Uptake of the World Health Organization's trauma care guidelines: a systematic review

Development and validation of a model to predict the need for artificial airways for acute trauma patients in the emergency department: a retrospective case-control study

OBJECTIVE

To develop scores for predicting the need for artificial airway procedures for acute trauma patients in the emergency department (ED).

DESIGN

Retrospective case-control.

SETTING

A tertiary comprehensive hospital in China.

PARTICIPANTS

8288 trauma patients admitted to the ED within 24 hours of injury and who were admitted from 1 August 2012 to 31 July 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study outcome was the establishment of an artificial airway within 24 hours of admission to the ED. Based on the different feature compositions, two scores were developed in the development cohort by multivariable logistic regression. The predictive performance was assessed in the validation cohort.

RESULTS

The O-SPACER (Oxygen saturation, Systolic blood pressure, Pulse rate, Age, Coma Scale, Eye response, Respiratory rate) score was developed based on the patient's basic information with an area under the curve (AUC) of 0.85 (95% CI 0.80 to 0.89) in the validation group. Based on the basic information and trauma scores, the IO-SPACER (Injury Severity Score, Oxygen saturation, Systolic blood pressure, Pulse rate, Age, Coma Scale, Eye response, Respiratory rate) score was developed, with an AUC of 0.88 (95% CI 0.84 to 0.92). According to the O-SPACER and IO-SPACER scores, the patients were stratified into low, medium and high-risk groups. According to these two scores, the high-risk patients were associated with an increased demand for artificial airways, with an OR of 40.16-40.67 compared with the low-risk patients.

CONCLUSIONS

The O-SPACER score provides risk stratification for injured patients requiring urgent airway intervention in the ED and may be useful in guiding initial management. The IO-SPACER score may assist in further determining whether the patient needs planned intubation or tracheotomy early after trauma.

The emergency burden in low and middle-income countries

Injuries are the greatest single cause of surgical disease globally, disproportionately affecting low and middle-income countries and representing 10% of global mortality and 32% greater annual mortality than HIV/AIDS, tuberculosis, and malaria combined. Road traffic injuries are the single greatest contributor to the global injury burden and the leading cause of death for young people aged 5 to 29 years. In May 2023, the 76th World Health Assembly resolved that emergency, critical, and operative care services are an integral part of a comprehensive national primary health care approach and foundational for health systems to effectively address emergencies. However, robust trauma systems and emergency medical services are lacking in low and middle-income countries to adequately address the prehospital injury burden in systematic and financially sustainable approaches, despite the disproportionate burden faced. Replicating formal Tier 2 emergency medical services (staffed by professional emergency responders within well-defined jurisdictions using dedicated vehicles and equipment) from high-income countries has failed, and the World Health Organization recommends Tier 1 systems (community bystander-driven prehospital care by provided by lay first responders) as the first step toward formal emergency medical services in these same settings. The Global Prehospital Consortium has identified 7 priority areas as a framework for future emergency medical services development, forming the basis for the remaining articles in this series, spanning infrastructure and operations, communication, education/training, impact evaluation, financing, governance/legal, and transportation/equipment.

Preventable trauma deaths in the Western Cape of South Africa: A consensus-based panel review

Injury causes 4.4 million deaths worldwide annually. 90% of all injury-related deaths occur in low-and-middle income countries. Findings from expert-led trauma death reviews can inform strategies to reduce trauma deaths. A cohort of trauma decedents was identified from an on-going study in the Western Cape Province of South Africa. For each case, demographics, injury characteristics, time and location of death and postmortem findings were collected. An expert multidisciplinary panel of reviewed each case, determined preventability and made recommendations for improvement. Analysis of preventable and non-preventable cases was performed using Chi-square, Fisher's exact, and Wilcoxon signed rank tests. A rapid qualitative analysis of recommendations was conducted and descriptively summarized. 138 deaths (48 deceased-on-scene and 90 pre- or in-hospital deaths) were presented to 23 panelists. Overall, 46 (33%) of deaths reviewed were considered preventable or potentially preventable. Of all pre- and in-hospital deaths, late deaths (>24 hours) were more frequently preventable (22, 56%) and due to multi-organ failure and sepsis, compared to early deaths (≤24 hours) with 32 (63%) that were non-preventable and due to central nervous system injury and haemorrhage. 45% of pre and in-hospital deaths were preventable or potentially preventable. The expert panel recommended strengthening community based primary prevention strategies for reducing interpersonal violence alongside health system improvements to facilitate high quality care. For the health system the panel's key recommendations included improving team-based care, adherence to trauma protocols, timely access to radiology, trauma specialists, operative and critical care.

Perceived trauma nursing core competency, interprofessional collaborative competency, and associated barriers among regional trauma center nurses

INTRODUCTION

As key members of interprofessional teams working in complex settings, nurses in trauma centers require trauma nursing core competency.

PURPOSE

This study sought to determine the levels and relationships of the perceived importance and performance of trauma nursing core competency, as well as the interprofessional collaborative competency and associated barriers among Korean regional trauma center nurses.

METHODS

This cross-sectional, descriptive, and correlational survey involved a convenience sample of 190 Korean trauma center nurses. Data were collected using a web-based self-reporting questionnaire about the perceived importance and performance of trauma nursing core competency, as well as the interprofessional collaborative competency and associated barriers. Data were analyzed using descriptive statistics, Pearson's correlation, and multiple regression (Enter method) analyses.

RESULTS

The perceived performance and importance of interprofessional collaborative competency, the perceived importance of trauma nursing core competency, and the perceived barriers to resources, training, competency, and interest significantly affected trauma nursing core competency performance, accounting for 64.5 % of the variance.

CONCLUSIONS

Training programs are needed to improve the core and interprofessional collaborative competencies of trauma nurses. Individual, team, and organizational approaches are essential to addressing the perceived barriers. The effects of training programs on the core competency of trauma nurses should be validated.

Establishing Consensus on Essential Resources for Musculoskeletal Trauma Care Worldwide: A Modified Delphi Study

BACKGROUND

Despite evidence that formalized trauma systems enhance patient functional outcomes and decrease mortality rates, there remains a lack of such systems globally. Critical to trauma systems are the equipment, materials, and supplies needed to support care, which vary in availability regionally. The purpose of the present study was to identify essential resources for musculoskeletal trauma care across diverse resource settings worldwide.

METHODS

The modified Delphi method was utilized, with 3 rounds of electronic surveys. Respondents consisted of 1 surgeon with expertise in musculoskeletal trauma per country. Participants were identified with use of the AO Trauma, AO Alliance, Orthopaedic Trauma Association, and European Society for Trauma and Emergency Surgery networks. Respondents rated resources on a Likert scale from 1 (most important) to 9 (least important). The "most essential" resources were classified as those rated ≤2 by ≥75% of the sampled group.

RESULTS

One hundred and three of 111 invited surgeons completed the first survey and were included throughout the subsequent rounds (representing a 93% response rate). Most participants were fellowship-trained (78%) trauma and orthopaedic surgeons (90%) practicing in an academic setting (62%), and 46% had >20 years of experience. Respondents represented low-income and lower-middle-income countries (LMICs; 35%), upper-middle income countries (UMICs; 30%), and high-income countries (HICs; 35%). The initial survey identified 308 unique resources for pre-hospital, in-hospital, and post-hospital phases of care, of which 71 resources achieved consensus as the most essential. There was a significant difference (p < 0.0167) in ratings between income groups for 16 resources, all of which were related to general trauma care rather than musculoskeletal injury management.

CONCLUSIONS

There was agreement on a core list of essential musculoskeletal trauma care resources by respondents from LMICs, UMICs, and HICs. All significant differences in resource ratings were related to general trauma management. This study represents a first step toward establishing international consensus and underscores the need to prioritize resources that are locally available. The information can be used to develop effective guidelines and policies, create best-practice treatment standards, and advocate for necessary resources worldwide.

CLINICAL RELEVANCE

This study utilized the Delphi method representing expert opinion; however, this work did not examine patient management and therefore does not have a clinical Level of Evidence.

Reducing the incidence and mortality of traumatic brain injury in Latin America

Traumatic brain injury (TBI) represents a considerable portion of the global injury burden. The incidence of TBI will continue to increase in view of an increase in population density, an aging population, and the increased use of motor vehicles, motorcycles, and bicycles. The most common causes of TBI are falls and road traffic injuries. Deaths related to road traffic injury are three times higher in low-and middle-income countries (LMIC) than in high-income countries (HIC). The Latin American Caribbean region has the highest incidence of TBI worldwide, primarily caused by road traffic injuries. Data from HIC indicates that road traffic injuries can be successfully prevented through concerted efforts at the national level, with coordinated and multisector responses to the problem. Such actions require implementation of proven measures to address the safety of road users and the vehicles themselves, road infrastructure, and post-crash care. In this review, we focus on the epidemiology of TBI in Latin America and the implementation of solutions and preventive measures to decrease mortality and long-term disability.

Burden, risk factors, neurosurgical evacuation outcomes, and predictors of mortality among traumatic brain injury patients with expansive intracranial hematomas in Uganda: a mixed methods study design

BACKGROUND

Expansive intracranial hematomas (EIH) following traumatic brain injury (TBI) continue to be a public health problem in Uganda. Data is limited regarding the neurosurgical outcomes of TBI patients. This study investigated the neurosurgical outcomes and associated risk factors of EIH among TBI patients at Mulago National Referral Hospital (MNRH).

METHODS

A total of 324 subjects were enrolled using a prospective cohort study. Socio-demographic, risk factors and complications were collected using a study questionnaire. Study participants were followed up for 180 days. Univariate, multivariable, Cox regression analyses, Kaplan Meir survival curves, and log rank tests were sequentially conducted. P-values of < 0.05 at 95% Confidence interval (CI) were considered to be statistically significant.

RESULTS

Of the 324 patients with intracranial hematomas, 80.6% were male. The mean age of the study participants was 37.5 ± 17.4 years. Prevalence of EIH was 59.3% (0.59 (95% CI: 0.54 to 0.65)). Participants who were aged 39 years and above; PR = 1.54 (95% CI: 1.20 to 1.97; P = 0.001), and those who smoke PR = 1.21 (95% CI: 1.00 to 1.47; P = 0.048), and presence of swirl sign PR = 2.26 (95% CI: 1.29 to 3.95; P = 0.004) were found to be at higher risk for EIH. Kaplan Meier survival curve indicated that mortality at the 16-month follow-up was 53.4% (95% CI: 28.1 to 85.0). Multivariate Cox regression indicated that the predictors of mortality were old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having GOS < 3, QoLIBRI < 50, SDH, contusion, and EIH.

CONCLUSION

EIH is common in Uganda following RTA with an occurrence of 59.3% and a 16-month higher mortality rate. An increased age above 39 years, smoking, having severe systemic disease, and the presence of swirl sign are independent risk factors. Old age, MAP above 95 mmHg, low GCS, complications such as infection, spasticity, wound dehiscence, CSF leaks, having a GOS < 3, QoLIBRI < 50, ASDH, and contusion are predictors of mortality. These findings imply that all patients with intracranial hematomas (IH) need to be monitored closely and a repeat CT scan to be done within a specific period following their initial CT scan. We recommend the development of a protocol for specific surgical and medical interventions that can be implemented for patients at moderate and severe risk for EIH.

Computer-interpretable guidelines: electronic tools to enhance the utility of thyroid nodule clinical practice guidelines and risk stratification tools

Clinicians seeking guidance for evaluating and managing thyroid nodules currently have several resources. The principal ones are narrative clinical guidelines and clinical risk calculators. This paper will review the strengths and weaknesses of both. The paper will introduce a concept of computer interpretable guideline, a novel way of transforming narrative guidelines in to a clinical decision support tool that can provide patient specific recommendations at the point of care. The paper then describes an experience of developing an interactive web based computer interpretable guideline for thyroid nodule management, called Thyroid Nodule Management App (TNAPP). The advantages of this approach and the potential barriers for widespread adaptation are discussed.

Standardization of Trauma, General Surgical Morbidity and Mortality Conferences: Development and Dissemination of a "Toolkit" in Peru

BACKGROUND

Morbidity and Mortality (M&M) conferences allow clinicians to review adverse events and identify areas for improvement. There are few reports of structured M&M conferences in low- and middle-income countries and no report of collaborative efforts to standardize them.

METHODS

The present study aims to gather general surgeons representing most of Peru's urban surgical care and, in collaboration, with trauma quality improvement experts develop a M&M conferences toolkit with the expectation that its diffusion impacts their reported clinical practice. Fourteen general surgeons developed a toolkit as part of a working group under the auspices of the Peruvian General Surgery Society. After three years, we conducted an anonymous written questionnaire to follow-up previous observations of quality improvement practices.

RESULTS

A four-component toolkit was developed: Toolkit component #1: Conference logistics and case selection; Toolkit component #2: Documenting form; Toolkit component #3: Presentation template; and Toolkit component #4: Code of conduct. The toolkit was disseminated to 10 hospitals in 2016. Its effectiveness was evaluated by comparing the results of surveys on quality improvement practices conducted in 2016, before toolkit dissemination (101 respondents) and 2019 (105 respondents). Lower attendance was reported by surgeons in 2019. However, in 2019, participants more frequently described "improve the system" as the perceived objective of M&M conferences (70.5% vs. 38.6% in 2016; p < 0.001).

CONCLUSION

We established a toolkit for the national dissemination of a standardized M&M conference. Three years following the initial assessment in Peru, we found similar practice patterns except for increased reporting of "system improvement" as the goal of M&M conferences.

Research on skull trauma biomechanical stress distribution in case of dental implants existence

BACKGROUND: When the jaw bone is subjected to an external force, the stress is transmitted from the force point along the alveolar bone to the skull and skull base. In the case of a dental implant, the stress distribution is mainly dependent on the implant position, type, and mechanical properties. OBJECTIVE: To investigate the dental implant position influence on the stress distribution and transmission in case of facial frontal trauma. Furthermore, the correlation between facial trauma and skull trauma in the case of a dental implant exists. METHODS: In this study, a Finite Element Method (FEM) model was constructed based on a real skull shape, size, and anatomy. Dental implants were modeled based on imported CAD Data. Five cases were investigated including no dental implant and the replacement of teeth no. 18, 19 20 and 21. Facial trauma was mimicked by applying an external load on the lower frontal jaw. Finally, the stress distribution based on the bone geometry and implant position were evaluated and compared. RESULTS: Results suggested that a dental implant could significantly influence the stress distribution in the skull in case of facial trauma. In addition, the dental position greatly affects stress transmission from the mandible to the skull bones through the zygomatic arch. CONCLUSION: The position of the dental implant could have a significant role in stress transmission and distribution in case of facial or even brain trauma. Thus, increasing the possibility of a correlation between facial and brain trauma.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Implementation of the World Health Organization Global Burn Registry: Lessons Learned

Burn injuries are a major cause of death and disability globally; however, the true epidemiologic burden is underestimated given the limited and fragmented availability of high-quality burn injury data from many regions. To address this gap, the World Health Organization (WHO) Global Burn Registry (GBR)—a minimum dataset aligned with a centralized registry—was officially launched in 2018 to facilitate hospital-level collection of key prevention, care, and outcome data from burn-injured patients around the world in a standardized manner. However, uptake and use of GBR has been low and inconsistent. Therefore, we aimed to identify and understand the barriers and facilitators to the implementation of the GBR to inform the development of a web-based GBR implementation guide through the Centre for Global Burn Injury Policy and Research and Interburns. We designed and conducted web-based surveys with “GBR users” and “GBR non-users” using purposive sampling. Themes of identified barriers and facilitators focused on awareness of the GBR, stakeholder buy-in, resource constraints, process management, and utility of the registry. The lessons learned could support current and future GBR users to promote and maximize the use of the GBR. To achieve the GBR’s full potential in global burn injury prevention and care, engagement with the GBR should be enhanced through education and promotion, development of a community of practice, tools for data utilization and quality improvement, and periodic re-evaluation.

Pediatric traumatic brain injury prehospital guidelines: a systematic review and appraisal

BACKGROUND

Traumatic brain injury (TBI) disproportionately affects children within low- and middle-income countries (LMICs). Prehospital emergency care can mitigate secondary brain injury and improve outcomes. Here, we systematically review clinical practice guidelines (CPGs) for pediatric TBI with the goal to inform LMICs prehospital care.

METHODS

A systematic search was conducted in PubMed/Medline, Embase, and Web of Science databases. We appraised evidence-based CPGs addressing prehospital management of pediatric TBI using the Appraisal of Guidelines for Research & Evaluation (AGREE) tool. CPGs were rated as high-quality if ≥ 5 (out of 6) AGREE domains scored > 60%.

RESULTS

Of the 326 articles identified, 10 CPGs were included in analysis. All 10 were developed in HICs, and 4 were rated as high-quality. A total of 154 pediatric prehospital recommendations were grouped into three subcategories, initial assessment (35.7%), prehospital treatment (38.3%), and triage (26.0%). Of these, 79 (51.3%) were evidence-based with grading, and 31 (20.1%) were consensus-based without direct evidence.

CONCLUSION

Currently available CPGs for prehospital pediatric TBI management were all developed in HICs. Four CPGs have high-quality, and recommendations from these can serve as frameworks for LMICs or resource-limited settings. Context-specific evaluation and implementation of evidence-based recommendations allow LMIC settings to respond to the public health crisis of pediatric TBI and address gaps in trauma care systems.

Identifying a 'super-responder' phenomenon in three African countries: Implications for prehospital emergency care training

BACKGROUND

Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The WHO recommends training lay first responders (LFRs) as the first step toward EMS development while Disease Control Priorities (DCP) suggests training 0.5%-1% of a population for adequate emergency catchment. After launching three LFR programs in Africa, this study investigated subsequent skill usage and conducted demographic analyses to inform future recruitment of high-responding LFRs.

METHODS

Demographic characteristics and individual LFR intervention frequencies were collected from a pooled sample of 887 of 1,291 total LFRs (68.7%) trained across programs launched in a staggered fashion between 2016-2019 in Uganda, Chad, and Sierra Leone. A Kruskal-Wallis Rank-Sum test assessed between-group differences among demographics in each location. Spearman's r was used to determine the relationship between response frequency and LFR characteristics.

RESULTS

Most LFRs trained did not use skills post-training (median LFR interventions=0.0 interventions/year [IQR:0.0,5.0]). Right-skewed intervention frequency distributions demonstrate high-responding outlier responder groups do exist in all locations (p<0.0001). Median LFR interventions of the top quartile of these active LFRs ("super-responders") was 26.0 interventions/year (IQR:16.7,35.0). "Super-responders" witnessed more road traffic injuries (RTIs) prior to training (p=0.033). LFRs who never responded were significantly younger (p=0.0020). Significant correlations were demonstrated between pooled RTIs witnessed and intervention frequency (r=0.13, p=0.032) and age and intervention frequency in Sierra Leone (r=-0.15, p=0.019).

CONCLUSION

Current DCP-recommended training of 0.5-1% of a given population for adequate emergency catchment may be an inefficient means of building emergency care capacity. Recruiting "super-responders" with select characteristics may achieve similar coverage while conserving valuable training resources in resource-limited African settings.

Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort

OBJECTIVE

Given the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania.

METHODS

A neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model.

RESULTS

In total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model.

CONCLUSIONS

The 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.

Equipos de trauma: realidad mundial e implementación en un país en desarrollo. Descripción narrativa

Introducción. El trauma es una de las entidades con mayor morbimortalidad en el mundo. Los equipos especializados en la atención del paciente traumatizado son llamados <<equipos de trauma>>. Dichos equipos surgieron de la necesidad de brindar tratamiento oportuno multidisciplinario a individuos con heridas que condicionan gran severidad en la guerra; sin embargo, con el paso del tiempo se trasladaron al ámbito civil, generando un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad. El objetivo de este estudio fue describir el proceso de desarrollo de los equipos de trauma a nivel mundial y la experiencia en nuestra institución en el suroccidente colombiano. Métodos. Se realizó una búsqueda en la base de datos PUBMED, que incluyó revisiones sistemáticas, metaanálisis, revisiones de Cochrane, ensayos clínicos y series de casos. Resultados. Se incluyeron 41 estudios para esta revisión narrativa, y se observó que el tiempo de permanencia en el Emergencias, el tiempo de traslado a cirugía, la mortalidad y las complicaciones asociadas al trauma fueron menores cuando se implementan equipos de trauma. Discusión. El diseño de un sistema de atención y valoración horizontal de un paciente con traumatismos severos produce un impacto positivo en términos de tiempos de atención, mortalidad y morbilidad. Se hace necesario establecer los parámetros operativos necesarios en las instituciones de salud de alta y mediana complejidad en nuestro país para implementar dichos equipos de trabajo.

Variations in processes for guideline adaptation: a qualitative study of World Health Organization staff experiences in implementing guidelines

BACKGROUND

The World Health Organisation (WHO) publishes a large number of clinical practice and public health guidelines to promote evidence-based practice across the world. Due to the variety of health system capacities and contextual issues in different regions and countries, adapting the recommendations in the guidelines to the local situation is vital for the success of their implementation. We aim to understand the range of experiences with guideline adaptation from the perspectives of those working in WHO regional and country offices. Our findings will inform development of guidance on how to improve adaptability of WHO guidelines.

METHODS

A grounded theory-informed, qualitative study was carried out between March 2018 and December 2018. Seventeen semi-structured interviews were conducted with participants who included WHO guideline developers and staff in the headquarters, regional and country offices recruited from a sample of published WHO guidelines. Participants were eligible for recruitment if they had recent experience in clinical practice or public health guideline implementation. Deidentified transcripts of these interview were analysed through three cycles of coding.

RESULTS

We categorised the adaptation processes described by the participants into two dominant models along a spectrum of guideline adaptation processes. First, the Copy or Customise Model is a pragmatic approach of either copying or customising WHO guidelines to suit local needs. This is done by local health authorities and/or clinicians directly through consultations with WHO staff. Selections and adjustments of guideline recommendations are made according to what the implementers deemed important, feasible and applicable through the consensus discussions. Second, the Capacity Building Model focuses on WHO building local capacity in evidence synthesis methods and adaptation frameworks to support local development of a national guideline informed by international guidelines.

CONCLUSIONS

In comparing and contrasting these two models of guideline adaptation, we outline the different kinds of support from WHO that may be necessary to improve the effectiveness and efficiency of the respective models. We also suggest clarifications in the descriptions of the process of guideline adaptation in WHO and academic literature, to help guideline adaptors and implementers decide on the appropriate course of action according to their specific circumstances.

ETHICS

This project was conducted with ethics approval from The University of Sydney (Project number: 2017/723) and WHO (Protocol ID: 00001).

Evaluation of a Lay First Responder Program in Sierra Leone as a Scalable Model for Prehospital Trauma Care

INTRODUCTION

Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The World Health Organization (WHO) recommends scaling-up lay first responder programs as the first step toward formal EMS development.

MATERIALS AND METHODS

We trained and equipped 4,529 lay first responders (LFRs) between June-December 2019 in Bombali District, Sierra Leone, with a 5-hour hands-on, contextually-adapted prehospital trauma course to cover 535,000 people. Instructors trained 1,029 LFRs and 50 local trainers in a training-of-trainers (TOT) model, who then trained an additional 3,500 LFRs. A validated, 23-question pre-/post-test measured knowledge improvement, while six- and nine-month follow-up tests measured knowledge retention. Incident reports tracked patient encounters to assess longitudinal impact.

RESULTS

Median pre-/post-test scores improved by 43.5 percentage points (34.8% vs. 78.3%, p<0.0001). Knowledge retention was assessed at six months, with median score dropping to 60.9%, while at nine months, median score dropped to 43.5%. Lay first responders participating in courses led by TOT trainers had a pre-/post-test median score improvement of 30.4 percentage points (21.7% vs. 52.2%, p<0.0001). LFRs treated 1,850 patients over six months, most frequently utilizing hemorrhage control skills in 61.2% of encounters (1,133/1,850). The plurality of patients were young adult males (36.8%) and 48.7% of encounters were motorcycle injury-related.

CONCLUSION

A 5-hour first responder course targeting laypeople demonstrates significant emergency care knowledge improvement and retention. By training networks of transportation providers, lay first responder programs represent a robust and scalable prehospital emergency care alternative for low-resource settings.

Exploring the factors motivating continued Lay First Responder participation in Uganda: a mixed-methods, 3-year follow-up

BACKGROUND

The WHO recommends training lay first responders (LFRs) as the first step towards establishing emergency medical services (EMS) in low-income and middle-income countries. Understanding social and financial benefits associated with responder involvement is essential for LFR programme continuity and may inform sustainable development.

METHODS

A mixed-methods follow-up study was conducted in July 2019 with 239 motorcycle taxi drivers, including 115 (75%) of 154 initial participants in a Ugandan LFR course from July 2016, to evaluate LFR training on participants. Semi-structured interviews and surveys were administered to samples of initial participants to assess social and economic implications of training, and non-trained motorcycle taxi drivers to gauge interest in LFR training. Themes were determined on a per-question basis and coded by extracting keywords from each response until thematic saturation was achieved.

RESULTS

Three years post-course, initial participants reported new knowledge and skills, the ability to help others, and confidence gain as the main benefits motivating continued programme involvement. Participant outlook was unanimously positive and 96.5% (111/115) of initial participants surveyed used skills since training. Many reported sensing an identity change, now identifying as first responders in addition to motorcycle taxi drivers. Drivers reported they believe this led to greater respect from the Ugandan public and a prevailing belief that they are responsible transportation providers, increasing subsequent customer acquisition. Motorcycle taxi drivers who participated in the course reported a median weekly income value that is 24.39% higher than non-trained motorcycle taxi counterparts (p<0.0001).

CONCLUSIONS

A simultaneous delivery of sustained social and perceived financial benefits to LFRs are likely to motivate continued voluntary participation. These benefits appear to be a potential mechanism that may be leveraged to contribute to the sustainability of future LFR programmes to deliver basic prehospital emergency care in resource-limited settings.

Developing a Lay First Responder Program in Chad: A 12-Month Follow-Up Evaluation of a Rural Prehospital Emergency Care Program

INTRODUCTION

The World Health Organization (WHO; Geneva, Switzerland) recommends lay first responder (LFR) programs as a first step toward establishing formal Emergency Medical Services (EMS) in low- and middle-income countries (LMICs) to address injury. There is a scarcity of research investigating LFR program development in predominantly rural settings of LMICs.

STUDY OBJECTIVE

A pilot LFR program was launched and assessed over 12 months to investigate the feasibility of leveraging pre-existing transportation providers to scale up prehospital emergency care in rural, low-resource settings of LMICs.

METHODS

An LFR program was established in rural Chad to evaluate curriculum efficacy, using a validated 15-question pre-/post-test to measure participant knowledge improvement. Pre-/post-test score distributions were compared using a Wilcoxon Signed-Rank test. For test evaluation, each pre-test question was mapped to its corresponding post-test analog and compared using McNemar's Chi-Squared Test to examine knowledge acquisition on a by-question basis. Longitudinal prehospital care was evaluated with incident reports, while program cost was tracked using a one-way sensitivity analysis. Qualitative follow-up surveys and semi-interviews were conducted at 12 months, with initial participants and randomly sampled motorcycle taxi drivers, and used a constructivist grounded theory approach to understand the factors motivating continued voluntary participation to inform future program continuity. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide design, analysis, and reporting the qualitative results.

RESULTS

A total of 108 motorcycle taxi participants demonstrated significant knowledge improvement (P <.001) across three of four curricular categories: scene safety, airway and breathing, and bleeding control. Lay first responders treated 71 patients over six months, encountering five deaths, and provided patient transport in 82% of encounters. Lay first responders reported an average confidence score of 8.53/10 (n = 38). In qualitative follow-up surveys and semi-structured interviews, the ability to care for the injured, new knowledge/skills, and the resultant gain in social status and customer acquisition motivated continued involvement as LFRs. Ninety-six percent of untrained, randomly sampled motorcycle taxi drivers reported they would be willing to pay to participate in future training courses.

CONCLUSION

Lay first responder programs appear feasible and cost-effective in rural LMIC settings. Participants demonstrate significant knowledge acquisition, and after 12 months of providing emergency care, report sustained voluntary participation due to social and financial benefits, suggesting sustainability and scalability of LFR programs in low-resource settings.

Mortality due to road injuries in the states of India: the Global Burden of Disease Study 1990-2017

Background

A systematic understanding of population-level trends in deaths due to road injuries at the subnational level over time for India's 1·4 billion people, by age, sex, and type of road user is not readily available; we aimed to fill this knowledge gap.

Methods

As part of the Global Burden of Diseases, Injuries, and Risk Factors Study, we estimated the rate of deaths due to road injuries in each state of India from 1990 to 2017 based on several verbal autopsy data sources. We calculated the number of deaths and death rate for road injuries by type of road user, and assessed the age and sex distribution of these deaths over time. Based on the trends of the age-standardised death rate from 1990 to 2017, we projected the age-standardised death rate to 2030 to assess if the states of India would meet the Sustainable Development Goal (SDG) target to halve the death rate for road injuries from 2015 by 2020 or 2030. We calculated 95% uncertainty intervals (UIs) for the point estimates.

Findings

In 2017, 218 876 deaths (95% UI 201 734 to 231 141) due to road injuries occurred in India, with an age-standardised death rate for road injuries of 17·2 deaths (15·7 to 18·1) per 100 000 population, which was much higher in males (25·7 deaths [23·5 to 27·4] per 100 000) than in females (8·5 deaths [7·2 to 9·1] per 100 000). The number of deaths due to road injuries in India increased by 58·7% (43·6 to 74·7) from 1990 to 2017, but the age-standardised death rate decreased slightly, by 9·2% (0·6 to 18·3). In 2017, pedestrians accounted for 76 729 (35·1%) of all deaths due to road injuries, motorcyclists accounted for 67 524 (30·9%), motor vehicle occupants accounted for 57 802 (26·4%), and cyclists accounted for 15 324 (7·0%). India had a higher age-standardised death rate for road injury among motorcyclists (4·9 deaths [3·9–5·4] per 100 000 population) and cyclists (1·2 deaths [0·9–1·4] per 100 000 population) than the global average. Road injury was the leading cause of death in males aged 15 to 39 years in India in 2017, and the second leading cause in this age group for both sexes combined. The overall age-standardised death rate for road injuries varied by up to 2·6 times between states in 2017. Wide variations were seen between the states in the percentage change in age-standardised death rate for road injuries from 1990 to 2017, ranging from a reduction of 38·2% (22·3 to 51·7) in Delhi to an increase of 17·0% (0·6 to 34·7) in Odisha. If the trends estimated up to 2017 were to continue, no state in India or India overall would achieve the SDG 2020 target in 2020 or even in 2030.

Interpretation

India's contribution to the global number of deaths due to road injuries is increasing, and the country is unlikely to meet the SDG targets if the trends up to 2017 continue. India needs to implement evidence-based road safety interventions, promote strong policies and traffic law enforcement, have better road and vehicle design, and improve care for road injuries at the state level to meet the SDG goal.

Funding

Bill & Melinda Gates Foundation and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Utilization of injury care case studies: a systematic review of the World Health Organization's "Strengthening care for the injured: Success stories and lessons learned from around the world"

OBJECTIVE

Translation of evidence to practice is a public health priority. Worldwide, injury is a leading cause of morbidity and mortality. Case study publications are common and provide potentially reproducible examples of successful interventions in healthcare from the patient to systems level. However, data on how well case study publications are utilized are limited. To our knowledge, the World Health Organization (WHO) published the only collection of international case studies on injury care at the policy level. We aimed to determine the degree to which these injury care case studies have been translated to practice and to identify opportunities for enhancement of the evidence-to-practice pathway for injury care case studies overall.

METHODS

We conducted a systematic review across 19 databases by searching for the title, "Strengthening care for the injured: Success stories and lessons learned from around the world." Data synthesis included realist narrative methods and two authors independently reviewed articles for injury topics, reference details, and extent of utilization.

FINDINGS

Forty-seven publications referenced the compilation of case studies, 20 of which included further descriptions of one or more of the specific cases and underwent narrative review. The most common category utilized was hospital-based care (15 publications), with the example of Thailand's quality improvement (QI) programme (10 publications) being the most commonly cited case. Also frequently cited were case studies on prehospital care (10 publications). There was infrequent utilization of case studies on rehabilitation (3 publications) and trauma systems (2 publications). No reference described a case translated to a new scenario.

CONCLUSIONS

The only available collection of policy-level injury care case studies has been utilized to a moderate extent however we found no evidence of case study translation to a new circumstance. QI programs seem especially amenable for knowledge-sharing through case studies. Prehospital care also showed promise. Greater emphasis on rehabilitation and health policy related to trauma systems is warranted. There is also a need for greater methodologic rigor in evaluation of the use of case study collections in general.

Expected years of life lost through road traffic injuries in Mexico

Background: Road traffic injuries (RTIs) are a leading cause of premature mortality, mainly in low- and middle-income countries

Objective: To estimate the 2014 burden of RTIs in Mexico calculating years of life lost (YLL) and age-standardized YLL rates (ASYLL), and to evaluate sex, age, and region-related differences in premature mortality.

Methods: Mortality data were obtained from the National Institute of Statistics and Geography and 14,637 deaths of individuals 15 years of age and older were analyzed. The YLL and ASYLL were computed.

Results: The overall burden of RTIs was 332,922 YLL and 82.4% of the deaths occurred in males. Males from 25 to 34 years of age and females from 15 to 24 years of age showed the highest age-adjusted YLL rates (933 and 158 YLL per 100,000 inhabitants, respectively). The national ASYLL rate was 416 per 100,000 inhabitants and the highest state-stratified mortality rates were observed in Tabasco (851), Sinaloa (709), Durango (656), Zacatecas (642), and Baja California Sur (570).

Conclusions: RTIs contributed to the premature mortality rate in the study population. Our findings may be useful from a health policy perspective for designing and prioritizing interventions focused on the prevention of premature loss of life.

Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia

BACKGROUND

Africa accounts for one sixth of global road traffic deaths-most in the pre-hospital setting. Ambulance transport is expensive relative to other modes of pre-hospital transport, but has advantages in time-sensitive, high-acuity scenarios. Many countries, including Ethiopia, are expanding ambulance fleets, but clinical characteristics of patients using ambulances remain ill-defined.

METHODS

This is a cross-sectional study of 662 road traffic collisions (RTC) patients arriving to a single trauma referral center in Addis Ababa, Ethiopia, over 7 months. Emergency Department triage records were used to abstract clinical and arrival characteristics, including acuity. The outcome of interest was ambulance arrival. Secondary outcomes of interest were inter-facility referral and referral communication. Descriptive and multivariable statistics were computed to identify factors independently associated with outcomes.

RESULTS

Over half of patients arrived with either high (13.1%) or moderate (42.2%) acuity. Over half (59.0%) arrived by ambulance, and nearly two thirds (65.9%) were referred. Among referred patients, inter-facility communication was poor (57.7%). Patients with high acuity were most likely to be referred (aOR 2.20, 95%CI 1.16-4.17), but were not more likely to receive ambulance transport (aOR 1.56, 95%CI 0.86-2.84) or inter-facility referral communication (aOR 0.98, 95%CI 0.49-1.94) than those with low acuity. Nearly half (40.2%) of all patients were referred by ambulance despite having low acuity.

CONCLUSIONS

Despite ambulance expansion in Addis Ababa, ambulance use among RTC patients remains heavily concentrated among those with low-acuity. Inter-facility referral appears a primary contributor to low-acuity ambulance use. In other contexts, similar routine ambulance monitoring may help identify low-value utilization. Regional guidelines may help direct ambulance use where most valuable, and warrant further evaluation.

International Association for Trauma Surgery and Intensive Care (IATSIC) Presidential Address: Improving Trauma Care Globally: How is IATSIC Doing?

ABSTARCT

IATSIC is the foremost professional society addressing trauma care globally. How is it doing in meeting the needs of most injured patients? The vast majority (65 %) of trauma deaths occur in the poorer half of the world (low-income and lower-middle-income countries), where injury rates are the highest. IATSIC has accomplished a tremendous amount and has much to be proud of. However, most of its work thus far has been concentrated in the wealthier half of the world (upper-middle-income and high-income countries). For example, most of the speakers on IATSIC's biannual program are from upper-middle-income and high-income countries and most of IATSIC's courses are conducted in these countries. IATSIC's trauma systems publications have been utilized in countries at all economic levels (including many low-income and lower middle-income countries), but much more needs to be done. IATSIC'S foundation is its membership. Only 5 % of our members come from the poorer half of the world. In order to make more of a difference for the majority of injured people in the world, IATSIC needs to expand its reach to where they live. Major priorities are: (1) increase representation from low- and lower middle-income countries in our scientific program; (2) disseminate of our courses more widely; (3) increase utilization of our trauma system publications, especially for higher yield activities, such as longitudinal monitoring of trauma systems, implementation in health policy, and developing curricula for trauma care in medical schools and in post-graduate training; and (4) especially, recruit new members from low- and lower-middle-income countries.

Global Emergency Medicine: A Review of the Literature From 2016

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners.

METHODS

This year 13,890 articles written in four languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles.

RESULTS

A total of 716 articles met our inclusion criteria and underwent full review. Fifty-nine percent were categorized as emergency care in resource-limited settings, 17% as EM development, and 24% as disaster and humanitarian response. Nineteen articles received scores of 18.5 or higher out of a maximum score of 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed Cohen's kappa of 0.441.

CONCLUSIONS

In 2016, the total number of articles identified by our search continued to increase. The proportion of articles in each of the three categories remained stable. Studies and reviews with a focus on infectious diseases, pediatrics, and the use of ultrasound in resource-limited settings represented the majority of articles selected for final review.

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

INTRODUCTION

Trauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs.

METHODS

We conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru.

RESULTS

336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent - 45% occurred less than every three months and poorly attended - 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation - notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16-10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73-19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59-14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice.

CONCLUSIONS

M&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care.

Guidelines in lower-middle income countries

Guidelines include recommendations intended to optimize patient care; used appropriately, they make healthcare consistent and efficient. In most lower-middle income countries (LMICs), there is a paucity of well-designed guidelines; as a result, healthcare workers depend on guidelines developed in Higher Income Countries (HICs). However, local guidelines are more likely to be implemented because they are applicable to the specific environment; and consider factors such as availability of resources, specialized skills and local culture. If guidelines developed in HICs are to be implemented in LMICs, developers need to incorporate local experts in their development. Involvement of local stakeholders may improve the rates of implementation by identifying and removing barriers to implementation in LMICs. Another option is to encourage local experts to adapt them for use in LMICs; these guidelines may recommend strategies different from those used in HICs, but will be aimed at achieving the best practicable standard of care. Infrastructural deficits in LMICs could be improved by learning from and building on the successful response to the human immunodeficiency virus/acquired immunodeficiency syndrome pandemic through interactions between HICs and LMICs. Similarly, collaborations between postgraduate medical colleges in both HICs and LMICs may help specialist doctors training in LMICs develop skills required for guideline development and implementation.