1
|
Pickering AE, Malherbe P, Nambuba J, Bills CB, Hynes EC, Rice B. Clinical emergency care quality indicators in Africa: a scoping review and data summary. BMJ Open 2023; 13:e069494. [PMID: 37130667 PMCID: PMC10163454 DOI: 10.1136/bmjopen-2022-069494] [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] [Indexed: 05/04/2023] Open
Abstract
OBJECTIVES Emergency care services are rapidly expanding in Africa; however, development must focus on quality. The African Federation of Emergency Medicine consensus conference (AFEM-CC)-based quality indicators were published in 2018. This study sought to increase knowledge of quality through identifying all publications from Africa containing data relevant to the AFEM-CC process clinical and outcome quality indicators. DESIGN We conducted searches for general quality of emergency care in Africa and for each of 28 AFEM-CC process clinical and five outcome clinical quality indicators individually in the medical and grey literature. DATA SOURCES PubMed (1964-2 January 2022), Embase (1947-2 January 2022) and CINAHL (1982-3 January 2022) and various forms of grey literature were queried. ELIGIBILITY CRITERIA Studies published in English, addressing the African emergency care population as a whole or large subsegment of this population (eg, trauma, paediatrics), and matching AFEM-CC process quality indicator parameters exactly were included. Studies with similar, but not exact match, data were collected separately as 'AFEM-CC quality indicators near match'. DATA EXTRACTION AND SYNTHESIS Document screening was done in duplicate by two authors, using Covidence, and conflicts were adjudicated by a third. Simple descriptive statistics were calculated. RESULTS One thousand three hundred and fourteen documents were reviewed, 314 in full text. 41 studies met a priori criteria and were included, yielding 59 unique quality indicator data points. Documentation and assessment quality indicators accounted for 64% of data points identified, clinical care for 25% and outcomes for 10%. An additional 53 'AFEM-CC quality indicators near match' publications were identified (38 new publications and 15 previously identified studies that contained additional 'near match' data), yielding 87 data points. CONCLUSIONS Data relevant to African emergency care facility-based quality indicators are highly limited. Future publications on emergency care in Africa should be aware of, and conform with, AFEM-CC quality indicators to strengthen understanding of quality.
Collapse
Affiliation(s)
- Ashley E Pickering
- Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Petrus Malherbe
- Emergency Medicine, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Joan Nambuba
- Emergency Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Corey B Bills
- Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Emilie Calvello Hynes
- Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Brian Rice
- Emergency Medicine, Stanford University, Palo Alto, California, USA
| |
Collapse
|
2
|
Limb Injuries and Disability in the Southwest Region of Cameroon. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202302000-00009. [PMID: 36795867 PMCID: PMC9937092 DOI: 10.5435/jaaosglobal-d-22-00148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 12/26/2022] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Extremity injuries are a leading cause of morbidity in low- and middle-income countries (LMICs), often resulting in marked short-term and long-term disabilities. Most of the existing knowledge on these injuries originates from hospital-based studies; however, poor access to health care in LMICs limits these data because of inherent selection bias. This subanalysis of a larger population-level cross-sectional study in the Southwest Region of Cameroon aims to determine patterns of limb injury, treatment-seeking behaviors, and predictors of disability. METHODS Households were surveyed in 2017 on injuries and subsequent disability sustained over the previous 12 months using a three-stage cluster sampling framework. Subgroups were compared using the chi square, Fisher exact, analysis of variance, Wald, and Wilcoxon rank-sum tests. Logarithmic models were used to identify predictors of disability. RESULTS Of 8,065 subjects, 335 persons (4.2%) sustained 363 isolated limb injuries. Over half of the isolated limb injuries (55.7%) were open wounds while 9.6% were fractures. Isolated limb injuries most commonly occurred in younger men and resulted from falls (24.3%) and road traffic injuries (23.5%). High rates of disability were reported, with 39% reporting difficulty with activities of daily living. Compared with individuals with other types of limb injuries, those with fractures were six times more likely to seek a traditional healer first for care (40% versus 6.7%), 5.3 times (95% CI, 1.21 to 23.42) more likely to have any level of disability after adjustment for injury mechanism, and 2.3 times more likely to have difficulty paying for food or rent (54.8% versus 23.7%). DISCUSSION Most traumatic injuries sustained in LMICs involve limb injuries and often result in high levels of disability that affect individuals during their most productive years. Improved access to care and injury control measures, such as road safety training and improvements to transportation and trauma response infrastructure, are needed to reduce these injuries.
Collapse
|
3
|
Suresh K, Dixon JM, Patel C, Beaty B, Del Junco DJ, de Vries S, Lategan HJ, Steyn E, Verster J, Schauer SG, Becker TE, Cunningham C, Keenan S, Moore EE, Wallis LA, Baidwan N, Fosdick BK, Ginde AA, Bebarta VS, Mould-Millman NK. The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa. Scand J Trauma Resusc Emerg Med 2022; 30:55. [PMID: 36253865 PMCID: PMC9574798 DOI: 10.1186/s13049-022-01041-1] [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: 09/16/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the “Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)” study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa. Methods The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient’s clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure). Discussion This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system. Trial Registration: Not applicable as this study is not a clinical trial.
Collapse
Affiliation(s)
- Krithika Suresh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Julia M Dixon
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Chandni Patel
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Brenda Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Deborah J Del Junco
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa
| | - Hendrick J Lategan
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elmin Steyn
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janette Verster
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Steven G Schauer
- U.S. Army Institute of Surgical Research, San Antonio Medical Center, San Antonio, TX, USA
| | - Tyson E Becker
- Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX, USA
| | - Cord Cunningham
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA
| | - Sean Keenan
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Lee A Wallis
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa.,Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Navneet Baidwan
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Bailey K Fosdick
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.
| |
Collapse
|
4
|
Lusetti A, Dagoli S, Banchini A, Gentile M, Lezzi P, Cecchi R. Over 30-year retrospective analyses of moped-motorcycle fatal road accidents in the northern area of the Italian region of Emilia Romagna and review of the literature: Aiming for further preventive measures in the future. Leg Med (Tokyo) 2022; 59:102139. [PMID: 36055135 DOI: 10.1016/j.legalmed.2022.102139] [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: 05/31/2022] [Revised: 07/25/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
Road traffic injuries are a major cause of morbidity and mortality worldwide, with pedestrians and riders of two-wheeled motor vehicles being the most vulnerable. The present study aims to determine the epidemiological characteristics of fatal motorcycle crashes in a portion of the Italian region of Emilia Romagna, and to compare them with the data available in literature. Data were retrieved from autopsy reports on 350 subjects who died following road accidents involving moped or motorcycle in the cities of Parma, Piacenza, and Reggio Emilia. Two types of data were extrapolated: circumstantial and traumatological. The population was divided into subgroups according to gender, crash time, alcohol positivity, presence or absence of the helmet, and the period elapsed between the accident and death. Most of the considered road accidents occurred during the day and on weekends. 25.5 % of the victims tested positive for alcohol. As far as traumas are concerned, the limbs resulted to be the most affected body segment, followed by the head (87.4 %), the thorax (85.7 %), the abdomen (65.7 %), and lastly the neck (50.3 %). According to similar studies, the sample victim of a moped/ motorcycle accident is a young male subject. The results obtained allow us to demonstrate that the mandatory use of the helmet has reduced skull and brain injury over the years. At present, no law regulates the use of protections for other body parts. Regulatory interventions in this sense would be desirable given the ever more rapid technical evolutions in the field of motorcycles.
Collapse
Affiliation(s)
- Andrea Lusetti
- Legal Medicine, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126 Parma, Italy
| | - Sara Dagoli
- Legal Medicine, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126 Parma, Italy
| | - Antonio Banchini
- Legal Medicine, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126 Parma, Italy
| | - Martino Gentile
- Legal Medicine, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126 Parma, Italy
| | - Pancrazio Lezzi
- Legal Medicine, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126 Parma, Italy
| | - Rossana Cecchi
- Legal Medicine, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126 Parma, Italy.
| |
Collapse
|
5
|
Baiden F, Anto-Ocrah M, Adjei G, Gyaase S, Abebrese J, Punguyire D, Owusu-Agyei S, Moresky RT. Head Injury Prevalence in a Population of Injured Patients Seeking Care in Ghana, West Africa. Front Neurol 2022; 13:917294. [PMID: 35812104 PMCID: PMC9266767 DOI: 10.3389/fneur.2022.917294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/20/2022] [Indexed: 11/18/2022] Open
Abstract
Background/Significance: Much of the literature on head injury (HI) prevalence comes from high-income countries (HICs), despite the disproportionate burden of injuries in low to middle-income countries (LMICs). This study evaluated the HI prevalence in the Kintampo Injury Registry, a collaborative effort between Kintampo Health Research Centre (KHRC) in Ghana and the sidHARTe Program at Columbia University Mailman School of Public Health. In our first aim, we characterize the HI prevalence in the registry. In aim 2, we examine if there are any sex (male/female) differences in head injury outcomes in these populations for points of potential intervention. Methods Secondary analysis of data from the Kintampo Injury Registry which had 7,148 registered patients collected during January 2013 to January 2015. The definition of a case was adopted to ensure consistency with the International Statistical Classification of Diseases and Related Health Problems, revision 10 (ICD-10). A 3-page questionnaire was used to collect data from injured patients to include in the registry. The questions were designed to be consistent with the World Health Organization (WHO) guidelines on injury surveillance and were adapted from the questionnaire used in a pilot, multi-country injury study undertaken in other parts of Africa. The questionnaire collected information on the anatomic site of injury (e.g., head), mechanism of injury (e.g., road traffic injuries, interpersonal injuries (including domestic violence), falls, drowning, etc.), severity and circumstances of the injury, as well as precipitating factors, such as alcohol and drug use. The questionnaire consisted mainly of close-ended questions and was designed for efficient data entry. For the secondary data analyses for this manuscript, we only included those with “1st visit following injury” and excluded all transfers and follow-up visits (n = 834). We then dichotomized the remaining 6,314 patients to head injured and non-head injured patients based on responses to the variable “Nature of injury =Head Injury”. We used chi-square and Fisher's exact tests with p < 0.05 as cut-off for statistical significance. Logistic regression estimates were used for effect estimates. Results Of the 6,314 patients, there were 208 (3.3%) head-injured patients and 6,106 (96.7%) patients without head injury. Head-injured patients tended to be older (Mean age: 28.9 +/-13.7; vs. 26.1 +/- 15.8; p = 0.004). Seven in 10 head injured patients sustained their injuries via transport/road traffic accidents, and head-injured patients had 13 times the odds of mortality compared with those without head injuries (OR: 13.3; 95% CI: 8.05, 22.0; p < 0.0001) even though over half of them had mild or moderate injury severity scores (p < 0.001). Evaluation of sex differences amongst the head-injured showed that in age-adjusted logistic regression models, males had 1.4 times greater odds of being head injured (OR: 1.4; 95% CI: 1.04, 2.00; p = 0.03) and over twice the risk of mortality (OR: 2.7; 95% CI: 0.74, 10.00; p = 0.13) compared to females. Conclusion In these analyses, HI was associated with a higher risk of mortality, particularly amongst injured males; most of whom were injured in transport/road-traffic-related accidents. This study provides an impetus for shaping policy around head injury prevention in LMICs like Ghana.
Collapse
Affiliation(s)
- Frank Baiden
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Martina Anto-Ocrah
- Department of Medicine, Division of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- *Correspondence: Martina Anto-Ocrah
| | - George Adjei
- Department of Community Medicine, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Stephaney Gyaase
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Jacob Abebrese
- Institutional Care Division, Ghana Health Service, Accra, Ghana
| | - Damien Punguyire
- Upper West Regional Health Directorate, Ghana Health Service, Wa, Ghana
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
| | - Rachel T. Moresky
- SidHARTe-Strengthening Emergency Systems Program, Heilbrunn Department of Population and Family Health Columbia University, Mailman School of Public Health, New York, NY, United States
- Department of Emergency Medicine Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, United States
| |
Collapse
|
6
|
Ding K, Sur PJ, Mbianyor MA, Carvalho M, Oke R, Dissak-Delon FN, Signe-Tanjong M, Mfopait FY, Essomba F, Mbuh GE, Etoundi Mballa GA, Christie SA, Juillard C, Chichom Mefire A. Mobile telephone follow-up assessment of postdischarge death and disability due to trauma in Cameroon: a prospective cohort study. BMJ Open 2022; 12:e056433. [PMID: 35383070 PMCID: PMC8984008 DOI: 10.1136/bmjopen-2021-056433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES In Cameroon, long-term outcomes after discharge from trauma are largely unknown, limiting our ability to identify opportunities to reduce the burden of injury. In this study, we evaluated injury-related death and disability in Cameroonian trauma patients over a 6-month period after hospital discharge. DESIGN Prospective cohort study. SETTING Four hospitals in the Littoral and Southwest regions of Cameroon. PARTICIPANTS A total of 1914 patients entered the study, 1304 were successfully contacted. Inclusion criteria were patients discharged after being treated for traumatic injury at each of four participating hospitals during a 20-month period. Those who did not possess a cellular phone or were unable to provide a phone number were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES The Glasgow Outcome Scale-Extended (GOSE) was administered to trauma patients at 2 weeks, 1 month, 3 months and 6 months post discharge. Median GOSE scores for each timepoint were compared and regression analyses were performed to determine associations with death and disability. RESULTS Of 71 deaths recorded, 90% occurred by 2 weeks post discharge. At 6 months, 22% of patients still experienced severe disability. Median (IQR) GOSE scores at the four timepoints were 4 (3-7), 5 (4-8), 7 (4-8) and 7 (5-8), respectively, (p<0.01). Older age was associated with greater odds of postdischarge disability (OR: 1.23, 95% CI: 1.07 to 1.41) and mortality (OR: 2.15, 95% CI: 1.52 to 3.04), while higher education was associated with decreased odds of disability (OR: 0.65, 95% CI: 0.58 to 0.73) and mortality (OR: 0.38, 95% CI: 0.31 to 0.47). Open fractures (OR: 1.73, 95% CI: 1.38 to 2.18) and closed fractures (OR: 1.83, 95% CI: 1.42 to 2.36) were associated with greater postdischarge disability, while higher Injury Severity Score (OR: 2.44, 95% CI: 2.13 to 2.79) and neurological injuries (OR: 4.40, 95% CI: 3.25 to 5.96) were associated with greater odds of postdischarge mortality. CONCLUSION Mobile follow-up data show significant morbidity and mortality, particularly for orthopaedic and neurologic injuries, up to 6 months following trauma discharge. These results highlight the need for reliable follow-up systems in Cameroon.
Collapse
Affiliation(s)
- Kevin Ding
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | - Patrick J Sur
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
- Riverside School of Medicine, University of California, Riverside, California, USA
| | | | - Melissa Carvalho
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | - Rasheedat Oke
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | | | | | - Florentine Y Mfopait
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
| | - Frank Essomba
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
| | - Golda E Mbuh
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
| | | | - S Ariane Christie
- Department of Trauma and Acute Care Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catherine Juillard
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | - Alain Chichom Mefire
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
| |
Collapse
|
7
|
Nguyen NT, Ding K, Oke R, Tanjong MMS, Mbuh L, Mbianyor MA, Carvalho M, Dissak Delon FN, Boeck M, Collins C, Yenshu EV, Etoundi GA, Juillard C, Mefire AC. Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon. J Surg Res 2022; 276:151-159. [PMID: 35344741 DOI: 10.1016/j.jss.2022.02.019] [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: 09/14/2021] [Revised: 12/14/2021] [Accepted: 02/14/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants' perceptions on leadership, medical errors, and the QI process in Cameroon. METHODS Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation. RESULTS A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants' perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4. CONCLUSIONS These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.
Collapse
Affiliation(s)
- Nicole T Nguyen
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Kevin Ding
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Rasheedat Oke
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Mary-Magdalene S Tanjong
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Lidwine Mbuh
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Mbiarikai A Mbianyor
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | | | - Marissa Boeck
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Caitlin Collins
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Emmanuel V Yenshu
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | | | - Catherine Juillard
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California.
| | - Alain Chichom Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| |
Collapse
|
8
|
Incidence, causes and factors associated with torso injury in Cameroon: A community-based study. Afr J Thorac Crit Care Med 2021; 27. [PMID: 34761212 PMCID: PMC8573817 DOI: 10.7196/ajtccm.2021.v27i3.161] [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] [Accepted: 07/14/2021] [Indexed: 11/08/2022] Open
Abstract
Background Morbidity and mortality linked to injury has become an increasingly important public health concern worldwide, especially in developing countries. Despite the potentially severe nature of torso injury, little is known about the population-based epidemiology of torso injury in sub-Saharan Africa. Objectives To determine the incidence, identify common mechanisms, and assess the socioeconomic consequences of torso injury in Cameroon. Methods We performed a torso injury sub-analysis of a larger descriptive cross-sectional community-based study on injury epidemiology in the preceding 12 months in the Southwest region of Cameroon. Sampling was done using the three-stage cluster sampling technique. The differences between groups were evaluated using χ² and adjusted Wald tests. Results We identified 39 cases of torso injuries out of 8 065 participants, providing a yearly incidence estimate of 488 (95% confidence interval (CI) 356 - 668) per 100 000 person-years. Road traffic injury was the most common mechanism of torso injury. The median (interquartile range (IQR)) cost of treatment for torso injury was USD58 (10 - 137), over four times the median (IQR) cost for non-torso injury at USD12 (3 - 43) (p=0.0004). About half of affected households (51%) reported being unable to afford necessities such as rent and food after injury v. 33% of households with members with non-torso injuries (p=0.018). Conclusion Torso injuries have an incidence of 488/100 000 person-years, and road traffic injuries account for the majority of the injuries. Road traffic control measures and trauma care strengthening may reduce the impact of torso injuries and injuries in Cameroon.
Collapse
|
9
|
Ding K, Nguyen N, Carvalho M, Dissak Delon FN, Mekolo D, Nkusu D, Tchekep MS, Oke RA, Mbianyor MA, Yenshu EV, Boeck M, Collins C, Jackson N, Mefire AC, Juillard C. Baseline Patient Safety Culture in Cameroon: Setting a Foundation for Trauma Quality Improvement. J Surg Res 2020; 255:311-318. [PMID: 32593889 DOI: 10.1016/j.jss.2020.05.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Trauma quality improvement (QI) has resulted in decreased trauma mortality and morbidity in high-income countries and has the potential to do the same in low- and middle-income countries. Effective implementation of QI programs relies on a foundational culture of patient safety; however, studies on trauma-related patient safety culture in Sub-Saharan Africa remain scarce. This study assesses baseline patient safety culture in Cameroon to best identify opportunities for improvement. MATERIALS AND METHODS Over a 3-week period, the Hospital Survey on Patient Safety Culture was administered in three hospitals in the Littoral region of Cameroon. Percentages of positive responses (PPRs) were calculated across 42 items in 12 survey dimensions. A mixed-effects logistic regression model was used to summarize dimension-level percentages and confidence intervals. RESULTS A total of 179 trauma-related hospital personnel were surveyed with an overall response rate of 76.8%. High PPRs indicate favorable patient safety culture. Of the 12 dimensions evaluated by the Hospital Survey on Patient Safety Culture, nine had a PPR below 50%. Dimensions particularly pertinent in the context of QI include Nonpunitive Response to Errors with a PPR of 25.8% and Organization Learning-Continuous Improvement with a PPR of 64.7%. CONCLUSIONS The present study elucidates an opportunity for the development of trauma patient safety culture in Cameroon. Low PPR for Nonpunitive Response to Errors indicates a need to shift cultural paradigms from ascribing individual blame to addressing systemic shortcomings of patient care. Moving forward, data from this study will inform interventions to cultivate patient safety culture in partnering Cameroonian hospitals.
Collapse
Affiliation(s)
- Kevin Ding
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Nicole Nguyen
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | | | - David Mekolo
- Emergency Unit, Laquintinie Hospital of Douala, Douala, Cameroon
| | | | - Mirene S Tchekep
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Rasheedat A Oke
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Mbiarikai A Mbianyor
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Emmanuel V Yenshu
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Marissa Boeck
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Caitlin Collins
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Nicholas Jackson
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, California
| | - Alain Chichom Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Catherine Juillard
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California.
| |
Collapse
|
10
|
Feldhaus I, Carvalho M, Waiz G, Igu J, Matthay Z, Dicker R, Juillard C. Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review. Trauma Surg Acute Care Open 2020; 5:e000424. [PMID: 32420451 PMCID: PMC7223475 DOI: 10.1136/tsaco-2019-000424] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/27/2020] [Accepted: 04/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings. Materials and methods This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized. Results Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility. Conclusions The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective. PROSPERO registration number CRD42017064600.
Collapse
Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Melissa Carvalho
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Ghazel Waiz
- Department of Surgery, Center for Global Surgical Studies, University of California San Francisco, San Francisco, California, USA
| | - Joel Igu
- Johns Hopkins University Carey Business School, Baltimore, Maryland, USA
| | - Zachary Matthay
- Department of Surgery, Center for Global Surgical Studies, University of California San Francisco, San Francisco, California, USA
| | - Rochelle Dicker
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Catherine Juillard
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
11
|
Christie SA, Mbianyor MA, Dissak-Delon FN, Tanjong MM, Chichom-Mefire A, Dicker RA, Juillard C. Feasibility of a Cellular Telephone Follow-Up Program After Injury in Sub-Saharan Africa. World J Surg 2020; 44:2533-2541. [PMID: 32347352 DOI: 10.1007/s00268-020-05529-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Injury disproportionately affects persons in low- and middle-income countries (LMIC). Most LMIC lack capacity for routine follow-up care, likely resulting in complications and disability. Cellular telephones may provide a new tool to improve health outcomes. The objective of this study was to establish the feasibility of a mobile health follow-up program after injury in Cameroon. METHODS Between February and October 2017, all injured patients admitted to a regional hospital in Cameroon were asked for mobile phone numbers as part of an existing trauma registry. Patients were contacted 2 weeks after leaving the hospital discharge to participate in a short triage survey. Data on program feasibility and patient condition were collected. RESULTS Of 1180 injured patients who presented for emergency care, 83% provided telephone numbers, 62% were reached, and 48% (565) of all injured patients ultimately participated in telephone follow-up. Successfully contacted patients were reached after an average of 1.76 call attempts (SD 1.91) and median call time was 4.43 min (IQR 3.67-5.36). Five patients (1%) had died from their injuries at the time of follow-up. Among surveyed patients, 27% required ongoing assistance to complete activities of daily living. Nearly, half (47%) of patients reported inability to take medicines or care for their injury as instructed at discharge. Adequate pain control was achieved in only 38% of discharged patients. CONCLUSION Pilot data suggest considerable under treatment of injury in Cameroon. Mobile telephone follow-up demonstrates potential as a feasible tool for screening discharged patients who could benefit from further care.
Collapse
Affiliation(s)
- S Ariane Christie
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Building 1, Rooms 400 & 401, San Francisco, CA, 94110, USA
| | - M Agbor Mbianyor
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Building 1, Rooms 400 & 401, San Francisco, CA, 94110, USA
| | | | - Mary M Tanjong
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Building 1, Rooms 400 & 401, San Francisco, CA, 94110, USA
| | - Alain Chichom-Mefire
- Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Rochelle A Dicker
- Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, 72-215 CHS, Los Angeles, CA, 90095, USA
| | - Catherine Juillard
- Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, 72-215 CHS, Los Angeles, CA, 90095, USA.
| |
Collapse
|
12
|
Ngunde PJ, Akongnwi ACN, Mefire CA, Puis F, Gounou E, Nkfusai NC, Nwarie UG, Cumber SN. Prevalence and pattern of lower extremity injuries due to road traffic crashes in Fako Division, Cameroon. Pan Afr Med J 2019; 32:53. [PMID: 31143358 PMCID: PMC6522147 DOI: 10.11604/pamj.2019.32.53.17514] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 01/07/2019] [Indexed: 12/30/2022] Open
Abstract
Introduction Low and middle income countries are disproportionately affected with road traffic injuries and the lower extremity is one of the most affected anatomical body parts. There exist very limited data on the pattern of lower extremity injuries in the Cameroon especially in the South West Region. We therefore, hypothesized that lower limb injuries are common in road traffic crashes and motorized two wheelers are the commonest cause. Methods This was a hospital based prospective, cross sectional study. It involved four hospitals (Limbe and Buea Regional Hospitals, Baptist hospital Mutengene and Tiko District Hospital) in the Fako Division. It was carried out for three months. Victims of road traffic crashes received at emergency department of these hospitals during this period were assessed. Crash characteristics and injury characteristics were assessed and recorded. Results We analyzed 411 crash victims, 197(47.93%) had lower extremity injuries. The male to female ratio was 1.4:1. Majority of crash victims were in their 3rd and 4th decades of life. The mean age of patients who had lower limb injuries was 33.30(±16.04). The most vulnerable road users were pedestrians (26.52%) and passengers on motor bikes (38.44%) and the commonest mechanism by which crash victims sustained injuries were: bike-car collisions (22.84%), and bike-pedestrian collisions (19.29%). Commercial motor bikes (62.77%) and taxis (22.38%) were the road users most involved in road traffic collisions. The leg 98(49.75%), thigh 23(11.68%), and knee 20(10.15%) were the most injured anatomical parts of the lower extremity. Fractures 68 (34.52%), lacerations 53(26.90%), and bruises 49(24.87%) were the most recurrent pattern of lower extremity injuries. Conclusion In view of our findings we conclude therefore as follows: The prevalence of lower extremity injuries from Road Traffic Crashes in our study area was 47.93%. Associated risk factors to the road traffic crashes as identified by the victims were bad roads (10.15%) and bad weather (5.05%). The safety gargets were not adequately utilized by our victims, with 87.72% confirming that they did not wear the helmet and 87.50% affirming that they did not wear the seat belt at the time of the crash. The occupations mostly affected in our series were pupils and students (20.3%) and business people (19.2%), then the bike riders (15.23%). We thus recommend that the laws on the use of road safety gargets, especially helmets and seatbelts, be enforced, with riding and driving speeds reduced to below 60km/hour. Road usage should be avoided in bad weather and pedestrians lanes and zebra crossings be provided to minimize pedestrian-car or -bike collision.
Collapse
Affiliation(s)
- Palle John Ngunde
- Department of Medicine and surgery, Faculty of Health Sciences, University of Buea, Buea Cameroon
| | | | - Chichom Alain Mefire
- Department of Medicine and surgery, Faculty of Health Sciences, University of Buea, Buea Cameroon
| | - Fokam Puis
- Department of Medicine and surgery, Faculty of Health Sciences, University of Buea, Buea Cameroon
| | - Eleanor Gounou
- Department of Medicine and surgery, Faculty of Health Sciences, University of Buea, Buea Cameroon
| | - Ngwayu Claude Nkfusai
- Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, Cameroon
| | - Udoamaka Glory Nwarie
- Department of Medicine and surgery, Faculty of Health Sciences, University of Buea, Buea Cameroon
| | - Samuel Nambile Cumber
- Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa.,Section for Epidemiology and Social Medicine, Department of Public Health, Institute of Medicine (EPSO), The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
13
|
St-Louis E, Paradis T, Landry T, Poenaru D. Factors contributing to successful trauma registry implementation in low- and middle-income countries: A systematic review. Injury 2018; 49:2100-2110. [PMID: 30333086 DOI: 10.1016/j.injury.2018.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/05/2018] [Accepted: 10/05/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma registries (TR) provide invaluable data, informing resource allocation and quality improvement. The purpose of this systematic review was to identify factors promoting and inhibiting successful TR implementation in low- and middle-income countries (LMICs). METHODS The protocol was registered a priori (CRD42017058586). With librarian oversight, a peer-reviewed search strategy was developed. Adhering to PRISMA guidelines, two independent reviewers performed first-screen and full-text screening. Studies describing implementation of a TR in LMICs or reviewed the experience of registry users/implementers were included. Extracted data, focusing on publication, institution, registry and data factors, was summarized using descriptive statistics and subjected to thematic qualitative analysis. RESULTS Out of 3842 screened references, 40 articles were included for analysis. Most registries were paper-based, implemented in single publicly-funded institutions within LMICs, benefited from funding, and were run by untrained house-staff with other clinical responsibilities. Constituent variables, injury scoring, outcome assessment, and quality assurance practices were very diverse. Principal obstacles to successful implementation were lack of funding, significant missing data, and insufficient resources. CONCLUSIONS This work may contribute to the planning of future efforts towards TR implementation in LMICs, where better injury data has the potential to alleviate the morbidity and mortality associated with trauma through advocacy and quality-improvement.
Collapse
Affiliation(s)
- Etienne St-Louis
- Montreal Children's Hospital, Division of Pediatric General and Thoracic Surgery, Canada; McGill University Health Centre, Centre for Global Surgery, Canada.
| | - Tiffany Paradis
- McGill University Health Centre, Centre for Global Surgery, Canada.
| | - Tara Landry
- McGill University Health Centre, Patient Resource Centre, Canada.
| | - Dan Poenaru
- Montreal Children's Hospital, Division of Pediatric General and Thoracic Surgery, Canada; McGill University Health Centre, Centre for Global Surgery, Canada.
| |
Collapse
|
14
|
Developing Trauma Audit Filters for Regional Referral Hospitals in Cameroon: Mixed-Methods Approach. J Surg Res 2018; 232:578-586. [PMID: 30463777 DOI: 10.1016/j.jss.2018.07.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/29/2018] [Accepted: 07/13/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Injuries are a leading cause of death and disability worldwide. Developing countries account for 90% of injury-related deaths globally. Trauma audit filters can facilitate trauma quality improvement initiatives and reduce the injury burden. Little is known about context-appropriate trauma audit filters for developing countries such as Cameroon. This study aimed to (1) develop context-appropriate trauma audit filters for the setting of a regional referral hospital in Cameroon and (2) to assess the barriers and facilitators to their implementation. METHODS Feasible audit filters were identified by a panel of Cameroonian surgeons using the Delphi technique. A Likert scale (1 to 5, with 5 as "Most Useful") was used to rank the filters for utility in a regional referral hospital setting, analyzed using the median and interquartile range. Semistructured interviews were conducted with 16 health care providers from three hospital facilities to explore their perceptions of supervision and support they receive from hospital administration, availability of resources, their work environment, and potential concerns and impacts of trauma audit filters. Interviews were coded and thematically analyzed. RESULTS Within a panel of seven surgeons, 23 of 40 trauma audit filter variables met majority consensus criteria. Twenty-one of these, comprising mostly of primary survey and basic resuscitation techniques, had a median score of ≥4. Filters meeting consensus include, but are not limited to, vitals obtained, breathing assessment made, and two large bore intravenous established within 15 min of arrival; patient with open fracture receives intravenous antimicrobials within 1 h of arrival; patients with suspected spine injury are immobilized and given X-ray. The provider interviews revealed that the barriers to providing quality care were limited human and material resources and patients' inability to pay. Regular staff training in trauma care and the belief that trauma audit filters would potentially streamline work practices and improve the quality of care were cited as promoters of successful implementation. CONCLUSIONS Primary survey and basic resuscitative techniques are key elements of context-appropriate audit filters in Cameroon. Such audit filters may not be costly, require complex infrastructure, or equipment that exceed the site's capabilities. Proper staff orientation and participation in the use of trauma audit filters, as quality improvement tools, are key to local buy-in and implementation success.
Collapse
|
15
|
Nwanna-Nzewunwa OC, Kouo Ngamby M, Shetter E, Etoundi Mballa GA, Feldhaus I, Monono ME, Hyder AA, Dicker R, Stevens KA, Juillard C. Informing prehospital care planning using pilot trauma registry data in Yaoundé, Cameroon. Eur J Trauma Emerg Surg 2018. [PMID: 29525968 DOI: 10.1007/s00068-018-0939-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION About 54% of deaths in low- and middle-income countries (LMICs) are attributable to lack of prehospital care. The single largest contributor to the disability-adjusted life years due to poor prehospital care is injury. Despite having disproportionately high injury burdens, most LMIC trauma systems have little prehospital organization. An understanding of existing prehospital care patterns in LMICs is warranted as a precursor to strengthening prehospital systems. METHODS In this retrospective pilot study, we collected demographic and injury characteristics, therapeutic itinerary, and transport data of patients that were captured by the trauma registry at the Central Hospital of Yaoundé (CHY) from April 15, 2009 to October 15, 2009. Bivariate and multivariate regression analyses were used to explore relationships between care-seeking behavior, method of transport, and predictor variables. RESULTS The mean age was 30.2 years (95% CI [29.7, 30.7]) and 73% were male. Therapeutic itinerary was available for 97.5% of patients (N = 2855). Nearly 18.7% of patients sought care elsewhere before CHY and 82% of such visits were at district hospitals or health clinics. Moderately (OR 1.336, p = 0.009) and severely (OR 1.605, p = 0.007) injured patients were more likely to seek care elsewhere before CHY and were less likely to be discharged home after their emergency ward visit as opposed to being admitted to the hospital for further treatment (OR 0.462, p < 0.001). Commercial vehicles provided most prehospital transport (65%), while police or ambulance transported few injured patients (7%). CONCLUSIONS Possible areas for prehospital trauma care strengthening include training lay commercial vehicle drivers in trauma care and formalizing triage, referral, and communication protocols for prehospital care to optimize timely transfer and care while minimizing secondary injury to patients.
Collapse
Affiliation(s)
- Obieze Chiemeka Nwanna-Nzewunwa
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 4th Floor, Building 1, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | | | - Elinor Shetter
- International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Isabelle Feldhaus
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, USA
| | | | - Adnan A Hyder
- International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Rochelle Dicker
- Department of Surgical Critical Care, University of California Los Angeles, Los Angeles, USA
| | - Kent A Stevens
- International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Catherine Juillard
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 4th Floor, Building 1, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
| |
Collapse
|
16
|
Paradis T, St-Louis E, Landry T, Poenaru D. Strategies for successful trauma registry implementation in low- and middle-income countries-protocol for a systematic review. Syst Rev 2018; 7:33. [PMID: 29467037 PMCID: PMC5822522 DOI: 10.1186/s13643-018-0700-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 02/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benefits of trauma registries have been well described. The crucial data they provide may guide injury prevention strategies, inform resource allocation, and support advocacy and policy. This has been shown to reduce trauma-related mortality in various settings. Trauma remains a leading cause of mortality in low- and middle-income countries (LMICs). However, the implementation of trauma registries in LMICs can be challenging due to lack of funding, specialized personnel, and infrastructure. This study explores strategies for successful trauma registry implementation in LMICs. METHODS The protocol was registered a priori (CRD42017058586). A peer-reviewed search strategy of multiple databases will be developed with a senior librarian. As per PRISMA guidelines, first screen of references based on abstract and title and subsequent full-text review will be conducted by two independent reviewers. Disagreements that cannot be resolved by discussion between reviewers shall be arbitrated by the principal investigator. Data extraction will be performed using a pre-defined data extraction sheet. Finally, bibliographies of included articles will be hand-searched. Studies of any design will be included if they describe or review development and implementation of a trauma registry in LMICs. No language or period restrictions will be applied. Summary statistics and qualitative meta-narrative analyses will be performed. DISCUSSION The significant burden of trauma in LMIC environments presents unique challenges and limitations. Adapted strategies for deployment and maintenance of sustainable trauma registries are needed. Our methodology will systematically identify recommendations and strategies for successful trauma registry implementation in LMICs and describe threats and barriers to this endeavor. SYSTEMATIC REVIEW REGISTRATION The protocol was registered on the PROSPERO international prospective register of systematic reviews ( CRD42017058586 ).
Collapse
Affiliation(s)
- Tiffany Paradis
- McGill University, 3655 Promenade Sir William Osler, Montreal, QC H3A 1A3 Canada
| | - Etienne St-Louis
- McGill University Health Centre, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada
| | - Tara Landry
- McGill University Health Centre, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada
| | - Dan Poenaru
- McGill University Health Centre, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada
| |
Collapse
|
17
|
Chichom-Mefire A, Palle-Ngunde J, Fokam P, Mokom-Awa A, Njock R, Ngowe-Ngowe M. Injury patterns in road traffic victims comparing road user categories: Analysis of 811 consecutive cases in the emergency department of a level I institution in a low-income country. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2017.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
18
|
Choua O, Rimtebaye K, Yamingue N, Moussa K, Kaboro M. [Epidemiological, clinical and therapeutic aspects of blunt abdominal trauma in patients undergoing surgery at the General Hospital of National Reference of N'Djamena, Chad: about 49 cases]. Pan Afr Med J 2017; 26:50. [PMID: 29187916 PMCID: PMC5702550 DOI: 10.11604/pamj.2017.26.50.8327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 08/10/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction Les traumatismes fermés de l’abdomen sont fréquents. Méthodes Il s’agissait d’une étude rétrospective sur 49 dossiers de patients opérés pour traumatisme fermé de l’abdomen en cinq ans à l’Hôpital General de Référence Nationale de N’Djaména au Tchad. Les paramètres épidémiologiques, cliniques et thérapeutiques étaient étudiés. Résultats C’étaient 42 hommes et 7 femmes d’âge moyen de 21,3 ans. Les étiologies étaient: les accidents de la voie publique dans 61,2% des cas; les écroulements de mur (14,3%); les agressions (8,2%). Les traumatismes fermés de l’abdomen étaient plus fréquents au mois d’Août (14,28%) et Octobre (16,32%). Le délai d’admission à l’hôpital était de 6 à 12h dans 43% des cas. Le moyen d’évacuation des blessés était une voiture privée dans 85,7% des cas. Cliniquement, l’état hémodynamique était souvent stable (55,1%). L’imagerie médicale était dominée par la radiographie directe de l’abdomen (57,1%). Les lésions les plus observées ont été celles du grêle seul (16,32%) ou associées à celle de la vessie (8,16%), et de la rate (2,04%). La laparotomie était négative dans 6,12% des cas. La morbidité (12,2%) était dominée par les abcès de paroi. Le taux de décès était de 6,1%. Conclusion Les accidents de la voie publique sont la première cause de traumatismes fermés de l’abdomen. Le délai diagnostic et thérapeutique est important. Des mesures de sécurité routière devraient prévenir les accidents.
Collapse
Affiliation(s)
- Ouchemi Choua
- Département de Chirurgie, Faculté des Sciences de la Santé Humaine BP 1117 N'Djaména, Tchad
| | - Kimassoum Rimtebaye
- Département de Chirurgie, Faculté des Sciences de la Santé Humaine BP 1117 N'Djaména, Tchad
| | - Ngueidjo Yamingue
- Département de Chirurgie, Faculté des Sciences de la Santé Humaine BP 1117 N'Djaména, Tchad
| | - Kalli Moussa
- Département de Chirurgie, Faculté des Sciences de la Santé Humaine BP 1117 N'Djaména, Tchad
| | - Mignagnal Kaboro
- Département de Chirurgie, Faculté des Sciences de la Santé Humaine BP 1117 N'Djaména, Tchad
| |
Collapse
|
19
|
Mowafi H, Oranmore-Brown R, Hopkins KL, White EE, Mulla YF, Seidenberg P. Analysis of Prehospital Transport Use for Trauma Patients in Lusaka, Zambia. World J Surg 2017; 40:2868-2874. [PMID: 27405748 DOI: 10.1007/s00268-016-3629-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Despite an increasing burden of injuries, prehospital transport systems remain underdeveloped in many low- and middle-income countries. Little information exists on the use of prehospital services for trauma patients in Zambia. METHOD A prospective, observational study of trauma presentations was undertaken for 6 months in Lusaka, Zambia, to establish the epidemiology and outcomes of injury in the region. In addition to demographics and mechanism of injury, data were collected on prehospital transport as well as inpatient resources utilization. Trained study personnel gathered data on trauma presentations 24 h a day. Statistical analysis was conducted using SAS 9.3 from a Microsoft® Access database. RESULTS 3498 trauma patients were enrolled in the study on arrival to University Teaching Hospital (UTH). 3264 patients had a transport means recorded (95.3 %). Two-thirds (66 %) arrived within 6 h of injury, and 23 % arrived within the first hour after injury. A majority arrived by private vehicle (53.4 %) or public transport (37.7 %); only 5.9 % were transported by public or private ambulance. Of those arriving within the first hour after injury, 69.1 % came by private car, 24.6 % by public transport and 3.1 % by ambulance. There was a small statistical increase in Kampala Trauma Score II among ambulance arrivals. CONCLUSION Trauma patient use a variety of transport methods to get to UTH. A majority of patients use no formal ambulance transport. Despite this fact, a majority arrives within 6 h of injury but receive no formal prehospital care. An integrated, multilayered prehospital care and transport system may be the most effective approach for Zambia.
Collapse
Affiliation(s)
- Hani Mowafi
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, 06510, USA.
| | | | - Kathryn L Hopkins
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yacob F Mulla
- University Teaching Hospital, University of Zambia, Lusaka, Zambia
| | - Phil Seidenberg
- Department of Emergency Medicine, University of New Mexico, Albuquerque, USA
| |
Collapse
|
20
|
Chichom-Mefire A, Nwanna-Nzewunwa OC, Siysi VV, Feldhaus I, Dicker R, Juillard C. Key findings from a prospective trauma registry at a regional hospital in Southwest Cameroon. PLoS One 2017; 12:e0180784. [PMID: 28723915 PMCID: PMC5516986 DOI: 10.1371/journal.pone.0180784] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/21/2017] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of trauma in Cameroon is limited. Regular, prospective injury surveillance can address the shortcomings of existing hospital administrative logs and medical records. This study aims to characterize trauma as seen at the emergency department (ED) of Limbe Regional Hospital (LRH) and assess the completeness of data obtained by a trauma registry. METHODS AND FINDINGS From January 2008 to October 2013, we prospectively captured data on injured patients using a strategically designed, context-relevant trauma registry instrument. Indicators around patient demographics, injury characteristics, delays in accessing care, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. About 5,617 patients, aged from 0.5-95years (median age of 26 years), visited the LRH ED with an injury; 67% were male. Students (27%) were the most affected occupation category. Road traffic injuries (RTIs) (56%), assault (22%), and domestic injuries (13%) were the leading causes of injury. Two-thirds of RTIs were motorcycle-related. Working in transportation (AOR 4.42, p<0.001) and law enforcement (AOR 1.73, p = 0.004) were significant predictors of having a RTI. The trauma registry showed a significant improvement in completeness of all data (p<0.001) and it improved over time compared with previous administrative records. However, proportions of missing data still ranged from 0.5% to 8.2% and involved respiratory rate or Glasgow Coma scale. CONCLUSIONS Implementation of a context-appropriate trauma registry in resource-constrained settings is feasible. Providing valuable, high-quality data, the trauma registry can inform trauma care quality improvement efforts and policy development. Study findings indicate the need for injury prevention interventions and policies that will prioritize high-risks groups, such as those aged 20-29 years, and those in occupations requiring frequent road travel. The high incidence of motorcycle-related injuries is concerning and calls for a proactive solution.
Collapse
Affiliation(s)
- Alain Chichom-Mefire
- Department of Surgery, Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, Buea, Cameroon
| | - Obieze C. Nwanna-Nzewunwa
- Center for Global Surgical Studies, Department of Surgery, University of California, San Francisco, San Francisco, California, United States of America
| | - Vincent Verla Siysi
- Department of Surgery, Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, Buea, Cameroon
| | - Isabelle Feldhaus
- Center for Global Surgical Studies, Department of Surgery, University of California, San Francisco, San Francisco, California, United States of America
| | - Rochelle Dicker
- Center for Global Surgical Studies, Department of Surgery, University of California, San Francisco, San Francisco, California, United States of America
| | - Catherine Juillard
- Center for Global Surgical Studies, Department of Surgery, University of California, San Francisco, San Francisco, California, United States of America
| |
Collapse
|
21
|
Botchey IM, Hung YW, Bachani AM, Saidi H, Paruk F, Hyder AA. Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital. Surgery 2017; 162:S54-S62. [PMID: 28438334 DOI: 10.1016/j.surg.2017.02.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility-based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes. METHODS An electronic, tablet-based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in-patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in-patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes. RESULTS A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity. CONCLUSION The establishment of hospital-based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs.
Collapse
Affiliation(s)
- Isaac M Botchey
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yuen Wai Hung
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Abdulgafoor M Bachani
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Hassan Saidi
- Department of Human Anatomy, University of Nairobi, Nairobi, Kenya
| | - Fatima Paruk
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Adnan A Hyder
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| |
Collapse
|
22
|
Laytin AD, Dicker RA, Gerdin M, Roy N, Sarang B, Kumar V, Juillard C. Comparing traditional and novel injury scoring systems in a US level-I trauma center: an opportunity for improved injury surveillance in low- and middle-income countries. J Surg Res 2017; 215:60-66. [PMID: 28688663 DOI: 10.1016/j.jss.2017.03.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 02/03/2017] [Accepted: 03/24/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND In most low- and middle-income countries (LMICs), the resources to accurately quantify injury severity using traditional injury scoring systems are limited. Novel injury scoring systems appear to have adequate discrimination for mortality in LMIC contexts, but they have not been rigorously compared where traditional injury scores can be accurately calculated. To determine whether novel injury scoring systems perform as well as traditional ones in a HIC with complete and comprehensive data collection. METHODS Data from an American level-I trauma registry collected 2008-2013 were used to compare three traditional injury scoring systems: Injury Severity Score (ISS); Revised Trauma Score (RTS); and Trauma Injury Severity Score (TRISS); and three novel injury scoring systems: Kampala Trauma Score (KTS); Mechanism, GCS, Age and Pressure (MGAP) score; and GCS, Age and Pressure (GAP) score. Logistic regression was used to assess the association between each scoring system and mortality. Standardized regression coefficients (β2), Akaike information criteria, area under the receiver operating characteristics curve, and the calibration line intercept and slope were used to evaluate the discrimination and calibration of each model. RESULTS Among 18,746 patients, all six scores were associated with hospital mortality. GAP had the highest effect size, and KTS had the lowest median Akaike information criteria. Although TRISS discriminated best, the discrimination of KTS approached that of TRISS and outperformed GAP, MGAP, RTS, and ISS. MGAP was best calibrated, and KTS was better calibrated than RTS, GAP, ISS, or TRISS. CONCLUSIONS The novel injury scoring systems (KTS, MGAP, and GAP), which are more feasible to calculate in low-resource settings, discriminated hospital mortality as well as traditional injury scoring systems (ISS and RTS) and approached the discrimination of a sophisticated, data-intensive injury scoring system (TRISS) in a high-resource setting. Two novel injury scoring systems (KTS and MGAP) surpassed the calibration of TRISS. These novel injury scoring systems should be considered when clinicians and researchers wish to accurately account for injury severity. Implementation of these resource-appropriate tools in LMICs can improve injury surveillance, guiding quality improvement efforts, and supporting advocacy for resource allocation commensurate with the volume and severity of trauma.
Collapse
Affiliation(s)
- Adam D Laytin
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California
| | - Rochelle A Dicker
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California
| | - Martin Gerdin
- Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden
| | - Nobhojit Roy
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California; Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, BARC Hospital (Govt of India), Mumbai, India
| | - Bhakti Sarang
- Department of Surgery, BARC Hospital (Govt of India), Mumbai, India
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Catherine Juillard
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, California.
| |
Collapse
|
23
|
Botchey IM, Hung YW, Bachani AM, Paruk F, Mehmood A, Saidi H, Hyder AA. Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study. Surgery 2017; 162:S45-S53. [PMID: 28385178 DOI: 10.1016/j.surg.2017.01.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/26/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Injury is a leading cause of disability and death worldwide, accounting for over 5 million deaths each year. The injury burden is higher in low- and middle-income countries where more than 90% of injury-related deaths occur. Despite this burden, the use of prospective trauma registries to describe injury epidemiology and outcomes is limited in low- and middle-income countries. Kenya lacks robust data to describe injury epidemiology and care. The objective of this study was to investigate the epidemiology and outcomes of injuries at 4 referral hospitals in Kenya using hospital-based trauma registries. METHODS From January 2014 to May 2015, all injured patients presenting to the casualty departments of Kenyatta National, Thika Level 5, Machakos Level 5, and Meru Level 5 Hospitals were enrolled prospectively. Data collected included demographic characteristics, type of prehospital care received, prehospital time, injury pattern, and outcomes. RESULTS A total of 14,237 patients were enrolled in our study. Patients were predominantly male (76.1%) and young (mean age 28 years). The most common mechanisms of injury were road traffic injuries (36.8%), falls (26.4%), and being struck/hit by a person or object (20.1%). Burn was the most common mechanism of injury in the age category under 5 years. Body regions commonly injured were lower extremity (35.1%), upper extremity (33.4%), and head (26.0%). The overall mortality rate was 2.4%. Significant predictors of mortality from multivariate analysis were Glasgow Coma Scale ≤12, estimated injury severity score ≥9, burns, and gunshot injuries. CONCLUSION Hospital-based trauma registries can be important sources of data to study the epidemiology of injuries in low- and middle-income countries. Data from such trauma registries can highlight key needs and be used to design public health interventions and quality-of-care improvement programs.
Collapse
Affiliation(s)
- Isaac M Botchey
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yuen W Hung
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Abdulgafoor M Bachani
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Fatima Paruk
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Amber Mehmood
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Hassan Saidi
- Department of Human Anatomy, University of Nairobi, Nairobi, Kenya
| | - Adnan A Hyder
- Johns Hopkins International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| |
Collapse
|
24
|
Ro YS, Shin SD, Jeong J, Kim MJ, Jung YH, Kamgno J, Alain EMG, Hollong B. Evaluation of demands, usage and unmet needs for emergency care in Yaoundé, Cameroon: a cross-sectional study. BMJ Open 2017; 7:e014573. [PMID: 28167749 PMCID: PMC5293974 DOI: 10.1136/bmjopen-2016-014573] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To assess the burden of emergent illnesses and emergency care system usage by Yaoundé residents and to evaluate unmet needs for emergency care and associated barriers. DESIGN A cross-sectional study using a community-based survey. SETTING Yaoundé, Cameroon. PARTICIPANTS All residents living in Yaoundé were selected as the target population to investigate the needs and usage of emergency care in Yaoundé. 14 households in every health area (47 in total) were selected using 2-stage sampling. PRIMARY OUTCOME MEASURES Unmet needs for emergency care. RESULTS Among the 3201 participants from 619 households who completed the survey, 1113 (34.8%) with median age of 22 experienced 1 or more emergency conditions in the previous year. Respondents who experienced emergency conditions used emergency units (7.0%), outpatient clinics (46.5%) or hospitalisation (13.0%), and in overall, 68.8% of them reported unmet needs for emergency care. The primary reasons for not seeking healthcare were economic issues (37.2%) and use of complementary medicine (22.2%). Young age (adjusted OR (95% CI) 1.80 (1.23 to 2.62)), rental housing (1.50 (1.11 to 2.03)) and moderate household income (0.60 (0.36 to 0.99)) were associated with unmet needs for emergency care. CONCLUSIONS Residents of Yaoundé had a high demand for emergency care, and high unmet needs were observed due to low emergency care usage. Development of a cost-effective, universal emergency care system is urgently needed in Cameroon.
Collapse
Affiliation(s)
- Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Joongsik Jeong
- Korea International Cooperation Agency, Korea
- Department of Emergency Medicine, Centre des Urgences de Yaoundé, Yaoundé, Cameroon
| | - Min Jung Kim
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Young Hee Jung
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Joseph Kamgno
- Faculty of Medicine and Biomedical Services, Department of Epidemiology, University of Yaoundé, Yaoundé, Cameroon
| | | | - Bonaventure Hollong
- Department of Emergency Medicine, Centre des Urgences de Yaoundé, Yaoundé, Cameroon
| |
Collapse
|
25
|
Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda. Afr J Emerg Med 2016; 6:191-197. [PMID: 30456094 PMCID: PMC6234177 DOI: 10.1016/j.afjem.2016.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/27/2016] [Accepted: 10/04/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction Injury accounts for 9.6% of the global mortality burden, disproportionately affecting those living in low- and middle-income countries. In an effort to improve trauma care in Rwanda, the Ministry of Health developed a prehospital service, Service d’Aide Médicale Urgente (SAMU), and established an emergency medicine training program. However, little is known about patients receiving prehospital and emergency trauma care or their outcomes. The objective was to develop a linked prehospital–hospital database to evaluate patient characteristics, mechanisms of injury, prehospital and hospital resource use, and outcomes among injured patients receiving acute care in Kigali, Rwanda. Methods A retrospective cohort study was conducted at University Teaching Hospital – Kigali, the primary trauma centre in Rwanda. Data was included on all injured patients transported by SAMU from December 2012 to February 2015. SAMU’s prehospital database was linked to hospital records and data were collected using standardised protocols by trained abstractors. Demographic information, injury characteristics, acute care, hospital course and outcomes were included. Results 1668 patients were transported for traumatic injury during the study period. The majority (77.7%) of patients were male. The median age was 30 years. Motor vehicle collisions accounted for 75.0% of encounters of which 61.4% involved motorcycles. 48.8% of patients sustained injuries in two or more anatomical regions. 40.1% of patients were admitted to the hospital and 78.1% required surgery. The overall mortality rate was 5.5% with nearly half of hospital deaths occurring in the emergency centre. Conclusion A linked prehospital and hospital database provided critical epidemiological information describing trauma patients in a low-resource setting. Blunt trauma from motor vehicle collisions involving young males constituted the majority of traumatic injury. Among this cohort, hospital resource utilisation was high as was mortality. This data can help guide the implementation of interventions to improve trauma care in the Rwandan setting.
Collapse
|
26
|
Ajiko MM, Davé D, Feldhaus I, Smith RN, Juillard C, Dicker RA. Patterns of surgical presentation at an African regional referral hospital: surveillance as a step towards improving access to care. Eur J Trauma Emerg Surg 2016; 43:265-272. [PMID: 26869519 DOI: 10.1007/s00068-016-0644-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/01/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Surgical disease is being increasingly recognized as a significant health burden in Africa. Efforts have been made to describe surgical disease and capacity at the district hospital level. Little is known about patterns seen at regional hospitals supporting the district hospital network. METHODS This retrospective study was conducted at Uganda's Soroti Regional Referral Hospital, serving eight districts. Data were collected from July 2010 to March 2012 using operative and inpatient records as available. Univariate and bivariate analyses were performed to explore patterns of procedures performed and in-patient diagnoses. RESULTS There were 8511 procedures recorded in the operative log between July 2010 and June 2011, averaging 709 per month. Caesarian sections (41 %), dilation and evacuations (28 %), and laparotomies (19 %) were most frequent. Referrals to Soroti averaged 260 per month, while transfers out averaged 5 patients per month. Inpatient records documented 2949 surgically related diagnoses between July 2010 and May 2011. In patients >4 years old, 21 % of mortality was due to surgical disease, 29 % of which was trauma-related. Women comprised 80 % of violent injury. Common hospital record elements, such as demographic data, important clinical information, and operative notes were absent from these data sources. CONCLUSIONS The World Health Assembly recently recognized strengthening of first referral hospitals as a crucial element to achieving universal health coverage. Inconsistencies in recordkeeping despite the large volume of surgical disease suggest that sustainable surveillance systems and capacity building at the referral hospital level are potential building blocks to improving access to surgical care.
Collapse
Affiliation(s)
- M M Ajiko
- Soroti Regional Referral Hospital, Soroti-Lira Rd, Soroti, Uganda
| | - D Davé
- Department of Surgery, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, USA.,Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA
| | - I Feldhaus
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA
| | - R N Smith
- Department of Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, 51 N 39th St., Philadelphia, PA, USA
| | - C Juillard
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA
| | - R A Dicker
- Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Avenue, Ward 3A Box 0807, San Francisco, CA, USA.
| |
Collapse
|
27
|
Laytin AD, Kumar V, Juillard CJ, Sarang B, Lashoher A, Roy N, Dicker RA. Choice of injury scoring system in low- and middle-income countries: Lessons from Mumbai. Injury 2015; 46:2491-7. [PMID: 26233630 DOI: 10.1016/j.injury.2015.06.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 06/11/2015] [Accepted: 06/15/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Injury is a major cause of morbidity and mortality in low- and middle-income countries. Effective trauma surveillance is imperative to guide research and quality improvement interventions, so an accurate metric for quantifying injury severity is crucial. The objectives of this study are (1) to assess the feasibility of calculating five injury scoring systems--ISS (injury severity score), RTS (revised trauma score), KTS (Kampala trauma score), MGAP (mechanism, GCS (Glasgow coma score), age, pressure) and GAP (GCS, age, pressure)--with data from a trauma registry in a lower middle-income country and (2) to determine which of these scoring systems most accurately predicts in-hospital mortality in this setting. PATIENTS AND METHODS This is a retrospective analysis of data from an institutional trauma registry in Mumbai, India. Values for each score were calculated when sufficient data were available. Logistic regression was used to compare the correlation between each score and in-hospital mortality. RESULTS There were sufficient data recorded to calculate ISS in 73% of patients, RTS in 35%, KTS in 35%, MGAP in 88% and GAP in 92%. ISS was the weakest predictor of in-hospital mortality, while RTS, KTS, MGAP and GAP scores all correlated well with in-hospital mortality (area under ROC (receiver operating characteristic) curve 0.69 for ISS, 0.85 for RTS, 0.86 for KTS, 0.84 for MGAP, 0.85 for GAP). Respiratory rate measurements, missing in 63% of patients, were a major barrier to calculating RTS and KTS. CONCLUSIONS Given the realities of medical practice in low- and middle-income countries, it is reasonable to modify the approach to characterising injury severity to favour simplified injury scoring systems that accurately predict in-hospital mortality despite limitations in trauma registry datasets.
Collapse
Affiliation(s)
- Adam D Laytin
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.
| | - Catherine J Juillard
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Bhakti Sarang
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India.
| | - Angela Lashoher
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India; Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India.
| | - Nobhojit Roy
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India.
| | - Rochelle A Dicker
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
28
|
Chichom-Mefire A, Atashili J, Tsiagadigui JG, Fon-Awah C, Ngowe-Ngowe M. A prospective pilot cohort analysis of crash characteristics and pattern of injuries in riders and pillion passengers involved in motorcycle crashes in an urban area in Cameroon: lessons for prevention. BMC Public Health 2015; 15:915. [PMID: 26384779 PMCID: PMC4575460 DOI: 10.1186/s12889-015-2290-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 09/15/2015] [Indexed: 01/15/2023] Open
Abstract
Background Low and middle-income countries carry over ninety per cent of the burden of injury related mortality and disability. Motorcycles are gradually becoming a major mode of transportation in Cameroon and other African countries in the absence of an organized public transport. Consequently, the contribution of motorcycle crash to injury-related deaths seems to be on the rise. Currently, data addressing motorcycle crash characteristics, pattern, and severity of motorcycle-related injuries in Cameroon are scarce. We hypothesised that head and limb injuries are the most frequent cause of morbidity and mortality and equally affect riders and pillion passengers. Methods This hospital-based prospective pilot cohort analysis involving 405 motorcycle crashes and 621 injury victims was conducted in Laquintinie Hospital, a large centre located in an urban area in Cameroon. All motorcycle riders and passengers received in the emergency department over a 4 months period with an injury following a traffic related crash were included. Crash characteristics and type, anatomical location and severity of injuries were recorded and analysed comparing the pattern of injuries between riders and pillion passengers involved in motorcyclecrashes. This pilot analysis is expected to propose a snapshot of motorcycle injuries in Douala and will be followed by a larger analysis over a longer period. Results We recorded a majority of motorcycle versus car and motorcycle versus motorcycle collisions. Most of these crashes occurred over the week-end and in the night. Helmet use was almost inexistent. We observed that females aged above 40 years represented the majority of pillion passengers. This accounted for the sex-ratio of 1.1/1. A total of 1311 injuries were identified in our patients, giving a mean of 2.1 injuries per victim. The head and the limbs were the most affected anatomical areas. Riders carried a higher risk of sustaining an injury to head and neck than pillion passengers. Riders and pillion passengers carried equal risk of injury to the lower limbs. Emergency room mortality was 4 · 3 % and riders were more likely to die than pillion passengers. Conclusion This study has identified females aged above 40 years as a special vulnerable group in Douala. It also carries strong messages useful for the implementation of preventive measures and management of patients injured in motorcycle-related crash in general.
Collapse
Affiliation(s)
- Alain Chichom-Mefire
- Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, P.O. Box 25526, Yaoundé, Cameroon.
| | - Julius Atashili
- Faculty of Health Sciences, University of Buea, Buea, Cameroon.
| | | | - Clovis Fon-Awah
- Faculty of Health Sciences, University of Buea, Buea, Cameroon.
| | | |
Collapse
|
29
|
Compliance of district hospitals in the Center Region of Cameroon with WHO/IATSIC guidelines for the care of the injured: a cross-sectional analysis. World J Surg 2015; 38:2525-33. [PMID: 24838483 DOI: 10.1007/s00268-014-2609-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Injuries are a major cause of death and disability worldwide. Low-income countries, particularly in Africa, are disproportionately affected. The burden of injuries can be alleviated by preventive measures and appropriate management of injury cases. African countries generally lack trauma care systems based on reliable and affordable guidelines. The aim of this study was to assess the compliance of some district hospitals in Cameroon with World Health Organization/International Association for Trauma and Intensive Care (WHO/IATSIC) guidelines for care of the injured. METHODS This cross-sectional descriptive survey used items from the WHO/IATSIC "Guidelines for Essential Trauma Care" to develop a checklist for inspection of physical equipment and a questionnaire assessing human resources and organizational capabilities in 25 district hospitals of the Center Region of Cameroon. RESULTS All hospitals surveyed had at least one doctor available. Each reported treating a mean of 338 ± 214 injury cases every year. Most hospitals (n = 22) were globally either not compliant or partly compliant with the guidelines. Staff generally had received the appropriate basic training but had no additional training specifically directed toward trauma management. Skills for managing specific injuries (e.g., chest injuries) were poor. Availability and utilization of equipment was globally inadequate, and organizational capabilities were almost nonexistent. CONCLUSIONS District hospitals of the Center Region of Cameroon still lack compliance with the WHO/IATSIC guidelines for essential trauma care but have significant potential for improvement. It seems possible to optimize the utilization of existing facilities.
Collapse
|
30
|
Bashah DT, Dachew BA, Tiruneh BT. Prevalence of injury and associated factors among patients visiting the Emergency Departments of Amhara Regional State Referral Hospitals, Ethiopia: a cross-sectional study. BMC Emerg Med 2015; 15:20. [PMID: 26302780 PMCID: PMC4547436 DOI: 10.1186/s12873-015-0044-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 08/06/2015] [Indexed: 11/30/2022] Open
Abstract
Background Injury significantly affecting the health and well-being of the society. The prevalence tends to be higher in low income countries. The aim of this study was to assess the prevalence of injury and associated factors among patients visiting emergency departments of Amhara Regional State referral hospitals. Methods Institution based cross sectional study was conducted from March to April 2014. The systematic random sampling technique was employed to select the study participants. The data were collected using an interviewer administered questionnaire. Bivariate and multivariate logistic regressions were performed to identify factors associated with injury. Odds ratios with 95 % confidence interval were computed to determine the level of significance. Result The prevalence of injury was 55.6 %. Being male (AOR = 2.8; 95 % CI, 1.79-4.47), monthly income less than 34.2 USD (AOR = 1.89; 95 % CI, 1.03–3.46), being age between 20 to 44 years (AOR = 2.25; 95 % CI, 1.06–4.81), being a daily laborer (AOR = 6.27; 95 % CI, 2.38-16.47), being a farmer (AOR = 2.9; 95 % CI, 1.31-6.41) and being a substance user (AOR = 2. 16; 95 % CI, 1.18-3.96) were significantly associated with injury. Conclusion The prevalence of injury was high. Being male, age 20 to 44 years, income < 34.2 USD, being a daily laborer, being a farmer and alcohol use were factors associated with injury. Hence, appropriate injury prevention strategy should be designed in order to lessen the magnitude of injury.
Collapse
Affiliation(s)
- Debrework Tesgera Bashah
- Department of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia.
| | - Berihun Assefa Dachew
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia.
| | - Bewket Tadesse Tiruneh
- Department of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia.
| |
Collapse
|
31
|
Tadesse BT, Dachew BA, Bifftu BB, Kelkay MM, Adane KC, Gorgas DL. High incidence of interpersonal violence in Northwest Ethiopia: A cross-sectional study. Int Emerg Nurs 2014; 23:213-7. [PMID: 25582608 DOI: 10.1016/j.ienj.2014.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 11/19/2014] [Accepted: 11/25/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Interpersonal violence has devastating consequences for the mental, physical and sexual health of the victim. It is a leading cause of injury in east Africa. Studies in Ethiopia report that the most common cause of injury was interpersonal conflict. Our objective was to study the incidence of interpersonal violence related injury and associated factors among patients visiting the emergency department of University of Gondar Hospital, Northwest Ethiopia. METHODS A cross-sectional institutional based study design was employed from November 2013-June 2014. The source population was a cohort sample of all patients presenting for treatment of a traumatic injury. Data were collected using injury surveillance guidelines developed by the World Health Organization. Bivariate and multivariate logistic regressions were performed to identify the presence and strength of association. Odds ratio with 95% confidence interval was computed to determine the level of significance. RESULTS The overall incidence of interpersonal violence related injury was 28.5% of all emergency department trauma patients. Multivariate logistic regression shows that conflict in the family prior to the event [AOR = 9.9 (95% CI: 4.433-9.536)], poor behavioral control [AOR = 2.5 (95% CI: 1.192-5.460)], alcohol use [AOR = .406 (95% CI: 1.813-6.398)] and paternal education [AOR = 2.441(95% CI: 1.209-4.929)] were found to be independently associated with interpersonal violence related injury. CONCLUSION AND RECOMMENDATION The incidence of interpersonal violence related injury was high. Counseling and education on conflict resolution methods should be given for the community using mass media.
Collapse
Affiliation(s)
- Bewket Tiruneh Tadesse
- Department of Nursing, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia.
| | - Berihun Assefa Dachew
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Ethiopia
| | - Berhanu Boru Bifftu
- Department of Nursing, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Mengistu Mekonnen Kelkay
- Department of Nursing, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Kasaw Chuffa Adane
- College of Medicine and Health Sciences, School of Biomedical and Laboratory Sciences, Unit of Quality Assurance and Laboratory Management, University of Gondar, Gondar, Ethiopia
| | - Diane L Gorgas
- Department of Emergency Medicine, The Ohio State University's Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
32
|
Seidenberg P, Cerwensky K, Brown RO, Hammond E, Mofu Y, Lungu J, Mulla Y, Biemba G, Mowafi H. Epidemiology of injuries, outcomes, and hospital resource utilisation at a tertiary teaching hospital in Lusaka, Zambia. Afr J Emerg Med 2014. [DOI: 10.1016/j.afjem.2014.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|
33
|
Juillard CJ, Stevens KA, Monono ME, Mballa GAE, Ngamby MK, McGreevy J, Cryer G, Hyder AA. Analysis of Prospective Trauma Registry Data in Francophone Africa: A Pilot Study from Cameroon. World J Surg 2014; 38:2534-42. [DOI: 10.1007/s00268-014-2604-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|