims to identify independent predictors of trauma mortality and significant differences between India and the USA. Methods A retrospective cohort study of two trauma databases was conducted. Demographic, injury, physiologic, anatomic and outcome data were analyzed from India’s Towards Improved Trauma Care Outcomes project database and the US National Trauma Data Bank from 2013 to 2015. Multivariate logistic regression analyses were performed to determine significant independent predictors of mortality. Results 687 407 adult trauma patients were included (India 11 796; USA 675 611). Patients from India were significantly younger with greater male preponderance, a higher proportion presented with physiologic abnormalities and suffered higher mortality rates (23.2% vs. 2.8%). When controlling for age, sex, physiologic abnormalities, and injury severity, sustaining an injury in India was the strongest predictor of mortality (OR 13.85, 95% CI 13.05 to 14.69). On subgroup analyses, the greatest mortality difference was seen in patients with lower Injury Severity Scores. Conclusion After adjusting for demographic, physiologic abnormalities, and injury severity, trauma-related mortality was found to be significantly higher in India. When compared with trauma patients in the USA, the odds of mortality are most notably different among patients with lower Injury Severity Scores. While troubling, this suggests that relatively simple, low-cost interventions focused on standard timely trauma care, early imaging, and protocolized treatment pathways could result in substantial improvements for injury mortality in India, and potentially other LMICs. Level of evidence Level 3, retrospective cohort study.
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Affiliation(s)
- Stas Amato
- Department of General Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Levi Bonnell
- Department of General Internal Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Monali Mohan
- Department of Health Systems Strengthening, Care India, Bihar, Patna, India
| | - Nobhojit Roy
- The George Institute for Global Health, New Delhi, India.,WHO Collaborating Centre for Research in Surgical Care Delivery, Mumbai, India
| | - Ajai Malhotra
- Department of General Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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16
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Willard S, Mahundo S, Wilson K. Improving trauma care - A case study from Dodoma, Tanzania. Int J Orthop Trauma Nurs 2021; 44:100900. [PMID: 35151091 DOI: 10.1016/j.ijotn.2021.100900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/21/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
AIM This article describes work done to support improvements to a trauma system in Dodoma, Tanzania. It was completed to augment a study-abroad program. BACKGROUND Dodoma is in the center of Tanzania in East Africa and has, in recent years, been designated as a center of government. Formerly the commercial and political center was Dar es Salaam which became an overcrowded city that was rich in resources but often inaccessible for the majority of the citizens. This has impacted the once quiet community f Dodoma with a great influx of people. Commerce and the services that are needed to support development have led to massive growth with plans for a well thought-out infrastructure to support it. It has also brought challenges to the region. Preparing for this growth, hospital personnel needed to be prepared to meet the health needs of the population. Rutgers' School of Nursing has embarked on a relationship with the region that has been beneficial to the Dodoma community as well as the Rutgers community. DESIGN This is a descriptive analysis of work that has been done in collaboration with Rutgers University, School of Nursing, University of Dodoma and the Regional Hospital of Dodoma which has included faculty and students. METHODS An analysis was completed of bi-lateral work that has been conducted over three years. RESULTS Systems have been developed both clinically as well as educationally to increase knowledge of trauma care of patients. CONCLUSION Bilateral relationships are important not only for the visiting students and faculty but also for the country that is being visited.
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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: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [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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18
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Whitaker J, Chirwa L, Munthali B, Dube A, Amoah AS, Leather AJM, Davies J. Development and use of clinical vignettes to assess injury care quality in Northern Malawi. Injury 2021; 52:793-805. [PMID: 33487406 DOI: 10.1016/j.injury.2021.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is known that outcomes after injury care in low-and-middle income countries (LMICs) are poorer than those in high income countries. However, little is known about healthcare provider competency to deliver quality injury care in these settings. We developed and used clinical vignettes to evaluate injury care quality in an LMIC setting. METHOD Four serious injury scenarios, developed from agreed best practice, testing diagnostic and management skills, were piloted with high and low-income setting clinicians. Scenarios were used with primary and referral facility clinicians in Malawi. Participants described their clinical course of action (assessment, diagnostic, treatment and management approaches) for each scenario, registering one point per agreed best practice response. Mean percentage total scores were calculated and univariable and multivariable comparison made across provider groups, facility types, injury care frequency and training level. RESULTS Fourteen Doctors, 51 Clinical Officers, 20 Medical Assistants from 11 facilities participated. Mean percentage total vignette scores varied significantly with clinician provider group (Doctors 63.1% vs Clinical Officers 49.6%, p<0.001, Clinical Officers vs Medical Assistants 39.4% p=0.001). Important care aspects most frequently included or omitted were: following chest injury, 88.2% reported chest drain insertion, 7.1% checked for tracheal deviation; following penetrating abdominal injury and shock, 98.8% secured IV access, 0% mentioned tranexamic acid; following severe head injury, 88.2% proposed CT or neurosurgical transfer, 7.1% ensured normotension; and following isolated open lower leg fracture, 90.1% arranged orthopaedic consultation, 2.4% assessed distal neurological status. CONCLUSION These clinical vignettes proved easy to use and collected rich data. This supports their use for assessing and monitoring clinical care quality in other similar settings.
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Affiliation(s)
- John Whitaker
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental 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.
| | - Lindani Chirwa
- Karonga District Hospital, Karonga District Health Office, Karonga, Malawi
| | - Boston Munthali
- Mzuzu Central Hospital, Department of Orthopaedic Surgery, Mzuzu, Malawi
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Chilumba, Karonga District Malawi
| | - Abena S Amoah
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Chilumba, Karonga District Malawi; Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Centre for 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; Extraordinary Professor, Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town
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Giaume L, Daniel Y, Calamai F, Derkenne C, Kedzierewicz R, Demeny A, Bertho K, Travers S, Prunet B, Dorandeu F. "I AM THOR/DUST DAHO": mnemonic devices used by the Paris Fire Brigade to teach initial measures in undertaking a CBRN event. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:116. [PMID: 33752723 PMCID: PMC7986030 DOI: 10.1186/s13054-021-03539-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Louise Giaume
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France.
| | - Yann Daniel
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France
| | - Franck Calamai
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France
| | - Clément Derkenne
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France
| | - Romain Kedzierewicz
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France
| | - Aude Demeny
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France
| | - Kilian Bertho
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France
| | - Stéphane Travers
- 1re chefferie du service de Santé, French Military Health service, Villacoublay, France.,Val-de-Grâce Military Health Academy, 1 Place Alphonse Laveran, 75005, Paris, France
| | - Bertrand Prunet
- Emergency Medical Department, Paris Fire Brigade, 1 Place Jules Renard, 75017, Paris, France.,Val-de-Grâce Military Health Academy, 1 Place Alphonse Laveran, 75005, Paris, France
| | - Fréderic Dorandeu
- Val-de-Grâce Military Health Academy, 1 Place Alphonse Laveran, 75005, Paris, France.,French Military Biomedical Research Institute, French Military Health service, 91220, Bretigny-sur-Orge, France
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20
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Checklist for Early Recognition and Treatment of Acute Illness and Injury: An Exploratory Multicenter International Quality-Improvement Study in the ICUs With Variable Resources. Crit Care Med 2021; 49:e598-e612. [PMID: 33729718 PMCID: PMC8132910 DOI: 10.1097/ccm.0000000000004937] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To determine whether the “Checklist for Early Recognition and Treatment of Acute Illness and Injury” decision support tool during ICU admission and rounding is associated with improvements in nonadherence to evidence-based daily care processes and outcomes in variably resourced ICUs. DESIGN, SETTINGS, PATIENTS: This before-after study was performed in 34 ICUs (15 countries) from 2013 to 2017. Data were collected for 3 months before and 6 months after Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation. INTERVENTIONS: Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation using remote simulation training. MEASUREMENTS AND MAIN RESULTS: The coprimary outcomes, modified from the original protocol before data analysis, were nonadherence to 10 basic care processes and ICU and hospital length of stay. There were 1,447 patients in the preimplementation phase and 2,809 patients in the postimplementation phase. After adjusting for center effect, Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation was associated with reduced nonadherence to care processes (adjusted incidence rate ratio [95% CI]): deep vein thrombosis prophylaxis (0.74 [0.68–0.81), peptic ulcer prophylaxis (0.46 [0.38–0.57]), spontaneous breathing trial (0.81 [0.76–0.86]), family conferences (0.86 [0.81–0.92]), and daily assessment for the need of central venous catheters (0.85 [0.81–0.90]), urinary catheters (0.84 [0.80–0.88]), antimicrobials (0.66 [0.62–0.71]), and sedation (0.62 [0.57–0.67]). Analyses adjusted for baseline characteristics showed associations of Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation with decreased ICU length of stay (adjusted ratio of geometric means [95% CI]) 0.86 [0.80–0.92]), hospital length of stay (0.92 [0.85–0.97]), and hospital mortality (adjusted odds ratio [95% CI], 0.81 (0.69–0.95). CONCLUSIONS: A quality-improvement intervention with remote simulation training to implement a decision support tool was associated with decreased nonadherence to daily care processes, shorter length of stay, and decreased mortality.
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Schade AT, Yesaya M, Bates J, Martin C, Harrison WJ. The Malawi Orthopaedic Association/AO Alliance guidelines and standards for open fracture management in Malawi: a national consensus statement. Malawi Med J 2021; 32:112-118. [PMID: 33488981 PMCID: PMC7812144 DOI: 10.4314/mmj.v32i3.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Open fractures are common injuries in Malawi that pose a large burden on the healthcare system and result in long-term disability. Aim Establishing a multiprofessional agreement on the management of open fractures in Malawi from a consensus meeting. Methods AO Alliance convened a consensus meeting to build an agreement on the management of open fractures in Malawi. Eighteen members from different professions and various regions of Malawi participated in a 1-day consensus meeting on 7 September 2019. Prior to the meeting the British Orthopaedic Audit Standards for Trauma (BOAST) for open fractures, as well as relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on open fracture management, followed by an open discussion meeting. At the 1-day consensus meeting panel members developed statements for each standard and guideline. Panel members then voted to accept or reject the statements. Results Substantial agreement (no rejections) was reached for all 17 guidelines and the associated terminology was agreed on. These guidelines were then presented to the members of the Malawi Orthopaedic Association (MOA) at their annual general meeting on 28 September 2019 and all participants agreed to adopt them. Conclusions These MOA/AO Alliance guidelines aim to set a standard for open fracture management that can be regularly measured and audited in Malawi to improve care for these patients.
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Affiliation(s)
| | | | - Jeremy Bates
- Queen Elizabeth Central Hospital, Blantyre, Malawi
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22
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Odland ML, Whitaker J, Nepogodiev D, Aling' CA, Bagahirwa I, Dushime T, Erlangga D, Mpirimbanyi C, Muneza S, Nkeshimana M, Nyundo M, Umuhoza C, Uwitonze E, Steans J, Rushton A, Belli A, Byiringiro JC, Bekele A, Davies J. Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi-disciplinary Stakeholder Exercise. World J Surg 2021; 44:2903-2918. [PMID: 32440950 PMCID: PMC7385009 DOI: 10.1007/s00268-020-05571-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. Methods A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem.
Results Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “Training and retention of specialist staff”, “Health education/awareness of injury severity”, “Geographical coverage of referral trauma centres”, and “Lack of protocol for bypass to referral centres”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map.
Conclusion Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.
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Affiliation(s)
- Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - John Whitaker
- Faculty of Life Sciences and Medicine, King's Centre for Global Health and Health Partnerships, King's College London, Room 2.13, Global Health Offices, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK. .,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Dmitri Nepogodiev
- National Institute for Health Research, Global Health Research Unit on Global Surgery, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | | | | | | | - Darius Erlangga
- Warwick Medical School, Population Evidence and Technologies, University of Warwick, Coventry, UK
| | | | | | | | - Martin Nyundo
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Christian Umuhoza
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | | | - Jill Steans
- Department of Political Science and International Studies, School of Government and Society, University of Birmingham, Birmingham, UK
| | - Alison Rushton
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Antonio Belli
- College of Medicine and Dental Sciences, NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - Jean Claude Byiringiro
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Faculty of Life Sciences and Medicine, King's Centre for Global Health and Health Partnerships, King's College London, Room 2.13, Global Health Offices, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK.,Faculty of Health Sciences, Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, University of Witwatersrand, Johannesburg, Gauteng, South Africa
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Taylor B, Joshi B, Hutchison L, Manivel V. Echocardiography does not prolong peri-shock pause in cardiopulmonary resuscitation using the COACH-RED protocol with non-expert sonographers in simulated cardiac arrest. Resusc Plus 2020; 4:100047. [PMID: 34223322 PMCID: PMC8244492 DOI: 10.1016/j.resplu.2020.100047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Focused echocardiography during peri-shock pause (PSP) can prognosticate and detect reversible causes in cardiac arrest but minimising interruptions to chest compressions improves outcome. The COACH-RED protocol was adapted from the COACHED protocol to systematically incorporate echocardiography into rhythm check without prolonging PSP beyond the recommended 10 s. The primary objective of this study was to test the feasibility of emergency nurses learning to perform all roles in the COACH-RED protocol. PSP duration and change in participant confidence were secondary outcomes. METHODS After an initial two-hour workshop, five ALS-trained nurses were assessed for the correct use of COACH-RED protocol, without critical error, in three simulated cardiac arrest scenarios of four cycles each. Assessments were repeated on days 7 and 35. On day 35, three COACHED scenarios were also assessed for comparison. Participant roles per scenario and cardiac rhythm per cycle were randomised. Participants completed questionnaires on their confidence levels. Sessions were videotaped for accurate measurement of PSP duration and results tabulated for simple comparison. Statistical analysis was not performed due to small sample size. RESULTS There were no critical errors, two minor team-leading errors and two minor echosonography errors. Minor errors occurred in separate scenarios resulting in a 100% pass rate overall by predetermined criteria. Echocardiographic recordings were 100% adequate. Overall median PSP was 9.35 s for COACH-RED and 6.94 s for COACHED. Sub-group analysis of COACH-RED revealed median PSP 10.80 s in shockable rhythms and 8.74 s (∼2 s less) in non-shockable rhythms. Mean participant confidence in performing COACH-RED improved from 1.6 to 4.6, on a 5-point scale. CONCLUSION The COACH-RED protocol can be effectively performed by ALS-trained nurses, in all roles of this protocol, including echocardiography, in a simulated environment, after a single training session. Using this protocol, focused echocardiography does not prolong PSP beyond 10 s.
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Key Words
- ALS, Advanced Life Support
- ARC, Australian Resuscitation Council
- Advanced cardiac life support
- CPR, Cardiopulmonary resuscitation
- Cardiac arrest
- Cardiopulmonary resuscitation
- ED, Emergency Department
- Echocardiography
- Education
- IQR, Interquartile Range
- Nursing
- PEA, Pulseless Electrical Activity
- PSP, Peri-Shock Pause
- SAH, Sydney Adventist Hospital
- Simulation training
- VF, Ventricular Fibrillation
- VT, Ventricular Tachycardia
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Affiliation(s)
- Benjamin Taylor
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
| | - Bhushan Joshi
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
| | - Leanne Hutchison
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
| | - Vijay Manivel
- Emergency Care, Sydney Adventist Hospital, Wahroonga, NSW 2076, Australia
- The University of Sydney, Sydney, NSW 2000, Australia
- Emergency Department, Nepean Hospital, Kingswood, NSW 2747, Australia
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24
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Akay T, Leblebici M. An Invited Commentary on "Implementation of the WHO Trauma Care Checklist a qualitative analysis of facilitators and barriers to use". Int J Surg 2020; 84:181. [PMID: 33246151 DOI: 10.1016/j.ijsu.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Tamer Akay
- Bandırma State Hospital, General Surgery Department, 10200, Balıkesir, Turkey.
| | - Metin Leblebici
- Istanbul Medeniyet University, Department of General Surgery, Istanbul, Turkey.
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25
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Ahmed HO. An Invited Commentary on “Implementation of the WHO trauma care checklist a qualitative analysis of facilitators and barriers to use” [Int. J. Surg. 83 (2020) 15–23]. Int J Surg 2020; 83:194-195. [DOI: 10.1016/j.ijsu.2020.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 11/15/2022]
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26
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S222-S283. [PMID: 33084395 DOI: 10.1161/cir.0000000000000896] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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27
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djärv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Orkin AM, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Scapigliati A, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A188-A239. [PMID: 33098918 DOI: 10.1016/j.resuscitation.2020.09.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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28
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Berg KM, Cheng A, Panchal AR, Topjian AA, Aziz K, Bhanji F, Bigham BL, Hirsch KG, Hoover AV, Kurz MC, Levy A, Lin Y, Magid DJ, Mahgoub M, Peberdy MA, Rodriguez AJ, Sasson C, Lavonas EJ. Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S580-S604. [PMID: 33081524 DOI: 10.1161/cir.0000000000000899] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.
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Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S337-S357. [DOI: 10.1161/cir.0000000000000918] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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30
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Wild H, Mock C, Lim A. Implementation of the WHO Trauma Care Checklist: A qualitative analysis of facilitators and barriers to use. Int J Surg 2020; 83:15-23. [PMID: 32931975 DOI: 10.1016/j.ijsu.2020.08.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The World Health Organization (WHO) Trauma Care Checklist (TCC) has been documented to improve care of the injured. Factors that promote TCC use have not been well evaluated. We sought to identify barriers and facilitators affecting TCC use. METHODS A qualitative study was conducted by interviewing regional leaders and health care providers at hospitals where the initial WHO TCC pilot study had been conducted in 2010-2012. Study participants included trauma system directors, surgeons, emergency medicine physicians, nurses, and house staff in nine countries. Interview transcripts were thematically analyzed in Dedoose software using deductive and inductive coding strategies incorporating elements of grounded theory. RESULTS Eighteen participants representing nine of the 11 original pilot sites were interviewed, including 14 doctors and four nurses. Participants represented departments of trauma/trauma surgery (n = 13) and emergency medicine (n = 5). Three sites continued to use the TCC in a nearly original form; three sites used a significantly modified version; and the remaining three sites no longer used it. The most commonly identified facilitator of TCC use was endorsement at both the front-line provider and institutional/leadership level (n = 7). Personnel-related issues and resistance from individual providers were the most commonly identified barriers (n = 10). CONCLUSION Presence of an institutional champion, context-specific adaptation, and integration of the TCC with existing care and documentation practices contribute to successful utilization. Personnel constraints such as revolving trainees and resistance from individual providers hinder utilization. To improve TCC uptake, participants also recommended that TCC be more closely integrated with courses such as Advanced Trauma Life Support.
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Affiliation(s)
- Hannah Wild
- Stanford University School of Medicine, Stanford, CA, USA; Department of Surgery, University of Washington, Seattle, WA, USA.
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Andrew Lim
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Stanford, University, Stanford, CA, USA; Critical Care Section, Virginia Mason Medical Center, Seattle, WA, USA
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Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti. Afr J Emerg Med 2020; 10:145-151. [PMID: 32923326 PMCID: PMC7474244 DOI: 10.1016/j.afjem.2020.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/27/2020] [Accepted: 05/20/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. METHODS We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. RESULTS Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). CONCLUSION Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.
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Bidhendi S, Ahmadi A, Fouladinejad M, Bazargan-Hejazi S. Evaluating implementation of WHO Trauma Care Checklist vs. modified WHO checklist in improving trauma patient clinical outcomes and satisfaction. J Inj Violence Res 2020; 13:5-12. [PMID: 32868497 PMCID: PMC8142336 DOI: 10.5249/jivr.v13i1.1579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/15/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Use of checklist in evaluation of trauma patients has been a critical component of improving the care process and reducing medical errors and increasing patient's quality of life. We aim to assess the impact of the modified World Health Organization Trauma Care Checklist (WHO TCC) on the management of pain, complications, mortality and patient satisfaction in trauma patients. Methods: This was a randomized control trial (RTC). Trauma patients referred to the trauma center and met the eligibility criteria were randomly assigned into three study groups. Group 1 were patients who received trauma care without using the WHO checklist, and only by the standard of care. Group 2 were patients who received trauma care according to the WHO's checklist, and group 3 were patients received trauma care according to the WHO's modified checklist. We used independent t-test and chi-square tests to assess the association between the study variables with checklist groups. The significance level of tests was set for p-value less than 0.05. Results: We observed patients’ level of pain, Injury Severity Score (ISS), Glasgow Coma Criterion (GCS) and patient satisfaction significantly improved across the checklist groups, but more so in the modified checklist group (P less than 0.001). Similarly, findings reveal significant relationships between all clinical characteristics of the patients and checklist groups, except for a CT Scan of the spinal cord. We were unable to establish any significant associations between the checklist groups and the majority of the selected trauma care process measures, except for missed injury (p = 0.001). Conclusions: Both the WHO TCC and the WHO modified checklist, in the initial assessment and during the treatment and care processes, enhance patients’ clinical outcomes. However, patients in the modified checklist compared to WHO TCC reported a higher level of satisfaction. Implications and future directions are discussed.
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Affiliation(s)
- Shahram Bidhendi
- Department of Anesthesiology, Critical & Pain Management, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Ahmadi
- Department of Anesthesiology, Critical & Pain Management, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Mona Fouladinejad
- College of Medicine, Charles R. Drew University of Medicine and Science, CA, U.S.A
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Kulp L, Sarcevic A, Zheng Y, Cheng M, Alberto E, Burd R. Checklist Design Reconsidered: Understanding Checklist Compliance and Timing of Interactions. PROCEEDINGS OF THE SIGCHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYSTEMS. CHI CONFERENCE 2020; 2020. [PMID: 32685940 DOI: 10.1145/3313831.3376853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We examine the association between user interactions with a checklist and task performance in a time-critical medical setting. By comparing 98 logs from a digital checklist for trauma resuscitation with activity logs generated by video review, we identified three non-compliant checklist use behaviors: failure to check items for completed tasks, falsely checking items when tasks were not performed, and inaccurately checking items for incomplete tasks. Using video review, we found that user perceptions of task completion were often misaligned with clinical practices that guided activity coding, thereby contributing to non-compliant check-offs. Our analysis of associations between different contexts and the timing of check-offs showed longer delays when (1) checklist users were absent during patient arrival, (2) patients had penetrating injuries, and (3) resuscitations were assigned to the highest acuity. We discuss opportunities for reconsidering checklist designs to reduce non-compliant checklist use.
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Affiliation(s)
- Leah Kulp
- Drexel University, Philadelphia, PA, USA
| | | | - Yinan Zheng
- Children's National Medical Center, Washington DC, USA
| | - Megan Cheng
- Children's National Medical Center, Washington DC, USA
| | - Emily Alberto
- Children's National Medical Center, Washington DC, USA
| | - Randall Burd
- Children's National Medical Center, Washington DC, USA
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Waydhas C, Trentzsch H, Hardcastle TC, Jensen KO. Survey on worldwide trauma team activation requirement. Eur J Trauma Emerg Surg 2020; 47:1569-1580. [PMID: 32123951 PMCID: PMC8476357 DOI: 10.1007/s00068-020-01334-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/15/2020] [Indexed: 11/24/2022]
Abstract
Purpose Trauma team activation (TTA) is thought to be essential for advanced and specialized care of very severely injured patients. However, non-specific TTA criteria may result in overtriage that consumes valuable resources or endanger patients in need of TTA secondary to undertriage. Consequently, criterion standard definitions to calculate the accuracy of the various TTA protocols are required for research and quality assurance purposes. Recently, several groups suggested a list of conditions when a trauma team is considered to be essential in the initial care in the emergency room. The objective of the survey was to post hoc identify trauma-related conditions that are thought to require a specialized trauma team that may be widely accepted, independent from the country’s income level. Methods A set of questions was developed, centered around the level of agreement with the proposed post hoc criteria to define adequate trauma team activation. The participants gave feedback before they answered the survey to improve the quality of the questions. The finalized survey was conducted using an online tool and a word form. The income per capita of a country was rated according to the World Bank Country and Lending groups. Results The return rate was 76% with a total of 37 countries participating. The agreement with the proposed criteria to define post hoc correct requirements for trauma team activation was more than 75% for 12 of the 20 criteria. The rate of disagreement was low and varied between zero and 13%. The level of agreement was independent from the country’s level of income. Conclusions The agreement on criteria to post hoc define correct requirements for trauma team activation appears high and it may be concluded that the proposed criteria could be useful for most countries, independent from their level of income. Nevertheless, more discussions on an international level appear to be warranted to achieve a full consensus to define a universal set of criteria that will allow for quality assessment of over- and undertriage of trauma team activation as well as for the validation of field triage criteria for the most severely injured patients worldwide. Electronic supplementary material The online version of this article (10.1007/s00068-020-01334-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Waydhas
- Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany. .,Medical Faculty of the University Duisburg-Essen, University Hospital, Hufelandstr. 55, 45147, Essen, Germany.
| | - Heiko Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum Der Universität München, Ludwig-Maximilians-Universität, Schillerstr. 53, 80336, Minich, Germany.,Committee On Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society, Berlin, Germany
| | - Timothy C Hardcastle
- Inkosi Albert Luthuli Central Hospital, Mayville and University of Kwa Zulu Natal, 800 Vusi Mzimela Rd, Congella, 4058, South Africa
| | - Kai Oliver Jensen
- Klinik für Traumatologie, UniversitätsSpital Zürich, Rämistrasse 100, 8091, Zurich, Switzerland
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Varghese M. Prehospital trauma care evolution, practice and controversies: need for a review. Int J Inj Contr Saf Promot 2020; 27:69-82. [DOI: 10.1080/17457300.2019.1708409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Mathew Varghese
- Department of Orthopaedic Surgery, St Stephen’s Hospital, Delhi, India
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Santhirapala V, Peden CJ, Meara JG, Biccard BM, Gelb AW, Johnson WD, Lipnick MS, Makasa EM, Martin J, Maswime S, Mellin-Olsen J, McClain CD. Towards high-quality peri-operative care: a global perspective. Anaesthesia 2020; 75 Suppl 1:e18-e27. [PMID: 31903566 DOI: 10.1111/anae.14921] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2019] [Indexed: 01/22/2023]
Abstract
Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.
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Affiliation(s)
- V Santhirapala
- Harvard Medical School, Boston, MA, USA.,Magill Department of Anaesthesia, Intensive Care and Pain Management, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - C J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - J G Meara
- Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - B M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, CA, USA
| | - W D Johnson
- World Health Organization, Geneva, Switzerland
| | - M S Lipnick
- Department of Anesthesia and Perioperative Care, University of California San Francisco, CA, USA
| | - E M Makasa
- Wits Centre of Surgical Care for Primary Health and Sustainable Development, School of Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - J Martin
- Department of Anesthesia and Perioperative Medicine and Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - S Maswime
- University of Cape Town, South Africa
| | - J Mellin-Olsen
- Department of Anaesthesia and Intensive Care Medicine, Baerum Hospital, Sandvika, Norway
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Lee JS, Roberts SWP, Götsch K, Moeller U, Hawryluck L. Caring for Critically Ill Patients in Humanitarian Settings. Am J Respir Crit Care Med 2020; 199:572-580. [PMID: 30290131 PMCID: PMC6677375 DOI: 10.1164/rccm.201806-1059cp] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Critical care medicine is far from the first medical field to come to mind when humanitarian action is mentioned, yet both critical care and humanitarian action share a fundamental purpose to save the lives and ease the suffering of people caught in acute crises. Critically ill children and adults will be present regardless of resource limitations and irrespective of geography, regional or cultural contexts, insecurity, or socioeconomic status, and they may be even more prevalent in a humanitarian crisis. Critical care is not limited to the walls of a hospital, and all hospitals will have critically ill patients regardless of designating a specific ward an ICU. Regular and consistent consideration of critical care principles in humanitarian settings provides crucial guidance to intensivists and nonintensivists alike. A multidisciplinary, systematic approach to patient care that encourages critical thinking, checklists that encourage communication among team members, and context-specific critical care rapid response teams are examples of critical care constructs that can provide high-quality critical care in all environments. Promoting critical care principles conveys the message that critical care is an integral part of health care and should be accessible to all, no matter the setting. These principles can be effectively adopted in humanitarian settings by normalizing them to everyday clinical practice. Equally, core humanitarian principles—dignity, accountability, impartiality, neutrality—can be applied to critical care. Applying principles of critical care in a context-specific manner and applying humanitarian principles to critical care can improve the quality of patient care and transcend barriers to resource limitations.
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Affiliation(s)
- James S Lee
- 1 Medical Department, Médecins Sans Frontières-Operational Centre Brussels, Brussels, Belgium.,2 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Simon W P Roberts
- 1 Medical Department, Médecins Sans Frontières-Operational Centre Brussels, Brussels, Belgium
| | - Kanya Götsch
- 1 Medical Department, Médecins Sans Frontières-Operational Centre Brussels, Brussels, Belgium.,3 Department of Gynecology and Obstetrics, Hochtaunuskliniken, Bad Homburg, Germany
| | - Ulrike Moeller
- 1 Medical Department, Médecins Sans Frontières-Operational Centre Brussels, Brussels, Belgium
| | - Laura Hawryluck
- 2 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; and
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Medication errors in the care transition of trauma patients. Eur J Clin Pharmacol 2019; 75:1739-1746. [PMID: 31529143 DOI: 10.1007/s00228-019-02757-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVE Traumatological patients are vulnerable to medication error given multiple handoffs throughout the hospital since they often require rapid diagnosis and management of multiple concurrent complex conditions. The purpose of this study was to analyze the medication errors (MEs) occurring in the care transition of the traumatological patient. The secondary objectives were to classify the MEs and the level of risk of the pharmacological groups involved. In addition, the causes and contributing factors of those MEs were analyzed. METHODS An observational, descriptive, and prospective study, spanning 4 months, was performed in a tertiary hospital. All patients admitted to the traumatology service were selected for the study. Data were collected in different locations of the hospital stay: Emergency Service, Resuscitation and Post-Anaesthesia Unit, and Traumatology Hospitalization Unit. In each location, data from the different processes (reconciliation, prescription, validation, dispensing, and administration of medicines) were collected. The medication error (ME) was established as a dependent variable. RESULTS A total of 31.3% (132) of the patients analyzed showed some ME. The Traumatology Unit was the location where most errors were detected, followed by the Emergency Service. Having analyzed all the locations, it was observed that 64.2% (172) of the MEs were detected in the reconciliation process, 29.5% (79) in the prescription, 3.7% (10) in the dispensing, 1.5% (4) in the administration, and 1.1% (3) in the validation. In terms of risk weighting, the drugs involved in the MEs detected were 53.8% of medium risk, 20.7% of high risk, and 20.3% of low risk. CONCLUSIONS There is a high prevalence of MEs in the reconciliation process of medication in traumatological patients (64.2%) from our hospital setting. Interestingly, most MEs occurred in this process regardless of the location in the healthcare chain.
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van Maarseveen OEC, Ham WHW, van de Ven NLM, Saris TFF, Leenen LPH. Effects of the application of a checklist during trauma resuscitations on ATLS adherence, team performance, and patient-related outcomes: a systematic review. Eur J Trauma Emerg Surg 2019; 46:65-72. [PMID: 31392359 PMCID: PMC7026213 DOI: 10.1007/s00068-019-01181-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 07/01/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE In this systematic literature review, the effects of the application of a checklist during in hospital resuscitation of trauma patients on adherence to the ATLS guidelines, trauma team performance, and patient-related outcomes were integrated. METHODS A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist. The search was performed in Pubmed, Embase, CINAHL, and Cochrane inception till January 2019. Randomized controlled- or controlled before-and-after study design were included. All other forms of observational study designs, reviews, case series or case reports, animal studies, and simulation studies were excluded. The Effective Public Health Practice Project Quality Assessment Tool was applied to assess the methodological quality of the included studies. RESULTS Three of the 625 identified articles were included, which all used a before-and-after study design. Two studies showed that Advanced Trauma Life Support (ATLS)-related tasks are significantly more frequently performed when a checklist was applied during resuscitation. [14 of 30 tasks (p < 0.05), respectively, 18 of 19 tasks (p < 0.05)]. One study showed that time to task completion (- 9 s, 95% CI = - 13.8 to - 4.8 s) and workflow improved, which was analyzed as model fitness (0.90 vs 0.96; p < 0.001); conformance frequency (26.1% vs 77.6%; p < 0.001); and frequency of unique workflow traces (31.7% vs 19.1%; p = 0.005). One study showed that the incidence of pneumonia was higher in the group where a checklist was applied [adjusted odds ratio (aOR) 1.69, 95% Confidence Interval (CI 1.03-2.80)]. No difference was found for nine other assessed complications or missed injuries. Reduced mortality rates were found in the most severely injured patient group (Injury Severity score > 25, aOR 0.51, 95% CI 0.30-0.89). CONCLUSIONS The application of a checklist may improve ATLS adherence and workflow during trauma resuscitation. Current literature is insufficient to truly define the effect of the application of a checklist during trauma resuscitation on patient-related outcomes, although one study showed promising results as an improved chance of survival for the most severely injured patients was found.
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Affiliation(s)
- Oscar E C van Maarseveen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Wietske H W Ham
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Institute of Nursing Studies, University of Applied Sciences Utrecht, Heidelberglaan 7, 3584 CS, Utrecht, The Netherlands
| | - Nils L M van de Ven
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Tim F F Saris
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Kulp L, Sarcevic A, Cheng M, Zheng Y, Burd RS. Comparing the Effects of Paper and Digital Checklists on Team Performance in Time-Critical Work. PROCEEDINGS OF THE SIGCHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYSTEMS. CHI CONFERENCE 2019; 2019. [PMID: 31633126 DOI: 10.1145/3290605.3300777] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This mixed-methods study examines the effects of a tablet-based checklist system on team performance during a dynamic and safety-critical process of trauma resuscitation. We compared team performance from 47 resuscitations that used a paper checklist to that from 47 cases with a digital checklist to determine if digitizing a checklist led to improvements in task completion rates and in how fast the tasks were initiated for 18 most critical assessment and treatment tasks. We also compared if the checklist compliance increased with the digital design. We found that using the digital checklist led to more frequent completions of the initial airway assessment task but fewer completions of ear and lower extremities exams. We did not observe any significant differences in time to task performance, but found increased compliance with the checklist. Although improvements in team performance with the digital checklist were minor, our findings are important because they showed no adverse effects as a result of the digital checklist introduction. We conclude by discussing the takeaways and implications of these results for effective digitization of medical work.
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Affiliation(s)
- Leah Kulp
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Megan Cheng
- Trauma and Burn Surgery, Children's National Medical Center, Washington, DC, USA
| | - Yinan Zheng
- Trauma and Burn Surgery, Children's National Medical Center, Washington, DC, USA
| | - Randall S Burd
- Trauma and Burn Surgery, Children's National Medical Center, Washington, DC, USA
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Lucumay NJ, Sawe HR, Mohamed A, Sylvanus E, George U, Mfinanga JA, Weber EJ. Pre-referral stabilization and compliance with WHO guidelines for trauma care among adult patients referred to an urban emergency department of a tertiary referral hospital in Tanzania. BMC Emerg Med 2019; 19:22. [PMID: 30819092 PMCID: PMC6394079 DOI: 10.1186/s12873-019-0237-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/20/2019] [Indexed: 12/22/2022] Open
Abstract
Background The outcomes of trauma are considered to be time dependent. Efficient and timely pre-referral stabilization of trauma patients has been shown to impact survival. Tanzania has no formal pre-hospital or trauma system. World Health Organisation has provided a set of standards for initial stabilization of trauma patients according to the level of the hospitals. We aimed to describe pre-referral stabilization provided to adult trauma patient referred to the national referral hospital and compliance with World Health Organisation guidelines. Methods This prospective observational cross-sectional study was conducted at the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH), between July 2017 and December 2017. Eligible patients were adults with head injury and extremity injury ≥18 years who were referred from a peripheral hospital and had a referral note. Research assistant enrolled patients using structured case report form clinical information, and initial stabilization received at the referring hospital. Primary outcome was the proportion of patients who had initial stabilization performed according to World Health Organisation recommendation. Results We enrolled 368 (29% of eligible patients), the median age was 34 years (Interquartile range 26–44 years), and 281 (76%) were male. Overall 69% of referred patients arrived at the EMD more than 24 h after injury. Of those enrolled, 50 (13.6%) patients had received at least one stabilization intervention prior to transfer to MNH. Among 206 patients with extremity injuries, splinting was inadequate or missing in all cases; No patients with head injury received cervical spine protection. Among patients referred from a health center, 26.9% received an initial stabilization, while stabilization procedures were administered to 13.2% of those from district hospitals, and 10% of those from regional hospitals. Conclusions In this urban public emergency department in Tanzania, majority of trauma patients were referred from lower health facilities after 24-h of injury. Most did not receive initial trauma stabilization as recommended by the World Health Organisation guidelines. Future studies should identify barriers to pre-referral stabilization of adult trauma patients.
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Affiliation(s)
- Nanyori J Lucumay
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania. .,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
| | - Amour Mohamed
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Erasto Sylvanus
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Upendo George
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Ellen J Weber
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
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Eichner FA, Groenwold RHH, Grobbee DE, Oude Rengerink K. Systematic review showed that stepped-wedge cluster randomized trials often did not reach their planned sample size. J Clin Epidemiol 2018; 107:89-100. [PMID: 30458261 DOI: 10.1016/j.jclinepi.2018.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/15/2018] [Accepted: 11/14/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine how often stepped-wedge cluster randomized controlled trials reach their planned sample size, and what reasons are reported for choosing a stepped-wedge trial design. STUDY DESIGN AND SETTING We conducted a PubMed literature search (period 2012 to 2017) and included articles describing the results of a stepped-wedge cluster randomized trial. We calculated the percentage of studies reaching their prespecified number of participants and clusters, and we summarized the reasons for choosing the stepped-wedge trial design as well as difficulties during enrollment. RESULTS Forty-six individual stepped-wedge studies from a total of 53 articles were included in our review. Of the 35 studies, for which recruitment rate could be calculated, 69% recruited their planned number of participants, with 80% having recruited the planned number of clusters. Ethical reasons were the most common motivation for choosing the stepped-wedge trial design. Most important difficulties during study conduct were dropout of clusters and delayed implementation of the intervention. CONCLUSION About half of recently published stepped-wedge trials reached their planned sample size indicating that recruitment is also a major problem in these trials. Still, the stepped-wedge trial design can yield practical, ethical, and methodological advantages.
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Affiliation(s)
- Felizitas A Eichner
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Bortolotti P, Faure E, Kipnis E. Inflammasomes in Tissue Damages and Immune Disorders After Trauma. Front Immunol 2018; 9:1900. [PMID: 30166988 PMCID: PMC6105702 DOI: 10.3389/fimmu.2018.01900] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 07/31/2018] [Indexed: 01/15/2023] Open
Abstract
Trauma remains a leading cause of death worldwide. Hemorrhagic shock and direct injury to vital organs are responsible for early mortality whereas most delayed deaths are secondary to complex pathophysiological processes. These processes result from imbalanced systemic reactions to the multiple aggressions associated with trauma. Trauma results in the uncontrolled local and systemic release of endogenous mediators acting as danger signals [damage-associated molecular patterns (DAMPs)]. Their recognition by the innate immune system triggers a pro-inflammatory immune response paradoxically associated with concomitant immunosuppression. These responses, ranging in intensity from inappropriate to overwhelming, promote the propagation of injuries to remote organs, leading to multiple organ failure and death. Some of the numerous DAMPs released after trauma trigger the assembly of intracellular multiprotein complexes named inflammasomes. Once activated by a ligand, inflammasomes lead to the activation of a caspase. Activated caspases allow the release of mature forms of interleukin-1β and interleukin-18 and trigger a specific pro-inflammatory cell death termed pyroptosis. Accumulating data suggest that inflammasomes, mainly NLRP3, NLRP1, and AIM2, are involved in the generation of tissue damage and immune dysfunction after trauma. Following trauma-induced DAMP(s) recognition, inflammasomes participate in multiple ways in the development of exaggerated systemic and organ-specific inflammatory response, contributing to organ damage. Inflammasomes are involved in the innate responses to traumatic brain injury and contribute to the development of acute respiratory distress syndrome. Inflammasomes may also play a role in post-trauma immunosuppression mediated by dysregulated monocyte functions. Characterizing the involvement of inflammasomes in the pathogenesis of post-trauma syndrome is a key issue as they may be potential therapeutic targets. This review summarizes the current knowledge on the roles of inflammasomes in trauma.
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Affiliation(s)
- Perrine Bortolotti
- Meakins-Christie Laboratories, Department of Medicine, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Emmanuel Faure
- Meakins-Christie Laboratories, Department of Medicine, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology and Critical Care, Centre Hospitalier Regional et Universitaire de Lille, Lille, France.,Host-Pathogen Translational Research, Faculté de Médecine, Université Lille 2 Droit et Santé, Lille, France
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Kulp L, Sarcevic A, Farneth R, Ahmed O, Mai D, Marsic I, Burd RS. Exploring Design Opportunities for a Context-Adaptive Medical Checklist Through Technology Probe Approach. DIS. DESIGNING INTERACTIVE SYSTEMS (CONFERENCE) 2017; 2017:57-68. [PMID: 30381804 DOI: 10.1145/3064663.3064715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This paper explores the workflow and use of an interactive medical checklist for trauma resuscitation-an emerging technology developed for trauma team leaders to support decision making and task coordination among team members. We used a technology probe approach and ethnographic methods, including video review, interviews, and content analysis of checklist logs, to examine how team leaders use the checklist probe during live resuscitations. We found that team leaders of various experience levels use the technology differently. Some leaders frequently glance at the checklist and take notes during task performance, while others place the checklist on a stand and only interact with the checklist when checking items. We compared checklist timestamps to task activities and found that most items are checked off after tasks are performed. We conclude by discussing design implications and new design opportunities for a future dynamic, adaptive checklist.
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Affiliation(s)
- Leah Kulp
- Drexel University, Philadelphia, PA 19104
| | | | | | - Omar Ahmed
- Children's Nat'l Med Center, Washington, DC 20010
| | - Dung Mai
- Drexel University, Philadelphia, PA 19104
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Roy N, Kizhakke Veetil D, Khajanchi MU, Kumar V, Solomon H, Kamble J, Basak D, Tomson G, von Schreeb J. Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths. BMC Health Serv Res 2017; 17:142. [PMID: 28209192 PMCID: PMC5314603 DOI: 10.1186/s12913-017-2085-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/09/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery. METHODS All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI). RESULTS During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging. CONCLUSION Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.
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Affiliation(s)
- Nobhojit Roy
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | | | | | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Harris Solomon
- Department of Cultural Anthropology and Global Health, Global Health Institute, Duke University, 205 Friedl Building, Box 90091, Durham, 27708 NC USA
| | - Jyoti Kamble
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | - Debojit Basak
- School of Habitat, Tata Institute of Social Sciences, Mumbai, India
| | - Göran Tomson
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME) and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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