Prehospital care training in a rapidly developing economy: a multi-institutional study

The Current Status and Challenges of Prehospital Trauma Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

This review aims to understand the present circumstances on the provision of prehospital trauma care in low- and middle-income countries (LMICs), particularly scoping the challenges experienced by LMICs in this regard. The objective is to systematically evaluate the currently available evidence on this topic. Based on the themes and challenges identified in the provision of prehospital trauma care in LMICs, we provide a series of recommendations and a knowledge base for future research in the field.

METHODS

A systematic database search was conducted of original articles that explored and reported on prehospital trauma care in LMIC in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to March 2022. All original articles reporting on prehospital trauma care from 2010 to 2022 in LMICs were assessed, excluding case reports, small case series, editorials, abstracts, and pre-clinical studies; those with data inconsistencies that impede data extraction; and those with study populations fewer than ten.

RESULTS

The literature search identified 2,128 articles, of which 29 were included in this review, featuring 27,848 participants from LMICs countries. Four main areas of focus within the studies were identified: (1) exploring emergency service systems, frameworks, and interconnected networks within the context of prehospital trauma care; (2) transportation of patients from the response site to hospital care; (3) medical education and the effects of first responder training in LMICs; and (4) cultural and social factors influencing prehospital trauma care-seeking behaviors. Due to overarching gaps in social and health care systems, significant barriers exist at various stages of providing prehospital trauma care in LMICs, particularly in injury identification, seeking treatment, transportation to hospital, and receiving timely treatment and post-intervention support.

CONCLUSION

The provision of prehospital trauma care in LMICs faces significant barriers at multiple levels, largely dependent on wider social, geographic, economic, and political factors impeding the development of such higher functioning systems within health care. However, there have been numerous breakthroughs within certain LMICs in different aspects of prehospital trauma care, supported to varying degrees by international initiatives, that serve as case studies for widespread implementation and targets. Such experiential learning is essential due to the heterogenous landscapes that comprise LMICs.

Prehospital care for traumatic spinal cord injury by first responders in 8 sub-Saharan African countries and 6 other low- and middle-income countries: A scoping review

INTRODUCTION

Traumatic spinal cord injury (TSCI) constitutes a considerable portion of the global injury burden, disproportionately affecting low- and middle-income countries (LMICs). Prehospital care can address TSCI morbidity and mortality, but emergency medical services are lacking in LMICs. The current standard of prehospital care for TSCI in sub-Saharan Africa and other LMICs is unknown.

METHODS

This review sought to describe the state of training and resources for prehospital TSCI management in sub-Saharan Africa and other LMICs. Articles published between 1 January 1995 and 1 March 2020 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for TSCI. Two reviewers assessed full texts meeting inclusion criteria for quality using the Newcastle-Ottawa Scale and extracted relevant characteristics to assess trends in the state of prehospital TSCI care in sub-Saharan Africa and other LMICs.

RESULTS

Of an initial 482 articles identified, 23 met inclusion criteria, of which ten were set in Africa, representing eight countries. C-spine immobilization precautions for suspected TSCI patients is the most prevalent prehospital TSCI intervention for and is in every LMIC first responder program reviewed, except one. Numerous first responder programs providing TSCI care operate without C-collar access (n = 13) and few teach full spinal immobilization (n = 5). Rapid transport is most frequently reported as the key mortality-reducing factor (n = 11). Despite more studies conducted in the Southeast Asia/Middle East (n = 13), prehospital TSCI studies in Africa are more geographically diverse, but responder courses are shorter, produce fewer professional responders, and have limited C-collar availability.

DISCUSSION

Deficits in training and resources to manage TSCI highlights the need for large prospective trials evaluating alternative C-spine immobilization methods for TCSI that are more readily available across diverse LMIC environments and the importance of understanding resource variability to sustainably improve prehospital TSCI care.

Developing sustainable prehospital trauma education in Rwanda

Introduction

Every year, >5 million people worldwide die from trauma. In Kigali, Rwanda, 50% of prehospital care provided by SAMU, the public prehospital system, is for trauma. Our collaboration developed and implemented a context-specific, prehospital Emergency Trauma Care Course (ETCC) and train-the-trainers program for SAMU, based on established international best practices.

Methods

A context-appropriate two-day ETCC was developed using established best practices consisting of traditional 30-minute lectures followed by 20-minute practical scenario-based team-driven simulation sessions. Also, hands-on skill sessions covered intravenous access, needle thoracostomy and endotracheal intubation among others. Two cohorts participated — SAMU staff who would form an instructor core and emergency staff from ten district, provincial and referral hospitals who are likely to respond to local emergencies in the community. The instructor core completed ETCC 1 and a one-day educator course and then taught the second cohort (ETCC2). Pre and post course assessments were conducted and analyzed using Student's t-test and matched paired t-tests.

Results

ETCC 1 had 17 SAMU staff and ETCC 2 had 19 hospital staff. ETCC 1 mean scores increased from 40% to 63% and ETCC 2 increased from 41% to 78% after the course (p < 0.001 using matched pair analysis). A one-way ANOVA mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores, F (1) = 15.18, p = 0.0004.

Discussion

This study demonstrates effective implementation of a context-appropriate prehospital trauma training program for prehospital staff in Kigali, Rwanda. The course resulted in improved knowledge for an instructor core and for staff from district and provincial hospitals confirming the effectiveness of a train-the-trainers model. This program may be effective to support capacity development for prehospital trauma care in the country using a qualified local source of instructors.

Critical Appraisal of Traumatic Brain Injury and Its Management

Critical appraisal of traumatic brain injury (TBI) management has always been marred with a conflict of differential approaches, with claims and counterclaims of outcomes among the research groups. We performed this study to review the management of TBI from risk factors to outcomes including the comorbidities and final clinical status. In conjunction with the aforesaid stabilization of TBI cases, prophylactic and definitive surgical approaches and other supporting interventions will ultimately decide the final outcomes in the long run. Improvements in the quality of care for patients with severe TBI, with the reduction in mortality, have been demonstrated in high-income areas due to improvements in the health care system and not just in one isolated intervention. In the management of TBI, a fast and high index of suspicion is the key to success, from the initial assessment to the final rehabilitation of the cases, from the victim of risk factors to the victims of situation. The research groups feel that TBI prophylactic measures and primary care mitigation models are as important as definitive care, starting from prehospital care to dedicated care.

Prehospital notification of injured patients presenting to a trauma centre in India: a prospective cohort study

OBJECTIVES

To assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes.

DESIGN

Longitudinal prospective cohort study with preintervention and postintervention cohorts.

SETTING

Major trauma centre in India.

PARTICIPANTS

Injured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories.

INTERVENTION

A prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality.

RESULTS

Data from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (p<0.001). After the intervention, more patients were managed with a trauma call-out (relative risk (RR) 1.30; 95% CI: 1.10 to 1.52); a trauma bay was ready for more patients (RR 1.47; 95% CI: 1.05 to 2.05) and a trauma team leader present for more patients (RR 1.50; 95% CI: 1.07 to 2.10). There was no difference in time to the initial chest X-ray (p=0.45). There was no association with mortality at hospital discharge (RR 0.94; 95% CI: 0.72 to 1.23), but the intervention was associated with significantly less risk of patients dying in the ED (RR 0.11; 95% CI: 0.03 to 0.39).

CONCLUSIONS

The prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India.

TRIAL REGISTRATION NUMBER

NCT02877342.

Designing and implementing a practical prehospital emergency trauma care curriculum for lay first responders in Guatemala

Background

Injury disproportionately affects low-income and middle-income countries, yet robust emergency medical services are often lacking to effectively address the prehospital injury burden. A half-day prehospital emergency trauma care curriculum was designed for first responders and piloted in the Sacatepéquez, Chimaltenango, and Escuintla departments in Guatemala.

Methods

Three hundred and fifty-four law enforcement personnel, firefighters, and civilians volunteered to participate in a 5-hour emergency care course teaching scene safety, triage, airway management, cardiopulmonary resuscitation, fracture management, and victim transport. A validated 26-question pretest/post-test study instrument was contextually adapted and used to measure overall test performance, the primary study outcome, as well as test performance stratified by occupation, the secondary study outcome. Pretest/post-test score distributions were compared using a Wilcoxon signed-rank test. For test evaluation, knowledge acquisition on a by-question and by-category basis was examined using McNemar’s χ² test, whereas item difficulty indices used frequency-of-distribution tests and item discrimination indices used point biserial correlation.

Results

Two hundred and eighty-seven participants qualified for inclusion. Participant mean pretest versus post-test scores improved 24 percentage points after course completion (43% vs 68%, p<0.001). Cronbach’s alpha yielded values of 0.86 (pretest) and 0.94 (post-test), suggesting testing instrument reliability. Between-group analyses demonstrated law enforcement and civilian participants improved more than firefighters (p<0.001). Performance on 23 of 26 questions improved significantly. All test questions except one showed an increase in their PPDI.

Discussion

A 1-day, contextually adapted, 5-hour course targeting laypeople demonstrates significant improvements in emergency care knowledge. Future investigations of similar curricula should be trialed in alternate low-resource settings with increased civilian participation to evaluate efficacy and replicability as adequate substitutes for longer courses. This study suggests future courses teaching emergency care for lay first responders may be reduced to 5 hours duration.

Level of evidence

Level II.

Impact of a postcrash first aid educational program on knowledge, perceived skills confidence, and skills utilization among traffic police officers: a single-arm before-after intervention study

Background

An overwhelming proportion of road traffic deaths and injuries in low- and middle-income countries (LMICs) occur in prehospital environments. Lay first responders such as police officers play an important role in providing initial assistance to victims of road traffic injuries either alone or in collaboration with others. The present study evaluated a postcrash first aid (PFA) educational program developed for police officers in Tanzania.

Method

A 16-h PFA educational program was conducted in Dar es Salaam, Tanzania, for 135 police officers. Participants completed training surveys before, immediately and 6 months after the training (before, N = 135; immediately after, N = 135; after 6 months, N = 102). The primary outcome measures were PFA knowledge, perceived skills confidence, and skills utilization. Parametric and nonparametric tests were used to analyse changes in outcome.

Results

The mean PFA knowledge score increased from 44.73% before training (SD = 20.70) to 72.92% 6 months after training (SD = 18.12), p < .001, N = 102. The mean PFA perceived skills confidence score (measured on a 1–5 Likert scale) increased from 1.96 before training (SD = 0.74) to 3.78 6 months after training (SD = 0.70), p < .001, N = 102. Following training, application of the recovery position skill (n = 42, 46%) and application of the bleeding control skill (n = 45, 49%) were reported by nearly half of the responding officers. Less than a quarter of officers reported applying head and neck immobilization skills (n = 20, 22%) following training.

Conclusion

A PFA educational program has shown to improve police officers’ knowledge and perceived skills confidence on provision of first aid. However qualitative research need to be conducted to shed more light regarding reasons for low utilization of trained first aid skills during follow-up.

SOSAS Study in Rural India: Using Accredited Social Health Activists as Enumerators

BACKGROUND

Global estimates show five billion people lack access to safe, quality, and timely surgical care. The wealthiest third of the world's population receives approximately 73.6% of the world's total surgical procedures while the poorest third receives only 3.5%. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey and the feasibility of using Accredited Social Health Activists (ASHAs) as enumerators.

MATERIAL AND METHODS

Data were collected in June and July 2015 in Nanakpur, Haryana from 50 households with the support of Indian community health workers, known as ASHAs. The head of household provided demographic data; two household members provided personal surgical histories. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem in which the respondent did not access care.

RESULTS

One hundred percent of selected households participated, totaling 93 individuals. Twenty-eight people (30.1%; 95% CI 21.0-40.5) indicated they had a current surgical need in the following body regions: 2 face, 1 chest/breast, 1 back, 3 abdomen, 4 groin/genitalia, and 17 extremities. Six individuals had an unmet surgical need (6.5%; 95% CI 2.45%-13.5%).

CONCLUSIONS

This pilot study in Nanakpur is the first implementation of the SOSAS survey in India and suggests a significant burden of surgical disease. The feasibility of employing ASHAs to administer the survey is demonstrated, providing a potential use of the ASHA program for a future countrywide survey. These data are useful preliminary evidence that emphasize the need to further evaluate interventions for strengthening surgical systems in rural India.

Public health crisis of road traffic accidents in India: Risk factor assessment and recommendations on prevention on the behalf of the Academy of Family Physicians of India

Roads are considered a sign of development bringing colossal benefits to community as socioeconomic and logistic facilitator. Yet, growth of road network has brought road crashes leading to civic pain from premature deaths of productive age group. In 2017, 16 citizens were killed and 53 injured every hour on Indian roads as per officially reported data, while a fair number go unreported. This is unacceptably high when compared with international standards. Risk correlates of road traffic injuries (RTIs) need to be redefined so as to form a continuum with other confounding factors that impact to take lives on road. Risk factors impacting RTIs vary from human components to the roles and responsibilities of healthcare stakeholders. We should have made roads safer for all citizens because a large percentage of population – children, pedestrians, cyclists, motorcyclists, and the elderly – are most vulnerable. A taskforce was set up by the Academy of Family Physicians of India to scientifically analyze the literature available to assess risks and put forward appropriate recommendations.