Are Primary Trauma Care (PTC) courses beneficial in low- and middle-income countries - A systematic review

Prospective multi-centre analysis of rural trauma team development training for medical trainees and traffic law enforcement professionals in Uganda: an interrupted time series study

BACKGROUND

Research shows that trauma team formation could potentially improve effectiveness of injury care in rural settings. The aim of this study was to determine the feasibility of rural trauma team training amongst medical trainees and traffic law enforcement professionals in Uganda.

METHODS

Prospective multi-centre interrupted time series analysis of an interventional training based on the 4th edition of rural trauma team development course of the American College of Surgeons. Trauma related multiple choice questions (MCQs), and trauma non-technical skills were assessed pre-and post-training between September 2019- August 2023. Acceptability of the training for promulgation to other rural regions and its relevance to participants' work needs were evaluated on 5- and 3-point Likert scales respectively. The median MCQ scores (IQR) were compared before and after training at 95% CI, regarding p < 0.05 as statistically significant. Triangulation with open-ended questions was obtained. Time series regression models were applied to test for autocorrelation in performance using Stata 15.0. Ethical approval was obtained from Uganda National Council for Science and Technology (Ref: SS 5082).

RESULTS

A total of 500 participants including: 66 (13.2%) traffic police officers, 30 (6.0%) intern doctors, 140 (28.0%) fifth year and 264 (52.8%) third-year medical students were trained. Among the 434 medical trainees who completed the trauma-based MCQ assessment, the median pre- and post-test scores were 60%, IQR (50-65) and 80%, IQR (70-85) respectively. Overall, the mean difference between pre- and post-test scores was statistically significant (z = 16.7%, P|z|=<0.0001). Most participants strongly agreed to promulgate 389 (77.8%), relevance to their educational 405 (81.0%), and work needs 399 (79.8%). Each of the course components was rated above 76.0% as being very relevant. There was an overall increment in median (IQR) trauma-nontechnical skills team performance scores from 12 (9-14) to 17 (15-20) after the training (p < 0.001), with police teams advancing from 9.5 (6.0-12.5) to 19.5 (17.0-21.5) (p < 0.001).

CONCLUSION

This study demonstrates that rural trauma team development training had a positive effect on the test scores of course participants. The training is feasible, highly acceptable and regarded as relevant amongst medical trainees and traffic law enforcement professionals who provide first-aid to trauma patients in resource-limited settings. The findings could inform the design of future trauma teams in rural communities.

TRIAL REGISTRATION

Retrospective registration (UIN: researchregistry9450).

Resuscitation following trauma & role of trauma training programmes in emergency settings: A literature review & survey

Background & objectives Traumatic injuries, especially in low- and middle- income countries (LMICs), present significant challenges in patient resuscitation and healthcare delivery. This study explores the role of trauma training programmes in improving patient outcomes and reducing preventable trauma-related deaths. Methods A dual approach was adopted, first a literature review of trauma training in LMICs over the past decade, along with a situational assessment survey. For the review of literature, we searched the PubMed database to identify key challenges and innovative practices in trauma training programmes in LMIC's. The survey, conducted among healthcare professionals in various LMICs, collected direct insights into the challenges and the status of trauma training programmes in these countries. Results The literature review analysed 68 articles, with a significant focus on the African subcontinent (36 studies), underscoring the region's emphasis on research on trauma training programmes. These studies mainly targeted physicians, clinicians, postgraduate trainees in surgical or anaesthesia fields and medical students (86.8%), highlighting innovations like simulation-based training and the cascading training model. In our survey, we received 34 responses from healthcare professionals in India, Belarus, Azerbaijan, Nepal and Pakistan. Around 52.9 per cent reported the absence of established trauma training programmes in their settings. The majority of respondents advocated for hands-on, simulation-based training (94.1%) and emphasised the need for structured training programmes (85.3%), feedback sessions (70.6%) and updated protocols (61.8%). This combined data underlined the critical gaps and potential improvements in trauma training programmes and resuscitation practices in LMICs. Interpretation & conclusions Effective trauma care in LMICs requires the establishment of comprehensive, tailored training programmes. Key interventions should include subsidization of pre-existing trauma courses and the adoption of World Health Organization Guidelines for essential trauma care, implementation of trauma quality improvement and review processes and the incorporation of focused assessment with sonography in trauma (FAST) in emergency departments. These steps are crucial for equipping healthcare workers with vital skills and knowledge, fostering a culture of continuous learning and improvement in the realm of trauma care.

Translating training to medical practice in trauma care, a literature review

Trauma, a global health challenge, remains a significant cause of mortality despite advances in trauma management. The establishment of trauma teams has revolutionized care in trauma resuscitation. The training of these teams is designed to promote self-trust and empower trainees in trauma care, enhance performance, and improve patient outcomes. Various training curricula have been developed, utilizing a plethora of teaching methods such as lectures, simulations, debriefings, skill workshops, and demonstrations. However, a universally accepted gold standard curriculum in trauma training is yet to be defined, and there is no standard method for delivering education in injury care teaching. In this review, we have examined relevant literature data on standard teaching programs, the educational delivery methods used, and their impact on adult trauma patients' outcomes and trained team-related outcomes. While most studies indicate improved trained team performance, they consistently show no improvement in patient-specific outcomes such as mortality, morbidity, and length of stay. However, data hints at optimal educational delivery and the role that technology may play in the future of trauma training development.

Using the Kirkpatrick Model to Evaluate the Effect of a Primary Trauma Care Course on Health Care Workers' Knowledge, Attitude, and Practice in Two Vietnamese Local Hospitals: Prospective Intervention Study

Background

The Primary Trauma Care (PTC) course was originally developed to instruct health care workers in the management of patients with severe injuries in low- and middle-income countries (LMICs) with limited medical resources. PTC has now been taught for more than 25 years. Many studies have demonstrated that the 2-day PTC workshop is useful and informative to frontline health staff and has helped improve knowledge and confidence in trauma management; however, there is little evidence of the effect of the course on changes in clinical practice. The Kirkpatrick model (KM) and the knowledge, attitude, and practice (KAP) model are effective methods to evaluate this question.

Objective

The aim of this study was to investigate how the 2-day PTC course impacts the satisfaction, knowledge, and skills of health care workers in 2 Vietnamese hospitals using a conceptual framework incorporating the KAP model and the 4-level KM as evaluation tools.

Methods

The PTC course was delivered over 2 days in the emergency departments (EDs) of Thanh Hoa and Ninh Binh hospitals in February and March 2022, respectively. This study followed a prospective pre- and postintervention design. We used validated instruments to assess the participants' satisfaction, knowledge, and skills before, immediately after, and 6 months after course delivery. The Fisher exact test and the Wilcoxon matched-pairs signed rank test were used to compare the percentages and mean scores at the pretest, posttest, and 6-month postcourse follow-up time points among course participants.

Results

A total of 80 health care staff members attended the 2-day PTC course and nearly 100% of the participants were satisfied with the course. At level 2 of the KM (knowledge), the scores on multiple-choice questions and the confidence matrix improved significantly from 60% to 77% and from 59% to 71%, respectively (P<.001), and these improvements were seen in both subgroups (nurses and doctors). The focus of level 3 was on practice, demonstrating a significant incremental change, with scenarios checklist points increasing from a mean of 5.9 (SD 1.9) to 9.0 (SD 0.9) and bedside clinical checklist points increasing from a mean of 5 (SD 1.5) to 8.3 (SD 0.8) (both P<.001). At the 6-month follow-up, the scores for multiple-choice questions, the confidence matrix, and scenarios checklist all remained unchanged, except for the multiple-choice question score in the nurse subgroup (P=.005).

Conclusions

The PTC course undertaken in 2 local hospitals in Vietnam was successful in demonstrating improvements at 3 levels of the KM for ED health care staff. The improvements in the confidence matrix and scenarios checklist were maintained for at least 6 months after the course. PTC courses should be effective in providing and sustaining improvement in knowledge and trauma care practice in other LMICs such as Vietnam.

Implementation of structured trauma training for first-year surgical residents in Ethiopia: a novel pilot program in a low income country

Purpose

Curricula for surgical residents should include training in trauma care; however, such training is absent in many low income countries. At the largest surgical training institution in Ethiopia, a trauma training program was developed, integrated into the existing surgical curriculum, and implemented. This study was conducted to evaluate the trainees' response to the new program.

Methods

Over a 5-month period, 35 first-year surgical residents participated in weekly trauma care training sessions. The program included journal clubs, practical sessions, didactic sessions, and case-based discussions. Six months after the conclusion of the training, changes in knowledge, attitude, and practices were evaluated through a self-report survey.

Results

For knowledge-based items, the survey data revealed reported improvements in 83.8% to 96.8% of students. Furthermore, 90.3% to 93.5% of participants indicated improvements in practice, while 96.7% exhibited a change in attitude. Respondents reported that attending didactic courses improved their presentation skills and facilitated the acquisition of knowledge. They suggested the inclusion of additional practical sessions.

Conclusions

Training structures that are simple to implement are crucial for residency programs with limited resources. Such programs can be developed using existing academic staff and can aid residents in delivering improved care to trauma patients.

Effect of Rural Trauma Team Development on the Outcomes of Motorcycle Accident-Related Injuries (Motor Registry Project): Protocol for a Multicenter Cluster Randomized Controlled Trial

BACKGROUND

Injury is a global health concern, and injury-related mortality disproportionately impacts low- and middle-income countries (LMICs). Compelling evidence from observational studies in high-income countries shows that trauma education programs, such as the Rural Trauma Team Development Course (RTTDC), increase clinician knowledge of injury care. There is a dearth of such evidence from controlled clinical trials to demonstrate the effect of the RTTDC on process and patient outcomes in LMICs.

OBJECTIVE

This multicenter cluster randomized controlled clinical trial aims to examine the impact of the RTTDC on process and patient outcomes associated with motorcycle accident-related injuries in an African low-resource setting.

METHODS

This is a 2-arm, parallel, multi-period, cluster randomized, controlled, clinical trial in Uganda, where rural trauma team development training is not routinely conducted. We will recruit regional referral hospitals and include patients with motorcycle accident-related injuries, interns, medical trainees, and road traffic law enforcement professionals. The intervention group (RTTDC) and control group (standard care) will include 3 hospitals each. The primary outcomes will be the interval from the accident to hospital admission and the interval from the referral decision to hospital discharge. The secondary outcomes will be all-cause mortality and morbidity associated with neurological and orthopedic injuries at 90 days after injury. All outcomes will be measured as final values. We will compare baseline characteristics and outcomes at both individual and cluster levels between the intervention and control groups. We will use mixed effects regression models to report any absolute or relative differences along with 95% CIs. We will perform subgroup analyses to evaluate and control confounding due to injury mechanisms and injury severity. We will establish a motorcycle trauma outcome (MOTOR) registry in consultation with community traffic police.

RESULTS

The trial was approved on August 27, 2019. The actual recruitment of the first patient participant began on September 01, 2019. The last follow-up was on August 27, 2023. Posttrial care, including linkage to clinical, social support, and referral services, is to be completed by November 27, 2023. Data analyses will be performed in Spring 2024, and the results are expected to be published in Autumn 2024.

CONCLUSIONS

This trial will unveil how a locally contextualized rural trauma team development program impacts organizational efficiency in a continent challenged with limited infrastructure and human resources. Moreover, this trial will uncover how rural trauma team coordination impacts clinical outcomes, such as mortality and morbidity associated with neurological and orthopedic injuries, which are the key targets for strengthening trauma systems in LMICs where prehospital care is in the early stage. Our results could inform the design, implementation, and scalability of future rural trauma teams and trauma education programs in LMICs.

TRIAL REGISTRATION

Pan African Clinical Trials Registry (PACTR202308851460352); https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=25763.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55297.

Rural trauma team development training amongst medical trainees and traffic law enforcement professionals in a low-income country: a protocol for a prospective multicenter interrupted time series

Background

Road traffic injuries and their resulting mortality disproportionately affect rural communities in low-middle-income countries (LMICs) due to limited human and infrastructural resources for postcrash care. Evidence from high-income countries show that trauma team development training could improve the efficiency, care, and outcome of injuries. A paucity of studies have evaluated the feasibility and applicability of this concept in resource constrained settings. The aim of this study protocol is to establish the feasibility of rural trauma team development and training in a cohort of medical trainees and traffic law enforcement professionals in Uganda.

Methods

Muticenter interrupted time series of prospective interventional trainings, using the rural trauma team development course (RTTDC) model of the American College of Surgeons. A team of surgeon consultants will execute the training. A prospective cohort of participants will complete a before and after training validated trauma related multiple choice questionnaire during September 2019-November 2023. The difference in mean prepost training percentage multiple choice questionnaire scores will be compared using ANOVA-test at 95% CI. Time series regression models will be used to test for autocorrelations in performance. Acceptability and relevance of the training will be assessed using 3 and 5-point-Likert scales. All analyses will be performed using Stata 15.0. Ethical approval was obtained from Research and Ethics Committee of Mbarara University of Science and Technology (Ref: MUREC 1/7, 05/05-19) and Uganda National Council for Science and Technology (Ref: SS 5082). Retrospective registration was accomplished with Research Registry (UIN: researchregistry9490).

The Emergency Preparedness of Level-Four Primary Health Care Centers in the Gaza Strip, the Occupied Palestinian Territory: An Assessment of Primary Care Providers' Competencies and Facilities Preparedness

INTRODUCTION

The Gaza Strip lives in a protracted emergency crisis and experienced several Israeli escalations. These escalations have overwhelmed the hospitals and highlighted the need to optimize Primary Health Care Centers (PHCCs) to form part of the emergency response system. This study, therefore, aimed to assess the emergency preparedness of the Ministry of Health (MoH)-run level-four PHCCs in the Gaza Strip (where Emergency Medical Services are provided along with preventive and curative services).

METHODS

The study was cross-sectional, used quantitative methods, and utilized two tools. The first tool was a self-administered structured questionnaire exploring Primary Care Providers' ([PCPs]; doctors and nurses) experiences, perceived capabilities, and training needs. The second tool was an observational checklist used to assess the preparedness of the emergency rooms (ERs) at level-four PHCCs in the Gaza Strip.

RESULTS

Two hundred and thirty-eight PCPs (34.5% doctors and 65.5% nurses) working in 16 level-four PHCCs were included. Overall, 64.4% of the participants had experience working in PHCCs during Israeli escalations, though 35.3% of them were unaware of the contingency plan (CP) of PHCCs. More nurses were aware of CPs than doctors (66.9% versus 42.7%; P <.001). Moreover, 65.7%, 46.7%, and 42.5% of the participants were trained in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Primary Trauma Care (PTC), respectively. However, many had received the training for more than two years, and none of the PHCCs had all its staff trained. Only 36.8% of the participants were trained in Post-Trauma/Post-Operative Care (wound care and dressing), and the percentage of trained nurses was significantly higher than those of doctors (36.8% versus 13.9%; P <.001). The majority of the participants admitted they need ACLS training (89.2%), PTC training (89%), BLS training (81.1%), and Post-Trauma/Post-Operative Care training (76.8%). Only 29.63% of emergency drugs and 37.5% of the equipment and disposables were available in the ERs of all PHCCs, and none of the PHCCs had all the essential emergency drugs, equipment, and disposables available.

CONCLUSION

Level-four PHCCs in the Gaza Strip are not adequately prepared to respond to emergencies. Generally, PCPs lack appropriate competencies for emergency response, and many PHCCs lack the infrastructure to support Primary Emergency Care (PEC). Thus, PCPs need continuous education and training in disaster preparedness and response and PEC.

Structured approach with primary and secondary survey for major trauma care: an overview of reviews

BACKGROUND

A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma.

METHODS

We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence).

CONCLUSIONS

The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.

Paediatric trauma education in low- and middle-income countries: A systematic literature review

Background

Trauma-specific training improves clinician comfort and reduces patient morbidity and mortality; however, curricular content, especially with regard to paediatric trauma, varies greatly by region and income status. We sought to understand how much paediatric education is included in trauma curricula taught in low- and middle-income countries (LMICs).

Methods

We conducted a systematic literature review in October 2020 and in July 2022 based on PRISMA guidelines, utilizing seven databases: MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Reviews, Cochrane Trials, and Global Index Medicus. Reports were limited to those from World Bank-designated LMICs. Key information reviewed included use of a trauma curriculum, patient-related outcomes, and provider/participant outcomes.

Results

The search yielded 2008 reports, with 987 included for initial screening. Thirty-nine of these were selected for review based on inclusion criteria. Sixteen unique trauma curricula used in LMICs were identified, with only two being specific to paediatric trauma. Seven of the adult-focused trauma programmes included sections on paediatric trauma. Curricular content varied significantly in educational topics and skills assessed. Among the 39 included curricula, 33 were evaluated based on provider-based outcomes and six on patient-based outcomes. All provider-based outcome reports showed increased knowledge acquisition and comfort. Four of the five patient-based outcome reports showed reduction in trauma-related morbidity and mortality.

Conclusion

Trauma curricula in LMICs positively impact provider knowledge and may decrease trauma-related morbidity and mortality; however, there is significant variability in existing trauma curricula regarding to paediatric-specific content. Trauma education in LMICs should expand paediatric-specific education, as this population appears to be underserved by most existing curricula.

PASS-A course in Pediatric Acute Surgical Support to build pediatric surgical emergencies capacity in developing countries

OBJECTIVES

The burden of pediatric trauma and emergency, including pediatric surgical emergencies in low middle income countries (LMIC) is high. The goal of Pediatric Acute Surgical Support (PASS) course is to prepare caregivers in LMIC for the acute management of life-threatening pediatric surgical emergencies. We aim to show the feasibility of its initial deployment.

METHODS

PASS was developed in 2016 with LMIC faculty from a teaching children hospital CH. The course contents consisted of a mix of didactic materials for serious general neonatal and pediatric surgery modified PALS/ATLS, in-person multidisciplinary team-based skill stations, interactive clinical scenarios and simulated trauma cases. The course was subsequently revised and delivered to 92 learners in four classes of 2.5-days sessions at two CHs between 2017 and 2019. Learners' demographics, written exams, team-based case performance, and post-course survey data were prospectively collected and retrospectively analyzed.

RESULTS

Physician (60%) and nurse learners (40%) from pediatric critical care (36%), surgery (23%), emergency medicine (20%) and anesthesiology (9%) had 3.6 +/- 3.6 years of clinical practice; pre- and post-course written exam score of 55.4+/-15.5% vs 71.6+/-12.8%, team-based trauma scenario management 22.6 ± 7.8% vs 54.7 ± 16.6% and team-based dynamic scores 17+/- 10% vs 53.3+/- 15.5%, respectively (p<0.0001). Self-reported satisfaction scores were ≥ 95% for course method, level of difficulty, clinical applicability, and quality of instructors.

CONCLUSION

PASS is well-received by LMIC learners, with short-term improvement in knowledge-, team-based management of acute pediatric surgery emergencies; and has the potential to be a model of horizontal capacity building for pediatric surgery in LMIC.

LEVEL OF EVIDENCE

II.

The State of Global Trauma and Acute Care Surgery/Surgical Critical Care

Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.

Teaching Trauma in Resource-Limited Settings: A Scoping Review of Pediatric Trauma Courses

PURPOSE

Injury remains an important cause of death and disability globally, with 95% of all childhood injury deaths occurring in low- and lower-middle-income countries (LMICs). Pediatric trauma training, tailored to the resources in LMICs, represents an opportunity to improve such outcomes. We explored the nature of course offerings in pediatric trauma in resource-limited settings.

METHODS

Seven databases were interrogated up to June 12, 2020, to retrieve articles examining pediatric trauma training in LMICs, as defined by the World Bank, without language restrictions. Independent authors reviewed and selected abstracts based on set criteria. Data from included studies was extracted and analyzed. An adapted Critical Appraisal Skills Programme checklist designed for cohort studies was used to assess the risk of bias.

RESULTS

After screening 3960 articles for eligibility, 16 were included for final analysis. Course delivery methods included didactic modules, simulations, clinical mentorship, small group discussion, audits, assessments, and feedback. Knowledge acquisition was primarily assessed through pre/post-tests, clinical skills assessments, and self-assessment questionnaires. Twelve studies detailed course content, nine of which were based on the WHO Emergency Triage, Assessment and Treatment model, which is not specific to trauma. The other three studies involved locally developed pediatric trauma-focused training courses, including airway management, head trauma and cervical spine management, thoracic and abdominal trauma, orthopedic trauma, burn and wound management, and shock.

CONCLUSION

Despite being essential to decreasing pediatric trauma morbidity and mortality worldwide, educational programs in pediatric trauma are not a widespread reality in low-and-middle-income countries. The development of accessible and efficient pediatric trauma education programs is critical for improving pediatric trauma quality of care.

A pilot multicentre cluster randomised trial to compare the effect of trauma life support training programmes on patient and provider outcomes

INTRODUCTION

Trauma accounts for nearly 10% of the global burden of disease. Several trauma life support programmes aim to improve trauma outcomes. There is no evidence from controlled trials to show the effect of these programmes on patient outcomes. We describe the protocol of a pilot study that aims to assess the feasibility of conducting a cluster randomised controlled trial comparing advanced trauma life support (ATLS) and primary trauma care (PTC) with standard care.

METHODS AND ANALYSIS

We will pilot a pragmatic three-armed parallel, cluster randomised controlled trial in India, where neither of these programmes are routinely taught. We will recruit tertiary hospitals and include trauma patients and residents managing these patients. Two hospitals will be randomised to ATLS, two to PTC and two to standard care. The primary outcome will be all-cause mortality at 30 days from the time of arrival to the emergency department. Our secondary outcomes will include patient, provider and process measures. All outcomes except time-to-event outcomes will be measured both as final values as well as change from baseline. We will compare outcomes in three combinations of trial arms: ATLS versus PTC, ATLS versus standard care and PTC versus standard care using absolute and relative differences along with associated CIs. We will conduct subgroup analyses across the clinical subgroups men, women, blunt multisystem trauma, penetrating trauma, shock, severe traumatic brain injury and elderly. In parallel to the pilot study, we will conduct community consultations to inform the planning of the full-scale trial.

ETHICS AND DISSEMINATION

We will apply for ethics approvals to the local institutional review board in each hospital. The protocol will be published to Clinical Trials Registry-India and ClinicalTrials.gov. The results will be published and the anonymised data and code for analysis will be released publicly.

Global emergency medicine: A scoping review of the literature from 2020

OBJECTIVE

The objective was to identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research (OR) and review articles (RE) in global emergency medicine (EM) published in 2020 in the peer-reviewed and gray literature.

METHODS

A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review (GEMLR) Group to identify those that met our criteria of OR or RE in the domains of disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and EM development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in-depth narrative summarization.

RESULTS

The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year's search. From these, 364 were scored based on their full text. Nearly three-fourths of the scored articles constituted OR, of which nearly three-fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID-19. Research involving ECRLS again constituted most of the articles in this year's review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in-depth narrative critiques.

CONCLUSIONS

The number of studies relevant to global EM identified by our search was very similar to that of last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to DHR. The number of COVID-19-related articles is likely to continue to increase in subsequent years.

Are Trauma Surgery Simulation Courses Beneficial in Low- and Middle-Income Countries—A Systematic Review and Meta-Analysis

Despite trauma-related injuries being a leading cause of death worldwide, low- and middle-income countries (LMICs) lack the infrastructure and resources required to offer immediate surgical care, further perpetuating the risk of morbidity and mortality. In high-income countries, trauma surgery simulation courses are routinely delivered to surgeons, teaching the fundamental skills of operative trauma. This study aimed to assess whether similar courses are beneficial in LMICs and how they can be improved. We performed a systematic review and meta-analysis using MEDLINE, Embase and Google Scholar, analysing studies evaluating trauma surgery simulation in LMICs. The outcomes measured included clinical knowledge improvement, participant confidence and general course-feedback. The review was carried out in-line with PRISMA guidelines. Five studies were included, summating a population of 172 participants. In three studies, meta-analysis showed an overall significant weighted mean improvement of knowledge post-course by 22.91% (95%CI 19.53, 26.29; p < 0.00001; I2 = 0%). One study reported a significant increase in participant confidence for 20/22 of operative skills taught (p < 0.04). We conclude that these courses are beneficial in LMICs; however, further research is necessary to establish the optimum course design, and whether patient outcomes are improved following their implementation. Collaboration between international trauma institutions is essential for closing the educational resource inequality gap between higher- and lower-income countries.

Protocol for a prospective cohort study of open tibia fractures in Malawi with a nested implementation of open fracture guidelines

Background: Road traffic injury (RTI) is the largest cause of death amongst 15-39-year-old people worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in Malawi. This study aims to investigate disability and economic outcomes of people with open tibia fractures in Malawi and improve these with locally delivered implementation of open fracture guidelines. Methods: This is a prospective cohort study describing function, quality of life and economic burden of open tibia fractures in Malawi. In total, 160 participants will be recruited across six centres and will be followed-up with face-to-face interviews at six weeks, three months, six months and one year following injury. The primary outcome will be function at one year measured by the short musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an interventional bundle for all open fractures will be developed based on other implementation studies from low- and middle-income countries (LMICs). Regression analysis will be used to model and investigate associations between SMFA score and fracture severity, infection and the pre- and post-training course period. Outcome: This prospective cohort study will report patient reported outcomes from open tibia fractures in low-resource settings. Subsequent detailed evaluation of both the clinical and implementation components of the study will promote sustainability of improved open fractures management in the study sites and further scale-up of open fracture management guidelines. Ethics: Ethics approval has been obtained from the Liverpool School of Tropical Medicine and College of Medicine Research and Ethics committee.

Attracting and retaining physicians in less attractive specialties: the role of continuing medical education

BACKGROUND

Less attractive specialties in medicine are struggling to recruit and retain physicians. When properly organized and delivered, continuing medical education (CME) activities that include short courses, coaching in the workplace, and communities of practice might offer a solution to this problem. This position paper discusses how educationalists can create CME activities based on the self-determination theory that increase physicians' intrinsic motivation to work in these specialties.

MAIN CONTENT

The authors propose a set of guidelines for the design of CME activities that offer physicians meaningful training experiences within the limits of the available resources and support. First, to increase physicians' sense of professional relatedness, educationalists must conduct a learner needs assessment, evaluate CME's long-term outcomes in work-based settings, create social learning networks, and involve stakeholders in every step of the CME design and implementation process. Moreover, providing accessible, practical training formats and giving informative performance feedback that authentically connects to learners' working life situation increases physicians' competence and autonomy, so that they can confidently and independently manage the situations in their practice contexts. For each guideline, application methods and instruments are proposed, making use of relevant literature and connecting to the self-determination theory.

CONCLUSIONS

By reducing feelings of professional isolation and reinforcing feelings of competence and autonomy in physicians, CME activities show promise as a strategy to recruit and retain physicians in less attractive specialties.

Participants' perception of the AIIMS Trauma Assessment and Management (ATAM) course for management of polytrauma: A multi-institutional experience from India

BACKGROUND

In India, the mortality due to polytrauma after road traffic injuries is high and there is a need to train medical and paramedical personnel. The AIIMS Trauma Assessment and Management (ATAM) course was developed at the Apex Trauma Centre of All India Institute of Medical Sciences, New Delhi to sensitize medical personnel with initial assessment and management of polytrauma victims. The aim of this study was to evaluate the impact on knowledge and skills and also evaluate the feedback and the perception of the participants of the ATAM course.

METHODS

The course was conducted for doctors, nurses and other paramedical/allied professionals in five tertiary level centres associated to medical colleges from geographically diverse locations (Anand, Bengaluru, Delhi, Lucknow and Thrissur). Cognitive knowledge was assessed using pre-training and post-training multiple choice question (MCQ) tests. The participants also self-rated their level of knowledge, skill, confidence and capability (Numerical rating scale of 1-10). Post-training feedback was obtained from the participants using a five-point Likert scale response.

RESULTS

26 ATAM courses were conducted by 68 course instructors and attended by 780 participants. These participants include 40.4% doctors, 44.2% nurses, 4.7% paramedical technicians, 4.2% medical students and 6.4% paramedical and allied health professionals. There was significant improvement (p < 0.0001) in the cognitive knowledge, skill, confidence and capability of the participants. 85%-86% of the participants strongly agreed or agreed that the course content was effective and 85% of participants perceived that the course was excellent or very good.

CONCLUSION

The ATAM course had a positive impact on the knowledge, skills, confidence and capability of health caregivers attending the course. The ATAM course is an effective, practical and favourable option that is tailored to the polytrauma training needs of India. We recommend widespread dissemination of this course.

WITHDRAWN: Participants' perception of the AIIMS Trauma Assessment and Management (ATAM) course for management of polytrauma due to road traffic injuries: A multi-institutional experience from India

OBJECTIVE

In India, the mortality due to polytrauma after road traffic injuries is high and there is a need to train medical and paramedical personnel. The AIIMS Trauma Assessment and Management (ATAM) course was developed at the Apex Trauma Centre of All India Institute of Medical Sciences, New Delhi to sensitize medical personnel with initial assessment and management of polytrauma victims. The aim of this study was to evaluate the impact on knowledge and skills and also evaluate the feedback and the perception of the participants of the ATAM course.

METHODS

The course was conducted for doctors, nurses and other paramedical/allied professionals in five tertiary level centres associated to medical colleges from geographically diverse locations (Anand, Bengaluru, Delhi, Lucknow and Thrissur). Cognitive knowledge was assessed using pre-training and post-training multiple choice question (MCQ) tests. The participants also self-rated their level of knowledge, skill, confidence and capability (Numerical rating scale of 1-10). Post-training feedback was obtained from the participants using a five-point Likert scale response.

RESULTS

26 ATAM courses were conducted by 68 course instructors and attended by 780 participants. These participants include 40.4% doctors, 44.2% nurses, 4.7% paramedical technicians, 4.2% medical students and 6.4% paramedical and allied health professionals. There was significant improvement (p < 0.0001) in the cognitive knowledge, skill, confidence and capability of the participants. 85%-86% of the participants strongly agreed or agreed that the course content was effective and 85% of participants perceived that the course was excellent or very good.

CONCLUSION

The ATAM course had a positive impact on the knowledge, skills, confidence and capability of health caregivers attending the course. The ATAM course is an effective, practical and favourable option that is tailored to the polytrauma training needs of India. We recommend widespread dissemination of this course.