Background: Open fractures are one of the leading causes of disability worldwide. The threshold time to debridement that reduces the infection rate is unclear.
Methods: We searched all available databases to identify observational studies and randomized trials related to open fracture care. We then conducted an extensive meta-analysis of the observational studies, using raw and adjusted estimates, to determine if there was an association between the timing of initial debridement and infection.
Results: We identified 84 studies (18,239 patients) for the primary analysis. In unadjusted analyses comparing various “late” time thresholds for debridement versus “early” thresholds, there was an association between timing of debridement and surgical site infection (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.11 to 1.49, p < 0.001, I2 = 30%, 84 studies, n =18,239). For debridement performed between 12 and 24 hours versus earlier than 12 hours, the OR was higher in tibial fractures (OR = 1.37, 95% CI = 1.00 to 1.87, p = 0.05, I2 = 19%, 12 studies, n = 2,065), and even more so in Gustilo type-IIIB tibial fractures (OR = 1.46, 95% CI =
1.13 to 1.89, p = 0.004, I2 = 23%, 12 studies, n = 1,255). An analysis of Gustilo type-III fractures showed a progressive increase in the risk of infection with time. Critical time thresholds included 12 hours (OR = 1.51, 95% CI = 1.28 to 1.78, p < 0.001, I2 = 0%, 16 studies, n = 3,502) and 24 hours (OR = 2.17, 95% CI = 1.73 to 2.72, p < 0.001, I2 = 0%, 29 studies, n = 5,214).
Conclusions: High-grade open fractures demonstrated an increased risk of infection with progressive delay to debridement.
Background. Polytrauma patients require special facilities to care for their injuries. In HICs, these patients are rapidly transferred from the scene or the frst-health facility directly to a trauma center. However, in many LMICs, prehospital systems do not exist and there are long delays between arrivals at the frst-health facility and the trauma center. We aimed to quantify the delay and determine the predictors of mortality among polytrauma patients. Methodology. We consecutively enrolled adult polytrauma patients (≥18 years) with ISS >15 referred to the Emergency Medicine Department of Muhimbili National Hospital, a major trauma center in Tanzania between August 2019 and January 2020. Based on a pilot study, the arrival of >6 hours after injury was considered a delay. Te outcome of interest was factors associated with delayed presentation and the association of timeliness with 7-day mortality. Results. We enrolled 120 (4.5%) referred polytrauma adult patients. Te median age was 30 years (IQR 25–39) and the ISS was 29 (IQR 24–34). The majority (85%) were males. While the median time from injury to frst-health facility was 40 minutes (IQR 33–50), the median time from injury to arrival at EMD-MNH, was 377 minutes (IQR 314–469). Delayed presentation was noted in more than half (54.2%) of participants, with the odds of dying being 1.4 times higher in the delayed
group (95% CI 0.3–5.6). Having a GCS <8 (AOR 16.3 (95% CI 3.1–86.3), hypoxia <92% (AOR 8.3 (95% CI 1.4–50.9), and hypotension <90 mmHg (R 7.3 (95% CI 1.6–33.6) were all independent predictors of mortality. Conclusion. Te majority of polytrauma patients arrive at the tertiary facilities delayed for more than 6 hours and a distance of more than 8 km between facilities is associated with delay. Hypotension, hypoxia, and GCS of less than 8 are independent predictors of poor outcome. In the interim, there is a need to expedite the transfer of polytrauma patients to trauma care capable centers.
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.
Background: Emergency medical services (EMS) are a critical but often overlooked component of essential public health care delivery in low- and middle-income countries (LMICs). Few countries in Africa have established EMS and there is scant literature to provide guidance for EMS growth.
Objective: This study aimed to characterize EMS utilization in Harare, Zimbabwe in order to guide system strengthening efforts.
Methods: We performed a retrospective chart review of patient care reports (PCR) generated by the City of Harare ambulance system for patients transported and/or treated in the prehospital setting over a 14-month period (February 2018 – March 2019).
Findings: A total of 875 PCRs were reviewed representing approximately 8% of the calls to EMS. The majority of patients were age 15 to 49 (76%) and 61% were female patients. In general, trauma and pregnancy were the most common chief complaints, comprising 56% of all transports. More than half (51%) of transports were for inter-facility transfers (IFTs) and 52% of these IFTs were maternity-related. Transports for trauma were mostly for male patients (63%), and 75% of the trauma patients were age 15–49. EMTs assessed and documented pulse and blood pressure for 72% of patients.
Conclusion: In this study, EMS cared primarily for obstetric and trauma emergencies, which mirrors the leading causes of premature death in LMICs. The predominance of requests for maternity-related IFTs emphasizes the role for EMS as an integral player in peripartum maternal health care. Targeted public health efforts and chief complaint-specific training for EMTs in these priority areas could improve quality of care and patient outcomes. Moreover, a focus on strengthening prehospital data collection and research is critical to advancing EMS development in Zimbabwe and the region through quality improvement and epidemiologic surveillance.
Background
Road traffic injuries (RTI) are the leading cause of death worldwide in children over 5 and adults aged 18–29. Nonfatal RTIs result in 20–50 million annual injuries. In Bangladesh, a new mechanism of RTI has emerged over the past decade known as a ‘scarf injury.’ Scarf injuries occur when scarves, part of traditional female dress, are caught in the driveshaft of an autorickshaw. The mechanism of injury results in novel, strangulation-like cervical spine trauma. This study aimed to understand the immediate emergency response, acute care pathway, and subsequent functional and health outcomes for survivors of scarf injuries.
Methods
Key informant interviews were conducted with female scarf injury survivors (n = 12), caregivers (n = 6), and health care workers (n = 15). Themes and subthemes were identified via inductive content analysis, then applied to the three-delay model to examine specific breakdowns in pre-hospital care and provide a basis for future interventions.
Findings
Over half of the scarf injury patients were between the ages of 10 and 15. All but two were tetraplegic. Participants emphasized less than optimal patient outcomes were due to unawareness of scarf injuries and spinal cord injuries among the general public and health professionals; unsafe and inefficient bystander first aid and transportation; and high cost of acute health care.
Conclusions
Females in Bangladesh are at significant risk of sustaining serious and life-threatening trauma through scarf injuries in autorickshaws, further worsened through inadequate care along the trauma care pathway. Interventions designed to increase awareness and knowledge of basic SCI care at the community and provider level would likely improve health and functional outcomes
Background
Trauma describes physical injury along with the bodies associate reponse, and is a leading cause of mortality and morbidity globally, with low and middle income countries (LMICs) disproportionately affected. Understanding the implementation of in-hospital Trauma Quality Improvement Programs (TQIPs) and the factors determining success is critical to reduce the global trauma burden. The purpose of the review was to identify key facilitators and barriers to TQIP implementation across income levels by evaluating the range of literature on the topic.
Methods
We used information sources PubMed, Web of Science, and Global Index Medicus. The eligibility criteria was English language studies, of any design, published from June 2009 – January 2022. The Preferred Reporting Items of Systematic Reviews and Meta-Analyses checklist extension for scoping reviews were used to carry out a three-stage screening process. Content analysis using the Consolidated Framework for Implementation Research (CFIR) identified facilitator and barrier themes for in-hospital TQIP implementation.
Results
Twenty-eight studies met the eligibility criteria from 3923 studies. The main facilitators and barriers identified were the need to prioritise staff education and training, strengthen dialogue with stakeholders, and provide standardised best-practice guidelines. Data quality improvements were more apparent in LMICs while high-income countries (HICs) emphasised increased communication training.
Conclusions
Stakeholder prioritisation of in-hospital TQIPs, along with increased knowledge and consensus on trauma care best practice will further advance efforts to lower the global trauma burden. The focus of future in-hospital TQIPs in LMICs should primarily be concerned with improving data quality of registries, while interventions in HICs should focus on communication skills of healthcare professionals.
Background Studies from high income countries suggest improved survival for females as compared to males following trauma. However, data regarding differences in trauma outcomes between females and males is severely lacking from low- and middle-income countries. The objective of this study was to determine the association between sex and clinical outcomes amongst Indian trauma patients using the Australia-India Trauma Systems Collaboration database.
Methods A prospective multicentre cohort study was performed across four urban public hospitals in India April 2016 through February 2018. Bivariate analyses compared admission physiological parameters and mechanism of injury. Logistic regression assessed association of sex with the primary outcomes of 30-day and 24-hour in-hospital mortality. Secondary outcomes included ICU admission, ICU length of stay, ventilator requirement, and time on a ventilator.
Results Of 8,605 patients, 1,574 (18.3%) were females. The most common mechanism of injury was falls for females (52.0%) and road traffic injury for males (49.5%). On unadjusted analysis, there was no difference in 30-day in-hospital mortality between females (11.6%) and males (12.6%, p = 0.323). However, females demonstrated a lower mortality at 24-hours (1.1% vs males 2.1%, p = 0.011) on unadjusted analysis. Females were also less likely to require a ventilator (17.3% vs 21.0% males, p = 0.001) or ICU admission (34.4% vs 37.5%, p = 0.028). Stratification by age or by ISS demonstrated no difference in 30-day in-hospital mortality for males vs females across age and ISS categories. On multivariable regression analysis, sex was not associated significantly with 30-day or 24-hour in-hospital mortality.
Conclusion This study did not demonstrate a significant difference in the 30-day trauma mortality or 24-hour trauma mortality between female and male trauma patients in India on adjusted analyses. A more granular data is needed to understand the interplay of injury severity, immediate post-traumatic hormonal and immunological alterations, and the impact of gender-based disparities in acute care settings.
Purpose of Review
Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.
Recent Findings
A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.
Summary
Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.
Introduction
Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants’ perceptions on leadership, medical errors, and the QI process in Cameroon.
Methods
Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation.
Results
A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants’ perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4.
Conclusions
These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.
Trauma results in long-term socioeconomic outcomes that affect quality of life (QOL) after discharge. However, there is limited research on the lived experience of these outcomes and QOL from low – and middle-income countries. The aim of this study was to explore the different socioeconomic and QOL outcomes that trauma patients have experienced during their recovery. We conducted semi-structured qualitative interviews of 21 adult trauma patients between three to eight months after discharge from two tertiary-care public hospitals in Mumbai, India. We performed thematic analysis to identify emerging themes within the range of different experiences of the participants across gender, age, and mechanism of injury. Three themes emerged in the analysis. Recovery is incomplete—even up to eight months post discharge, participants had needs unmet by the healthcare system. Recovery is expensive—participants struggled with a range of direct and indirect costs and had to adopt coping strategies. Recovery is intersocial—post-discharge socioeconomic and QOL outcomes of the participants were shaped by the nature of social support available and their sociodemographic characteristics. Provisioning affordable and accessible rehabilitation services, and linkages with support groups may improve these outcomes. Future research should look at the effect of age and gender on these outcomes.
