Emergency Medical Services (EMS) Utilization in Zimbabwe: Retrospective Review of Harare Ambulance System Reports

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.

Scarf Injury: a qualitative examination of the emergency response and acute care pathway from a unique mechanism of road traffic injury in Bangladesh

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

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation: A scoping review on the implementation of TQIPs across income levels

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.

A cohort study of differences in trauma outcomes between females and males at four Indian Urban Trauma Centers

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.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

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.

Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon

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.

‘Coming home does not mean that the injury has gone’—exploring the lived experience of socioeconomic and quality of life outcomes in post-discharge trauma patients in urban India

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.

Changes in patterns and outcomes of trauma patients after betterment in law and order situation of the city

Objective: To assess the impact of the law and order situation of a city on the pattern of traumatic injuries and the overall outcomes of trauma victims.

Method: The retrospective study of prospective trauma surgery data was done at Aga Khan University Hospital, Karachi, and comprised data of patients with torso injuries before the improvement of law and order situation from January 2012 to March 2013 in Group A, and of those with similar injuries after the law and order situation improved in the city from January 2018 to March 2019 in Group B. The required data was collected by a single researcher using a predesigned questionnaire. Inter-group comparison was done to see the difference in patterns of injuries and outcomes. Data were analysed using SPSS 22.

Results: Of the 676 cases reviewed, Group A had 416(61.5%); 363(87%) males and 53(13%) females with overall mean age of 37±13 years. Group B had 260(38.5%); 219(84%) males and 41(16%) females with overall mean age of 36±13 years (p>0.05). Penetrating trauma alone or combined with blunt force was the most common mechanism in Group A i.e. 245 (59%) patients, while in group B blunt trauma was the commonest cause 209 (80.4%) patients. There was an overall 156 (37.5%) cases reduction in torso trauma cases. Mortality in Group A was 22(5.3%) and in Group B it was 7(2.7%).

Conclusion: With the improvement in the law and order situation, there was reduction in overall trauma cases and the pattern of trauma shifted from penetrating to blunt injuries.

Trauma Care in Low- and Middle-Income Countries

Background Trauma-related injury causes higher mortality than a combination of prevalent infectious diseases. Mortality secondary to trauma is higher in low- and middle-income countries (LMICs) than high-income countries. This review outlines common issues, and potential solutions for those issues, identified in trauma care in LMICs that contribute to poorer outcomes.

Methods A literature search was performed on PubMed and Google Scholar using the search terms “trauma,” “injuries,” and “developing countries.” Articles conducted in a trauma setting in low-income countries (according to the World Bank classification) that discussed problems with management of trauma or consolidated treatment and educational solutions regarding trauma care were included.

Results Forty-five studies were included. The problem areas broadly identified with trauma care in LMICs were infrastructure, education, and operational measures. We provided some solutions to these areas including algorithm-driven patient management and use of technology that can be adopted in LMICs.

Conclusion Sustainable methods for the provision of trauma care are essential in LMICs. Improvements in infrastructure and education and training would produce a more robust health care system and likely a reduction in mortality in trauma-related injuries.

Diagnosis and Management of Traumatic Subarachnoid Hemorrhage: Protocol for a Scoping Review

Background:
Globally, 69 million people suffer from traumatic brain injury (TBI) each year and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (TSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and an increase in morbidity and mortality, but there are a limited number of studies which evaluate recent trends in the diagnostic and management of SAH in the context of trauma.

Objective:
The objective of this scoping review was to understand the extent and type of evidence in relation to the diagnostic criteria and management of TSAH.

Methods:
This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. A 3-step search strategy (an initial limited search in PubMed and Scopus databases; a main search of EMBASE, Web of Science, EBSCO, MEDLINE; and manual searches of reference lists of included articles) will be utilized. The search will be limited to studies with human participants and published in English, Spanish, and French between 2005 and 2020. This review will consider studies of adolescent and adult patients with SAH secondary to trauma. Study selection will be performed by 2 authors (DG and LF) in a 2-phase process; if any disagreement arises, a third author (AR) will be consulted. Data to be extracted from each study will include population, intervention, comparator and outcome measures, and a summary of findings. Citation screening, full-text review, risk of bias assessment, and extraction of study characteristics and outcomes will be carried out using a web-based software platform that streamlines the production of scoping reviews.

Results:
Ethics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in December 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at conferences that engage the most pertinent stakeholders.

Conclusions:
This scoping review will serve as an initial step in providing more evidence for health care professionals, economists, and policymakers so that they might devote more resources toward this significant problem affecting both health and economic outcomes worldwide.