Pathways to care: a case study of traffic injury in Vietnam

Background
Traffic injuries place a significant burden on mortality, morbidity and health services worldwide. Qualitative factors are important determinants of health but they are often ignored in the study of injury and corresponding development of prehospital Emergency Medical Services (EMS), especially in developing country settings. Here we report our research on sociocultural factors shaping pathways to hospital care for those injured on the roads and streets of Vietnam.

Methods
Qualitative fieldwork on pathways to emergency care of traffic injury was carried out from March to August 2016 in four hospitals in Vietnam, two in Ho Chi Minh City and two in Hanoi. Forty-eight traffic injured patients and their families were interviewed at length using a semi-structured topic guide regarding their journey to the hospital, help received, personal beliefs and other matters that they thought important. Transcribed interviews were analysed thematically guided by the three-delay model of emergency care.

Results
Seeking care was the first delay and reflected concerns over money and possessions. The family was central for transporting and caring for the patient but their late arrival prolonged time spent at the scene. Reaching care was the second delay and detours to inappropriate primary care services had postponed the eventual trip to the hospital. Ambulance services were misunderstood and believed to be suboptimal, making taxis the preferred form of transport. Receiving care at the hospital was the third delay and both patients and families distrusted service quality. Request to transfer to other hospitals often created more conflict. Overall, sociocultural beliefs of groups of people were very influential.

Conclusions
Analysis using the three-delay model for road traffic injury in Vietnam has revealed important barriers to emergency care. Hospital care needs to improve to enhance patient experiences and trust. Socioculture affects each of the three delays and needs to inform thinking of future developments of the EMS system, especially for countries with limited resources.

Continuing Education for Prehospital Healthcare Providers in India – A Novel Course and Concept

Background
Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public–private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India.

Methods
From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide).

Lessons Learned
During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials.

Conclusion
These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

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.