Current trauma care system in Saudi Arabia: A scoping literature review

Impact of easing COVID-19 lockdown restrictions on traumatic injuries in Riyadh, Saudi Arabia: one-year experience at a major trauma centre

INTRODUCTION

Lockdown restrictions due to the COVID-19 pandemic have reduced the number of injuries recorded. However, little is known about the impact of easing COVID-19 lockdown restrictions on the nature and outcome of injuries. This study aims to compare injury patterns prior to and after the easing of COVID-19 lockdown restrictions in Saudi Arabia.

METHOD

Data were collected retrospectively from the Saudi TraumA Registry for the period between March 25, 2019, and June 21, 2021. These data corresponded to three periods: March 2019-February 2020 (pre-restrictions, period 1), March 2020-June 2020 (lockdown, period 2), and July 2020-June 2021 (post easing of restrictions, period 3). Data related to patients' demographics, mechanism and severity of injury, and in-hospital mortality were collected and analysed.

RESULTS

A total of 5,147 traumatic injury patients were included in the analysis (pre-restrictions n = 2593; lockdown n = 218; post easing of lockdown restrictions n = 2336). An increase in trauma cases (by 7.6%) was seen in the 30-44 age group after easing restrictions (n = 648 vs. 762, p < 0.01). Motor vehicle crashes (MVC) were the leading cause of injury, followed by falls in all the three periods. MVC-related injuries decreased by 3.1% (n = 1068 vs. 890, p = 0.03) and pedestrian-related injuries decreased by 2.7% (n = 227 vs. 143, p < 0.01); however, burn injuries increased by 2.2% (n = 134 vs. 174, p < 0.01) and violence-related injuries increased by 0.9% (n = 45 vs. 60, p = 0.05) post easing of lockdown restrictions. We observed an increase in in-hospital mortality during the period of 12 months after easing of lockdown restrictions-4.9% (114/2336) compared to 12 months of pre-lockdown period-4.3% (113/2593).

CONCLUSION

This is one of the first studies to document trauma trends over a one-year period after easing lockdown restrictions. MVC continues to be the leading cause of injuries despite a slight decrease; overall injury cases rebounded towards pre-lockdown levels in Saudi Arabia. Injury prevention needs robust legislation with respect to road safety measures and law enforcement that can decrease the burden of traumatic injuries.

Assessment of opioid administration patterns following lower extremity fracture among opioid-naïve inpatients: retrospective multicenter cohort study

BACKGROUND

Prescribing habits during admission have largely contributed to the opioid epidemic. Orthopedic surgeons represent the third-highest opioid-prescribing specialty. Since more than half of body fractures in Saudi Arabia have been lower extremity fractures, it is imperative to understand opioid administration patterns and correlates among opioid-naïve inpatients.

OBJECTIVES

Assess opioid administration patterns and correlates among opioid-naïve inpatients with lower extremity fractures.

DESIGN AND SETTINGS

Retrospective cohort PATIENTS AND METHODS: Opioid naïve individuals aged 18 to 64 years, admitted due to lower extremity fracture from 2016 to 2020 were included. Data was collected from health records of the Ministry of National Guard Health Affairs (MNG-HA) at five different medical centers. The high-dose (≥50 MME) patients were compared with low dose (<50 MME) patients. Any association between inpatient factors and high-dose opioid use was analyzed by multiple logistic regression.

MAIN OUTCOME MEASURES

Opioids taken during inpatient admission as measured by milligram morphine equivalents (MME)/per day.

SAMPLE SIZE

1520 patients RESULTS: Most of the 1520 patients (88.5%) received an opioid medication, while (20.3%) received high-dose opioids at a median daily dose of 33.7 MME/per day. The proportion of patients received naloxone (20.7%) was double among high-dose opioid inpatients. High-dose opioid patients during admission were two times more likely to receive an opioid prescription after discharge (odds ratio, 2.32; 95% confidence interval, 1.53, 3.51), and three more times likely to receive ketamine during admission (odds ratio, 3.02; 95% confidence interval, 1.64, 5.54).

CONCLUSION

Notable variabilities exist in opioid administration patterns that were not explained by patient factors. Evidence-based opioid prescribing practices should be developed for orthopedic patients to prevent opioid overprescribing and potential opioid overdose among orthopedic patients.

LIMITATIONS

Retrospective, unmeasurable confounders might have biased our results. Since based on National Guard employees, results may not be generalizable.

CONFLICT OF INTEREST

None.

Predicting Suitable Percutaneous Endovascular Arterial Embolization for Traumatic Abdominopelvic Injuries: A Retrospective Cohort Study

Purpose

This study evaluated the pre-procedural attributes of trauma patients to determine their suitability to undergo Percutaneous Endovascular Arterial Embolization (PEAE), and the current state of endovascular repair as an option for trauma-related injuries in traumatic abdominopelvic arterial injuries was explored.

Patients and Methods

We retrospectively evaluated the charts of 638 adults with traumatic abdominopelvic injuries treated from March 2011 to February 2021, extensively reviewing their pre-operative indices, pre-operative optimization requirements, and multi-modality imaging records.

Results

In total, 235 patients (30.63%) were “hemodynamically unstable” on admission, mainly due to hypotension (n=437 [68.5%]). Additionally, laboratory-defined acquired coagulopathies and inherited bleeding disorders were found in 268 patients (42.01%). The computerized tomography bleeding protocol was performed on 408 (63.94%) patients. Percutaneous endovascular therapy by arterial embolization was performed on 146 patients. The mean number of requested pre-intervention blood units for trauma patients significantly exceeded the number of units transfused post-intervention (P<0.0005). Apart from hemodynamics (ie heart rate, mean blood pressure); hemoglobin, and lactic acid levels were independently associated indices of PEAE outcomes (p <0.01).

Conclusion

Despite the recommendations from the Society of Interventional Radiology on endovascular intervention for trauma and bleeding risk, 36.84% of study patients had hemodynamic instability and other unfeasible parameters that would limit the option of minimally invasive procedures. Early recognition and consideration of suitable treatment options is essential for optimizing patient outcomes. It is imperative that standardized algorithms and management protocols based on available resources be developed.

International Perspectives of Prehospital and Hospital Trauma Services: A Literature Review

Background: Evidence suggests that reductions in the incidence in trauma observed in some countries are related to interventions including legislation around road and vehicle safety measures, public behaviour change campaigns, and changes in trauma response systems. This study aims to briefly review recent refereed and grey literature about prehospital and hospital trauma care services in different regions around the world and describe similarities and differences in identified systems to demonstrate the diversity of characteristics present. Methods: Articles published between 2000 and 2020 were retrieved from MEDLINE and EMBASE. Since detailed comparable information was lacking in the published literature, prehospital emergency service providers’ annual performance reports from selected example countries or regions were reviewed to obtain additional information about the performance of prehospital care. Results: The review retained 34 studies from refereed literature related to trauma systems in different regions. In the U.S. and Canada, the trauma care facilities consisted of five different levels of trauma centres ranging from Level I to Level IV and Level I to Level V, respectively. Hospital care and organisation in Japan is different from the U.S. model, with no dedicated trauma centres; however, patients with severe injury are transported to university hospitals’ emergency departments. Other similarities and differences in regional examples were observed. Conclusions: The refereed literature was dominated by research from developed countries such as Australia, Canada, and the U.S., which all have organised trauma systems. Many European countries have implemented trauma systems between the 1990s and 2000s; however, some countries, such as France and Greece, are still forming an integrated system. This review aims to encourage countries with immature trauma systems to consider the similarities and differences in approaches of other countries to implementing a trauma system.

Designing and conducting initial application of a performance assessment model for in-hospital trauma care

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.

Exploring Factors That Influence Injured Patients’ Outcomes following Road Traffic Crashes: A Multi-Site Feasibility Study

Background: Injuries arising from Road Traffic Crashes (RTCs) are a major health problem in Saudi Arabia (SA). The purpose of the study was to determine the feasibility of conducting a multi-center research study to explore factors that influence the mortality of RTC-related trauma patients in SA. Methods: A multi-center observational study was undertaken involving both prospective and retrospective data collected from three hospitals. In-hospital patient mortality thirty days post-crash was the primary outcome variable. The feasibility of the study methods including the quality of data were evaluated and pilot results pertaining to factors predicting mortality were examined. Results: The overall mortality rate (n = 572 RTC victims) was (7.5%). A logistic regression model identified four independent predictors of mortality following an RTC: treatment at a non-trauma center-based hospital, SBP ≤ 90 mmHg, GCS ≤ 8, and ISS ≥ 20. With respect to the assessment of the study method’s feasibility, missing data was problematic, especially for variables pertaining to crash characteristics and prehospital care. Conclusions: Collecting multi-center injury data in SA has logistic challenges, predominantly associated with the comparability and completeness of data sets as well as the need for manual screening and data collection at some institutions. Despite these limitations, this study has demonstrated the feasibility of a method that could be utilized in further large nationwide studies to understand and examine the factors that influence injured patients’ outcomes following RTCs.

Psychometric evaluation of the Arabic version of the Quebec user evaluation of satisfaction with assistive technology (A-QUEST 2.0) in prosthesis users

BACKGROUND

The evaluation of patient satisfaction and perceptions plays a vital role in determining the quality of prosthesis users' devices and the competency of healthcare services.

AIM

To evaluate the psychometric properties of the Arabic Quebec User Evaluation of Satisfaction with Assistive Technology (A-QUEST 2.0) with prosthetics users.

DESIGN

A methodological study.

SETTING

Saudi Arabia, Turkey.

POPULATION

A convenience sample of outpatient prosthesis users (N.=183).

METHODS

The A-QUEST 2.0 includes two subscales respectively evaluating the user's satisfaction with the device and the services provided. The data for each subscale were investigated using Rasch analysis to evaluate the item fit, reliability indices, item difficulty, local item dependency, and differential item functioning (DIF).

RESULTS

Both subscales met the Rasch criteria for the functioning of rating scale categories. All items showed an acceptable fit to the Rasch model. The person separation indices for the Device and Services subscales were 2.21 (Cronbach's α=0.90) and 1.72 (Cronbach's α=0.85), respectively. Therefore, the two subscales are sensitive enough to distinguish between at least three different levels of satisfaction. The unidimensionality of each subscale was confirmed, and none of the items displayed differential item functioning across age, gender, location of amputation, country, and duration of use.

CONCLUSIONS

Overall, the findings indicate the psychometric evaluation of A-QUEST 2.0 is effective with prosthesis users across different clinical contexts and cultures. Thus, the A-QUEST 2.0 allows for a comprehensive understanding of users' perceptions of prosthesis characteristics, particularly among subjects with lower limb amputations caused by traumatic injuries.

CLINICAL REHABILITATION IMPACT

Our paper provides clinicians dealing with Arabic patients a validated outcome measure for satisfaction with prosthesis. Besides providing information in the development of new products and service delivery. Further studies are necessary to improve the measure's metric quality in different contexts and for different prosthesis devices.

Emergency trauma care during the COVID-19 pandemic: A phenomenological study of nurses’ experiences

Objective

This study aimed to explore nurses’ experiences in delivering emergency trauma care during the COVID-19 pandemic at a level I trauma centre in Saudi Arabia.

Methods

A qualitative, descriptive phenomenological design was utilised, in which face-to-face, unstructured interviews were carried out with emergency and trauma nurses at a level I trauma centre in Saudi Arabia. The study included nine registered emergency and trauma nurses who were interviewed twice from February to April 2021. The collected data were analysed using Colaizzi’s descriptive phenomenological method.

Results

The analysis of the data revealed an overarching theme that was about the inevitable change on the ground due to the pandemic and two primary themes, each containing two subthemes: 1 dealing with an interrupted path of care; 1.1 experiencing additional complexity; 1.2 encountering extra demands; 2 optimising the path of care; 2.1 modifying the steps; and 2.2 transforming the system.

Conclusion

The COVID-19 pandemic imposed change on how trauma patients would be handled and treated. Nurses took an active and critical role in creating another form of change, which helped optimise the path of trauma care and accommodate urgent treatment needs of the injured patients.

The client satisfaction with device: a Rasch validation of the Arabic version in patients with upper and lower limb amputation

Background

The Client Satisfaction with Devices (CSD) module of the Orthotics and Prosthetics Users’ Survey is an extensively used questionnaire that measures patients’ satisfaction with orthosis and prosthesis. However, the validated version for Arabic speakers (CSD-Ar) is only applicable for orthosis users.

Objectives

The aim of this study was to evaluate the psychometric proprieties of the CSD-Ar for prosthetics users.

Methods

The study used a convenience sample of prosthesis users from Saudi Arabia and Turkey (N = 183), who completed the CSD-Ar. The collected data were analysed using Rasch analysis to evaluate item fit, reliability indices, item difficulty, local item dependency, and differential item functioning (DIF) using WINSTEPS version 4.6.1.

Results

Based on the analysis, the four-response Likert-scale was acceptable, as shown by the category functioning test, All eight items did achieve a fit to the Rasch Model [(infit) and (outfit) mean-square 0.75 to 1.3]. Person separation reliability was 0.76, and item separation reliability was 0.94. A principal component analysis (PCA) showed satisfactory unidimensionality and no local item dependency. The DIF analysis showed no notable dependency among items on participant characteristics in terms of age, gender, duration of use, country, and level of amputation.

Conclusion

This study contributes to the confidence of using CSD-Ar to evaluate users’ satisfaction with different prostheses, affirming the need for further refinement of the quality of the outcome measure.

The effect of trauma care systems on the mortality of injured adult patients: A protocol for systematic review and meta-analysis

PURPOSE

The aim of this study was to have a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients.

MATERIALS AND METHODS

This protocol established in this study has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Web of Science, PubMed, EMBASE, Scopus, and the Cochrane Library were searched for all clinical trials evaluating the effect of trauma care systems on the mortality of injured adult patients until July 31, 2020. We will use a combination of Medical Subject Heading and free-text terms with various synonyms to search based on the eligibility criteria. Two investigators independently reviewed the included studies and extracted relevant data. The odds ratio (OR) and 95% confidence intervals (CIs) were used as effect estimate. I-square (I) test, substantial heterogeneity, sensitivity analysis, and publication bias assessment will be performed accordingly. Stata 15.0 and Review Manger 5.3 are used for meta-analysis and systematic review.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

The results of this review will be widely disseminated through peer-reviewed publications and conference presentations. This evidence may also provide a comprehensive evaluation of the effect of trauma care systems on the mortality of injured adult patients.

REGISTRATION NUMBER

INPLASY202080058.