j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 3 ( 2 0 1 5 ) 2 1 7 e2 2 2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Prioritizing injury care: a review of trauma capacity in low and middle-income countries Evan G. Wong, MD, MPH,a,b,* Shailvi Gupta, MD, MPH,b,c Dan L. Deckelbaum, MD, MPH,a Tarek Razek, MD,a and Adam L. Kushner, MD, MPHb,d,e a
Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada Surgeons OverSeas (SOS), New York, New York c Department of Surgery, University of California, San Francisco e East Bay, Oakland, California d Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland e Department of Surgery, Columbia University, New York, New York b
article info
abstract
Article history:
Background: Trauma is a large contributor to the global burden of disease, particularly in
Received 24 June 2014
low and middle-income countries (LMICs). This study aimed to summarize the literature
Received in revised form
assessing surgical capacity in LMICs to provide a current assessment of trauma capacity,
18 August 2014
which will help guide future efforts.
Accepted 28 August 2014
Materials and methods: The MEDLINE database was queried via PubMed to identify studies
Available online 4 September 2014
assessing baseline surgical capacity in individual LMICs. Data were collected from each study by extracting the relevant information from the full-published text or tables. Trauma
Keywords:
capacity was evaluated using 12 surrogate criteria of trauma care, including laparotomy,
Trauma
cricothyroidotomy and chest tube insertion capabilities, and accessibility to a blood bank.
Capacity
Results: Seventeen studies were reviewed, documenting data from 531 hospitals in
Low income
seventeen countries. None of the countries had access to all twelve trauma criteria in all
Injury
their hospitals. Endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. Bag mask valves were available at 61% (234/383) of the institutions. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. A third or less of district hospitals had access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97), blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95). Conclusions: Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Trauma is a large contributor to the global burden of disease and now a leading cause of death and disability, particularly in low
and middle-income countries (LMICs). In fact, 90% of the world’s trauma deaths occur in LMICs. Moreover, injury-related deaths, particularly violence and war-related, as well as self inflicted and road traffic injuries are expected to rise significantly until 2020 [1].
* Corresponding author. Department of Surgery, McGill University, 1650 Cedar Avenue, L9 411, Montreal, QC H3G 1A4, Canada. Tel.: þ1 514 934 1934; fax: þ1 514 843 1503. E-mail address: [email protected] (E.G. Wong). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.08.055
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Efforts have been made to augment the capacity to provide trauma care in LMICs. In 2004, the World Health Organization (WHO) issued guidelines for essential trauma care [2], which provided a framework for assessing and improving trauma care in these settings. These guidelines have been implemented in a number of countries, and studies have shown some benefit in terms of trauma capacity [3e7]. More recently, a growing body of literature assessing surgical capacity in LMICs is becoming available, using the WHO’s tool for situational analysis to assess emergency and essential surgical care (TSAAEESC) [8] and the personnel, infrastructure, procedures, equipment, and supplies (PIPES) index developed by Surgeons Overseas [9]. These survey tools represent snapshots of workforce and hospital-based resources required to provide surgical care; as hospital-based trauma care inevitably relies on a subset of these resources, these assessments also provide information on components required for adequate trauma care. This study aimed to summarize the literature using these tools to provide a current assessment of trauma capacity, which will help guide future capacitybuilding efforts.
2.
Material and methods
2.1.
Data sources and study selection
The MEDLINE database was queried via PubMed to identify studies assessing baseline surgical capacity in individual LMICs. All studies from inception to July 2013 were included. References from included studies were also examined for any further articles that were missed. When multiple studies assessing surgical capacity for a given country were available, only the study including the largest number of facilities was included to avoid duplicate data. The remaining studies were excluded. Any disagreements were adjudicated through discussion amongst the authors.
2.2.
Data extraction and synthesis
By group consensus, twelve criteria from those included in both the TSAAEESC and PIPES were included as surrogates of trauma care capacity. These included basic resuscitation; pulse oximeter; fluids; endotracheal tube; bag mask valve; blood bank; chest tube; laparotomy; closed fracture reduction; open fracture repair; cricothyrotomy and/or tracheostomy; and amputation. The availability of a given item was scored on a binary system; if a criterion was always available, one point was accorded, whereas none were given otherwise. Because the TSAAEESC is rated on a more complex scale, a point was only attributed if the given criterion was always available (1) to have comparable scales between PIPES and TSAAEESC and (2) because we believe we should strive to always have these criteria available. Data were collected from each study by extracting the relevant information from the full-published text, tables, or graphs. When data for a given criterion were not available, facilities in that study were excluded and a new denominator was calculated. If a reviewed article did not provide any information on the chosen criteria, the article was excluded. When only percentages were offered, the absolute
number of corresponding facilities was calculated. For the studies in which the data were reported as a range, the midrange was calculated and used. All data were then aggregated into a single file and analyzed with descriptive statistics. Initially, results were globally compared across countries. To gain a further understanding of the distribution of resources within trauma systems, the availability of items were further categorized, when defined in the original article, into levels of health care facility as follows: primary and/or district, secondary and/or provincial, and tertiary and/or regional. Mission hospitals and nongovernmental hospitals were included in the tertiary and/or regional category. For this subanalysis, articles that did not provide a breakdown of resources according to facility level were excluded.
3.
Results
Seventeen studies were identified, documenting data from 531 hospitals in 17 LMICs (Table 1). These countries spanned five continents: Africa (10); Asia (4); North and Central America (1); South America (1); and Oceania (1). The number of facilities per country ranged from 9 in the Solomon Islands to 103 in Zambia. None of the countries had access to all twelve trauma criteria in all their hospitals. Airway management criteria were least prevalent. Overall, endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. In Ghana, endotracheal intubation was available at 18% (3/17) of surveyed hospitals, whereas Uganda fared better, with 79% (22/28) of facilities able to provide intubation. More advanced airway techniques, including cricothyrotomy and tracheostomy, were also limited in Ghana (12%; 2/17), although they were least available in Sri Lanka (5%; 1/20). Overall, bag mask valves were available at 61% (234/383) of institutions, whereas pulse oximeters were available at 52% (185/357) of hospitals. Only 9% (4/44) of facilities in Mongolia had access to bag mask valves, in contrast to the Solomon Islands, where these masks were always available in 100% (9/ 9) of hospitals. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. Specifically in Ghana, 6% (1/17) of facilities were able to provide basic resuscitation. Although all hospitals surveyed in Afghanistan and Bolivia claimed to have the capabilities to provide basic resuscitation, only 65% (11/17) and 32% (10/31) had access to a blood bank, respectively. Less than a quarter (23%; 10/44) of facilities surveyed in Mongolia had access to a blood bank, whereas all hospitals (100%; 20/20) in Ethiopia could provide transfusions. Chest tube insertion capabilities were always available at 65% (247/378) of facilities. Although 90% (93/103) of surveyed facilities in Zambia offered chest tube capabilities, this was only available in 32% (14/44) of hospitals in Rwanda. In terms of definitive management, 70% (271/385) of hospitals had the capacity to perform a laparotomy. For orthopedic injuries, 51% (159/314) and 75% (242/323) of facilities were able to perform an open fracture repair and closed fracture reduction, respectively. None (0%; 0/31) of the
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Table 1 e Availability of selected trauma resources in 17 countries. Country Afghanistan [20] Bangladesh [21] Bolivia [22] Ethiopia [23] Gambia [24] Ghana [25] Liberia [26] Mongolia [27] Nicaragua [28] Nigeria [29] Rwanda [30] Sierra Leone [31] Solomon Islands [32] Sri Lanka [33] Tanzania [34] Uganda [35] Zambia [36] Total
Country
Afghanistan Bangladesh Bolivia Ethiopia Gambia Ghana Liberia Mongolia Nicaragua Nigeria Rwanda Sierra Leone Solomon Islands Sri Lanka Tanzania Uganda Zambia Total
Number of facilities 17 14 31 20 18 17 16 44 28 41 44 10 9 31 48 28 103 531
Number of facilities 17 14 31 20 18 17 16 44 28 41 44 10 9 31 48 28 103 531
Resuscitation, %
Pulse oximeter, %
Fluids, %
Endotracheal tube, %
Bag mask, %
100 (17/17) 100 (31/31)
71 (10/14) 90 (28/31) 60 (12/20)
6 (1/17) 94 (15/16)
97 (36/37)
67 (12/18) 59 (10/17)
18 (3/17)
67 (12/18)
50 (22/44)
25 (11/44)
79 (22/28) 44 (18/41) 57 (25/44)
34 (14/41) 59 (26/44) 80 (8/10) 100 (9/9)
90 (93/103) 87 (193/221)
Chest tube, % 71 (12/17)
13 46 53 52
(6/48) (13/28) (55/103) (185/357)
Laparotomy, % 88 (15/17)
55 (12/22) 90 (43/48)
65 (31/48) 79 (22/28)
73 (75/103) 70 (191/271)
Closed fracture reduction, % 88 (15/17)
48 (107/222)
Open fracture repair, % 59 (10/17)
94 (29/31) 33 41 69 41
(6/18) (7/17) (11/16) (21/44)
61 (25/41) 32 (14/44) 40 (4/10)
55 82 81 32
(10/18) (14/17) (13/16) (14/44)
63 (10/16) 9 (4/44) 78 59 80 100 50 67 93 62 61
(32/41) (26/44) (8/10) (9/9) (11/22) (32/48) (26/28) (64/103) (234/383)
Cricothyrotomy/ tracheostomy, % 47 (8/17)
41 76 44 55
(7/18) (13/17) (7/16) (24/44)
28 12 6 48
(11/17) (9/14) (10/31) (20/20) (12/17) (12/17)
23 71 37 61
(10/44) (20/28) (15/41) (27/44)
29 (14/48) 32 (9/28) 48 (169/349)
Amputation, % 65 (11/17)
(5/18) (2/17) (1/16) (21/44)
39 12 19 50
(7/18) (2/17) (3/16) (22/44)
44 59 63 41
(5/41) (6/44) (4/10) (2/9) (1/20) (13/48)
46 (19/41)
63 (26/41)
41 (17/41)
70 (7/10) 89 (8/9)
20 (2/10)
40 (8/20) 63 (30/48)
70 33 0 75
88 (42/48)
60 (29/48)
12 14 40 22 5 27
90 (93/103) 65 (247/378)
90 (93/103) 70 (271/385)
90 (93/103) 75 (242/323)
70 (72/103) 51 (159/314)
70 (72/103) 41 (163/418)
hospitals in Sri Lanka claimed to be able to always perform laparotomies. However, hospitals in Bolivia had increased capacity for laparotomies, with 94% (29/31) able to perform the procedure. In Liberia, 44% (7/16) and 6% (1/16) of facilities were able to perform closed and open fracture procedures, respectively. The availability of these resources according to the level of health care facility is presented in Table 2. For this subanalysis, nine articles presented data with enough granularity to separate results among levels of referral. Overall, tertiary and regional facilities were the best equipped, with access to all resources in 100% of facilities, except for pulse oximetry, which was available in 88% (14/16) of these hospitals. Primary or district hospitals were particularly deficient in resources required for initial patient stabilization, with a third or less of these facilities having access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97),
65 64 32 100 71 70
58 (18/31)
90 (37/41) (7/10) (3/9) (0/31) (36/48)
Blood bank, %
(8/18) (10/17) (10/16) (18/44)
90 (93/103) 66 (169/256)
blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95).
4.
Discussion
Mock et al., in collaboration with the WHO, have pioneered the field of trauma care in developing countries. By developing the guidelines for essential trauma care [2] and by implementing them in select countries [4e6], they have highlighted widespread deficiencies in trauma care and offered areas for improvement. However, the present study demonstrates that resources essential to initial and definitive trauma care remain limited despite these efforts. This study should thus supplement these previous studies and add to the plea for higher prioritization of trauma care in developing countries.
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Table 2 e Availability of selected trauma resources according to level of health care facility across nine countries. Resource
Primary/ district, %
Secondary/ provincial, %
Tertiary/ regional, %
Resuscitation Pulse oximeter Fluids Endotracheal tube Bag mask Blood bank Chest tube Laparotomy Closed fracture reduction Open fracture repair Cricothyrotomy/ tracheostomy Amputation
33 51 53 32
(8/24) (18/35) (34/64) (31/97)
95 64 93 25
(21/22) (16/25) (13/14) (4/16)
100 88 100 100
(4/4) (14/16) (2/2) (15/15)
41 31 45 61 58
(34/83) (32/102) (43/95) (58/95) (55/95)
93 68 61 72 72
(28/30) (17/25) (17/28) (26/36) (26/36)
100 100 100 100 100
(17/17) (16/16) (5/5) (6/6) (6/6)
36 (34/95)
32 (9/28)
100 (5/5)
32 (30/95)
19 (7/36)
100 (6/6)
45 (41/92)
59 (13/22)
100 (4/4)
The lack of surgical capacity in LMICs has been well documented. In fact, Weiser et al. [10] estimate that of 234 million operations performed globally per year, only 8.1 million (3.5%) are performed in developing countries. Deficiencies in human and material resources have been cited as the most common obstacles to proper surgical care [11]. The provision of comprehensive trauma care inevitably relies on access to surgical services; the improvement of trauma care in these settings will undoubtedly go hand in hand with the development of surgical capacity. As injuries currently cause more deaths than HIV, malaria, and tuberculosis combined, and with these numbers projected to increase significantly in the coming years [1], the strain on hospital resources will be compounded by limited baseline capacity. Therefore, as the growing literature sheds light on the unmet burden of surgical disease, efforts will hopefully be made to address this issue. However, with limited resources, stakeholders will be forced to prioritize. Given that injury represents a significant burden of disease and a leading cause of mortality and disability, these efforts should focus on improving trauma care. The present study provides specific resources that are lacking in LMICs. To improve trauma care, clear-cut goals must be established. Therefore, this study not only provides a snapshot of the baseline trauma capabilities, it also delineates possible alleys to guide resources. In establishing a baseline, this study also provides a comparison for future improvements. Specifically, this study has important implications for the development of trauma systems in LMICs and provides potential areas of focus for future international collaborations. Substantial evidence exists in higher-income settings that the establishment of trauma systems significantly decreases injury-related mortality [12,13], and some evidence suggests that this hold true in lower-resource settings [14]. Future efforts to improve trauma outcomes in LMICs could therefore address prehospital care. Currently, an important proportion of prehospital care and transport in LMICs is provided by layperson bystanders and commercial drivers [15]. To build
prehospital programs based on these already-used resources, some have successfully implemented training programs for laypersons as first responders [16,17]. It is clear that material resources should also be allocated to first responders, as point-of-care interventions may have important survival benefits and hospital care may be futile without proper stabilization in the field. Furthermore, this study demonstrates that substantial deficiencies exist in the primary care facilities and district hospitals. This is not surprising as it is likely that policy makers are rationally allocating their limited resources to higher-level referral centers. However, our finding that a third or less of these primary facilities are capable of providing basic resuscitation or definitive airway management points toward areas for improvement. Strengthening district hospitals, at least to a point of patient stabilization for transport to a referral center, will undoubtedly be beneficial. This is not to say that future efforts should not also expand resources at referral centers, as these are likely to be strained as prehospital and referral systems develop. Ultimately, rehabilitation services should also be addressed as trauma-associated morbidity remains significant and is likely to increase as mortality decreases. As the maturation of trauma systems is a long-term process, prevention programs are also primordial and may have the most immediate benefits. This study also raises the issue of the use of surrogates as measures of trauma capacity. As alluded to previously, quantifying capabilities are essential to advocating to stakeholders, providing targets for improvement and monitoring changes over time. A small number of tools have been developed to evaluate trauma capacity, notably the WHO’s guidelines for essential trauma care [2] and the International Assessment of Capacity for Trauma (INTACT) index [18]. However, these tools solely focus on resources as measures of trauma capacity. Future efforts to evaluate trauma capacity should incorporate more detailed metrics. For example, actual hospital output (i.e., surgical procedures performed for trauma) and in-hospital mortality could be evaluated. Trauma system outcomes, including prehospital time to care, interhospital transfer patterns, and long-term disability, should also be measured. Ultimately, methods of evaluation of leadership, access to care, prevention, and education and/or quality improvement, such as the Global Trauma System Evaluation Tool (G-TSET), could also be implemented [19]. This review does present limitations. Our findings are limited to published data; the availability of each criterion was limited by what was stated in the text or shown in the tables and/or graphs. Moreover, our findings rely on the validity of the data collection procedures in the initial studies; given the pressures to improve trauma care, it is possible that resources were overreported by hospital administrators or conversely, in an effort to attract increased funding, it is possible that certain resources were underreported by hospital personnel. However, as most studies included on-site visits by study authors to corroborate survey answers, we are confident of the validity of our findings. We made the assumption that improvements in material and human resources would necessarily equate improved trauma outcomes, which would be difficult to prove without proper outcomes of data. We also chose to focus on hospital-based trauma care. We did not
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 3 ( 2 0 1 5 ) 2 1 7 e2 2 2
address the other essential components of trauma systems. Nevertheless, we believe that the included studies provide a valid snapshot of shortages in hospital resources required for trauma care and that our review adequately provides alleys to guide future capacity-building efforts.
5.
Conclusions
Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs. As injury-related deaths are expected to rise, particularly in these settings, future efforts to improve trauma capacity should be prioritized.
Acknowledgment Authors’ contributions: All authors contributed to the study design. E.G.W., S.G., and A.L.K. acquired and analyzed the data. All authors helped interpret the data. E.G.W., S.G., and A.L.K. drafted the initial article and all authors critically revised it. All authors provided final approval of the submitted article.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
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[10] Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372:139. [11] Grimes CE, Bowman KG, Dodgion CM, et al. Systematic review of barriers to surgical care in low-income and middleincome countries. World J Surg 2011;35:941. [12] Jurkovich GJ, Mock C. Systematic review of trauma system effectiveness based on registry comparisons. J Trauma 1999; 47:S46. [13] Mann NC, Mullins RJ, MacKenzie EJ, et al. Systematic review of published evidence regarding trauma system effectiveness. J Trauma 1999;47:S25. [14] Mock CN, Jurkovich GJ, nii-Amon-Kotei D, et al. Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma 1998;44:804. discussion 812e4. [15] Nielsen K, Mock C, Joshipura M, et al. Assessment of the status of prehospital care in 13 low- and middle-income countries. Prehosp Emerg Care 2012;16:381. [16] Callese TE, Richards CT, Shaw P, et al. Layperson trauma training in low- and middle-income countries: a review. J Surg Res 2014;190:104. [17] Wisborg T, Murad MK, Edvardsen O, et al. Prehospital trauma system in a low-income country: system maturation and adaptation during 8 years. J Trauma 2008;64:1342. [18] Wong EG, Gupta S, Deckelbaum DL, et al. The International Assessment of Capacity for Trauma (INTACT): an index for trauma capacity in low-income countries. J Surg Res 2014; 190:522. [19] Remick KN, Wong EG, Chep CC, et al. Development of a novel global trauma system evaluation tool and initial results of implementation in the Republic of south Sudan. Injury; 2014 [Epub ahead of print]. [20] Contini S, Taqdeer A, Cherian M, et al. Emergency and essential surgical services in Afghanistan: still a missing challenge. World J Surg 2010;34:473. [21] Lebrun DG, Dhar D, Sarkar MI, et al. Measuring global surgical disparities: a survey of surgical and anesthesia infrastructure in Bangladesh. World J Surg 2013;37:24. [22] Markin A, Barbero R, Leow JJ, et al. A quantitative analysis of surgical capacity in Santa Cruz, Bolivia. J Surg Res 2013; 185:190. [23] Chao TE, Burdic M, Ganjawalla K, et al. Survey of surgery and anesthesia infrastructure in Ethiopia. World J Surg 2012;36: 2545. [24] Iddriss A, Shivute N, Bickler S, et al. Emergency, anaesthetic and essential surgical capacity in the Gambia. Bull World Health Organ 2011;89:565. [25] Choo S, Perry H, Hesse AA, et al. Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Trop Med Int Health 2010;15: 1109. [26] Sherman L, Clement PT, Cherian MN, et al. Implementing Liberia’s poverty reduction strategy: an assessment of emergency and essential surgical care. Arch Surg 2011; 146:35. [27] Spiegel DA, Choo S, Cherian M, et al. Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J Surg 2011;35:272. [28] Solis C, Leon P, Sanchez N, et al. Nicaraguan surgical and anesthesia infrastructure: survey of ministry of health hospitals. World J Surg 2013;37:2109. [29] Henry JA, Windapo O, Kushner AL, et al. A survey of surgical capacity in rural southern Nigeria: opportunities for change. World J Surg 2012;36:2811. [30] Petroze RT, Nzayisenga A, Rusanganwa V, et al. Comprehensive national analysis of emergency and essential surgical capacity in Rwanda. Br J Surg 2012;99:436.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Prioritizing injury care: a review of trauma capacity in low and middle-income countries Evan G. Wong, MD, MPH,a,b,* Shailvi Gupta, MD, MPH,b,c Dan L. Deckelbaum, MD, MPH,a Tarek Razek, MD,a and Adam L. Kushner, MD, MPHb,d,e a
Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada Surgeons OverSeas (SOS), New York, New York c Department of Surgery, University of California, San Francisco e East Bay, Oakland, California d Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland e Department of Surgery, Columbia University, New York, New York b
article info
abstract
Article history:
Background: Trauma is a large contributor to the global burden of disease, particularly in
Received 24 June 2014
low and middle-income countries (LMICs). This study aimed to summarize the literature
Received in revised form
assessing surgical capacity in LMICs to provide a current assessment of trauma capacity,
18 August 2014
which will help guide future efforts.
Accepted 28 August 2014
Materials and methods: The MEDLINE database was queried via PubMed to identify studies
Available online 4 September 2014
assessing baseline surgical capacity in individual LMICs. Data were collected from each study by extracting the relevant information from the full-published text or tables. Trauma
Keywords:
capacity was evaluated using 12 surrogate criteria of trauma care, including laparotomy,
Trauma
cricothyroidotomy and chest tube insertion capabilities, and accessibility to a blood bank.
Capacity
Results: Seventeen studies were reviewed, documenting data from 531 hospitals in
Low income
seventeen countries. None of the countries had access to all twelve trauma criteria in all
Injury
their hospitals. Endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. Bag mask valves were available at 61% (234/383) of the institutions. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. A third or less of district hospitals had access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97), blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95). Conclusions: Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Trauma is a large contributor to the global burden of disease and now a leading cause of death and disability, particularly in low
and middle-income countries (LMICs). In fact, 90% of the world’s trauma deaths occur in LMICs. Moreover, injury-related deaths, particularly violence and war-related, as well as self inflicted and road traffic injuries are expected to rise significantly until 2020 [1].
* Corresponding author. Department of Surgery, McGill University, 1650 Cedar Avenue, L9 411, Montreal, QC H3G 1A4, Canada. Tel.: þ1 514 934 1934; fax: þ1 514 843 1503. E-mail address: [email protected] (E.G. Wong). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.08.055
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Efforts have been made to augment the capacity to provide trauma care in LMICs. In 2004, the World Health Organization (WHO) issued guidelines for essential trauma care [2], which provided a framework for assessing and improving trauma care in these settings. These guidelines have been implemented in a number of countries, and studies have shown some benefit in terms of trauma capacity [3e7]. More recently, a growing body of literature assessing surgical capacity in LMICs is becoming available, using the WHO’s tool for situational analysis to assess emergency and essential surgical care (TSAAEESC) [8] and the personnel, infrastructure, procedures, equipment, and supplies (PIPES) index developed by Surgeons Overseas [9]. These survey tools represent snapshots of workforce and hospital-based resources required to provide surgical care; as hospital-based trauma care inevitably relies on a subset of these resources, these assessments also provide information on components required for adequate trauma care. This study aimed to summarize the literature using these tools to provide a current assessment of trauma capacity, which will help guide future capacitybuilding efforts.
2.
Material and methods
2.1.
Data sources and study selection
The MEDLINE database was queried via PubMed to identify studies assessing baseline surgical capacity in individual LMICs. All studies from inception to July 2013 were included. References from included studies were also examined for any further articles that were missed. When multiple studies assessing surgical capacity for a given country were available, only the study including the largest number of facilities was included to avoid duplicate data. The remaining studies were excluded. Any disagreements were adjudicated through discussion amongst the authors.
2.2.
Data extraction and synthesis
By group consensus, twelve criteria from those included in both the TSAAEESC and PIPES were included as surrogates of trauma care capacity. These included basic resuscitation; pulse oximeter; fluids; endotracheal tube; bag mask valve; blood bank; chest tube; laparotomy; closed fracture reduction; open fracture repair; cricothyrotomy and/or tracheostomy; and amputation. The availability of a given item was scored on a binary system; if a criterion was always available, one point was accorded, whereas none were given otherwise. Because the TSAAEESC is rated on a more complex scale, a point was only attributed if the given criterion was always available (1) to have comparable scales between PIPES and TSAAEESC and (2) because we believe we should strive to always have these criteria available. Data were collected from each study by extracting the relevant information from the full-published text, tables, or graphs. When data for a given criterion were not available, facilities in that study were excluded and a new denominator was calculated. If a reviewed article did not provide any information on the chosen criteria, the article was excluded. When only percentages were offered, the absolute
number of corresponding facilities was calculated. For the studies in which the data were reported as a range, the midrange was calculated and used. All data were then aggregated into a single file and analyzed with descriptive statistics. Initially, results were globally compared across countries. To gain a further understanding of the distribution of resources within trauma systems, the availability of items were further categorized, when defined in the original article, into levels of health care facility as follows: primary and/or district, secondary and/or provincial, and tertiary and/or regional. Mission hospitals and nongovernmental hospitals were included in the tertiary and/or regional category. For this subanalysis, articles that did not provide a breakdown of resources according to facility level were excluded.
3.
Results
Seventeen studies were identified, documenting data from 531 hospitals in 17 LMICs (Table 1). These countries spanned five continents: Africa (10); Asia (4); North and Central America (1); South America (1); and Oceania (1). The number of facilities per country ranged from 9 in the Solomon Islands to 103 in Zambia. None of the countries had access to all twelve trauma criteria in all their hospitals. Airway management criteria were least prevalent. Overall, endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. In Ghana, endotracheal intubation was available at 18% (3/17) of surveyed hospitals, whereas Uganda fared better, with 79% (22/28) of facilities able to provide intubation. More advanced airway techniques, including cricothyrotomy and tracheostomy, were also limited in Ghana (12%; 2/17), although they were least available in Sri Lanka (5%; 1/20). Overall, bag mask valves were available at 61% (234/383) of institutions, whereas pulse oximeters were available at 52% (185/357) of hospitals. Only 9% (4/44) of facilities in Mongolia had access to bag mask valves, in contrast to the Solomon Islands, where these masks were always available in 100% (9/ 9) of hospitals. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. Specifically in Ghana, 6% (1/17) of facilities were able to provide basic resuscitation. Although all hospitals surveyed in Afghanistan and Bolivia claimed to have the capabilities to provide basic resuscitation, only 65% (11/17) and 32% (10/31) had access to a blood bank, respectively. Less than a quarter (23%; 10/44) of facilities surveyed in Mongolia had access to a blood bank, whereas all hospitals (100%; 20/20) in Ethiopia could provide transfusions. Chest tube insertion capabilities were always available at 65% (247/378) of facilities. Although 90% (93/103) of surveyed facilities in Zambia offered chest tube capabilities, this was only available in 32% (14/44) of hospitals in Rwanda. In terms of definitive management, 70% (271/385) of hospitals had the capacity to perform a laparotomy. For orthopedic injuries, 51% (159/314) and 75% (242/323) of facilities were able to perform an open fracture repair and closed fracture reduction, respectively. None (0%; 0/31) of the
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Table 1 e Availability of selected trauma resources in 17 countries. Country Afghanistan [20] Bangladesh [21] Bolivia [22] Ethiopia [23] Gambia [24] Ghana [25] Liberia [26] Mongolia [27] Nicaragua [28] Nigeria [29] Rwanda [30] Sierra Leone [31] Solomon Islands [32] Sri Lanka [33] Tanzania [34] Uganda [35] Zambia [36] Total
Country
Afghanistan Bangladesh Bolivia Ethiopia Gambia Ghana Liberia Mongolia Nicaragua Nigeria Rwanda Sierra Leone Solomon Islands Sri Lanka Tanzania Uganda Zambia Total
Number of facilities 17 14 31 20 18 17 16 44 28 41 44 10 9 31 48 28 103 531
Number of facilities 17 14 31 20 18 17 16 44 28 41 44 10 9 31 48 28 103 531
Resuscitation, %
Pulse oximeter, %
Fluids, %
Endotracheal tube, %
Bag mask, %
100 (17/17) 100 (31/31)
71 (10/14) 90 (28/31) 60 (12/20)
6 (1/17) 94 (15/16)
97 (36/37)
67 (12/18) 59 (10/17)
18 (3/17)
67 (12/18)
50 (22/44)
25 (11/44)
79 (22/28) 44 (18/41) 57 (25/44)
34 (14/41) 59 (26/44) 80 (8/10) 100 (9/9)
90 (93/103) 87 (193/221)
Chest tube, % 71 (12/17)
13 46 53 52
(6/48) (13/28) (55/103) (185/357)
Laparotomy, % 88 (15/17)
55 (12/22) 90 (43/48)
65 (31/48) 79 (22/28)
73 (75/103) 70 (191/271)
Closed fracture reduction, % 88 (15/17)
48 (107/222)
Open fracture repair, % 59 (10/17)
94 (29/31) 33 41 69 41
(6/18) (7/17) (11/16) (21/44)
61 (25/41) 32 (14/44) 40 (4/10)
55 82 81 32
(10/18) (14/17) (13/16) (14/44)
63 (10/16) 9 (4/44) 78 59 80 100 50 67 93 62 61
(32/41) (26/44) (8/10) (9/9) (11/22) (32/48) (26/28) (64/103) (234/383)
Cricothyrotomy/ tracheostomy, % 47 (8/17)
41 76 44 55
(7/18) (13/17) (7/16) (24/44)
28 12 6 48
(11/17) (9/14) (10/31) (20/20) (12/17) (12/17)
23 71 37 61
(10/44) (20/28) (15/41) (27/44)
29 (14/48) 32 (9/28) 48 (169/349)
Amputation, % 65 (11/17)
(5/18) (2/17) (1/16) (21/44)
39 12 19 50
(7/18) (2/17) (3/16) (22/44)
44 59 63 41
(5/41) (6/44) (4/10) (2/9) (1/20) (13/48)
46 (19/41)
63 (26/41)
41 (17/41)
70 (7/10) 89 (8/9)
20 (2/10)
40 (8/20) 63 (30/48)
70 33 0 75
88 (42/48)
60 (29/48)
12 14 40 22 5 27
90 (93/103) 65 (247/378)
90 (93/103) 70 (271/385)
90 (93/103) 75 (242/323)
70 (72/103) 51 (159/314)
70 (72/103) 41 (163/418)
hospitals in Sri Lanka claimed to be able to always perform laparotomies. However, hospitals in Bolivia had increased capacity for laparotomies, with 94% (29/31) able to perform the procedure. In Liberia, 44% (7/16) and 6% (1/16) of facilities were able to perform closed and open fracture procedures, respectively. The availability of these resources according to the level of health care facility is presented in Table 2. For this subanalysis, nine articles presented data with enough granularity to separate results among levels of referral. Overall, tertiary and regional facilities were the best equipped, with access to all resources in 100% of facilities, except for pulse oximetry, which was available in 88% (14/16) of these hospitals. Primary or district hospitals were particularly deficient in resources required for initial patient stabilization, with a third or less of these facilities having access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97),
65 64 32 100 71 70
58 (18/31)
90 (37/41) (7/10) (3/9) (0/31) (36/48)
Blood bank, %
(8/18) (10/17) (10/16) (18/44)
90 (93/103) 66 (169/256)
blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95).
4.
Discussion
Mock et al., in collaboration with the WHO, have pioneered the field of trauma care in developing countries. By developing the guidelines for essential trauma care [2] and by implementing them in select countries [4e6], they have highlighted widespread deficiencies in trauma care and offered areas for improvement. However, the present study demonstrates that resources essential to initial and definitive trauma care remain limited despite these efforts. This study should thus supplement these previous studies and add to the plea for higher prioritization of trauma care in developing countries.
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Table 2 e Availability of selected trauma resources according to level of health care facility across nine countries. Resource
Primary/ district, %
Secondary/ provincial, %
Tertiary/ regional, %
Resuscitation Pulse oximeter Fluids Endotracheal tube Bag mask Blood bank Chest tube Laparotomy Closed fracture reduction Open fracture repair Cricothyrotomy/ tracheostomy Amputation
33 51 53 32
(8/24) (18/35) (34/64) (31/97)
95 64 93 25
(21/22) (16/25) (13/14) (4/16)
100 88 100 100
(4/4) (14/16) (2/2) (15/15)
41 31 45 61 58
(34/83) (32/102) (43/95) (58/95) (55/95)
93 68 61 72 72
(28/30) (17/25) (17/28) (26/36) (26/36)
100 100 100 100 100
(17/17) (16/16) (5/5) (6/6) (6/6)
36 (34/95)
32 (9/28)
100 (5/5)
32 (30/95)
19 (7/36)
100 (6/6)
45 (41/92)
59 (13/22)
100 (4/4)
The lack of surgical capacity in LMICs has been well documented. In fact, Weiser et al. [10] estimate that of 234 million operations performed globally per year, only 8.1 million (3.5%) are performed in developing countries. Deficiencies in human and material resources have been cited as the most common obstacles to proper surgical care [11]. The provision of comprehensive trauma care inevitably relies on access to surgical services; the improvement of trauma care in these settings will undoubtedly go hand in hand with the development of surgical capacity. As injuries currently cause more deaths than HIV, malaria, and tuberculosis combined, and with these numbers projected to increase significantly in the coming years [1], the strain on hospital resources will be compounded by limited baseline capacity. Therefore, as the growing literature sheds light on the unmet burden of surgical disease, efforts will hopefully be made to address this issue. However, with limited resources, stakeholders will be forced to prioritize. Given that injury represents a significant burden of disease and a leading cause of mortality and disability, these efforts should focus on improving trauma care. The present study provides specific resources that are lacking in LMICs. To improve trauma care, clear-cut goals must be established. Therefore, this study not only provides a snapshot of the baseline trauma capabilities, it also delineates possible alleys to guide resources. In establishing a baseline, this study also provides a comparison for future improvements. Specifically, this study has important implications for the development of trauma systems in LMICs and provides potential areas of focus for future international collaborations. Substantial evidence exists in higher-income settings that the establishment of trauma systems significantly decreases injury-related mortality [12,13], and some evidence suggests that this hold true in lower-resource settings [14]. Future efforts to improve trauma outcomes in LMICs could therefore address prehospital care. Currently, an important proportion of prehospital care and transport in LMICs is provided by layperson bystanders and commercial drivers [15]. To build
prehospital programs based on these already-used resources, some have successfully implemented training programs for laypersons as first responders [16,17]. It is clear that material resources should also be allocated to first responders, as point-of-care interventions may have important survival benefits and hospital care may be futile without proper stabilization in the field. Furthermore, this study demonstrates that substantial deficiencies exist in the primary care facilities and district hospitals. This is not surprising as it is likely that policy makers are rationally allocating their limited resources to higher-level referral centers. However, our finding that a third or less of these primary facilities are capable of providing basic resuscitation or definitive airway management points toward areas for improvement. Strengthening district hospitals, at least to a point of patient stabilization for transport to a referral center, will undoubtedly be beneficial. This is not to say that future efforts should not also expand resources at referral centers, as these are likely to be strained as prehospital and referral systems develop. Ultimately, rehabilitation services should also be addressed as trauma-associated morbidity remains significant and is likely to increase as mortality decreases. As the maturation of trauma systems is a long-term process, prevention programs are also primordial and may have the most immediate benefits. This study also raises the issue of the use of surrogates as measures of trauma capacity. As alluded to previously, quantifying capabilities are essential to advocating to stakeholders, providing targets for improvement and monitoring changes over time. A small number of tools have been developed to evaluate trauma capacity, notably the WHO’s guidelines for essential trauma care [2] and the International Assessment of Capacity for Trauma (INTACT) index [18]. However, these tools solely focus on resources as measures of trauma capacity. Future efforts to evaluate trauma capacity should incorporate more detailed metrics. For example, actual hospital output (i.e., surgical procedures performed for trauma) and in-hospital mortality could be evaluated. Trauma system outcomes, including prehospital time to care, interhospital transfer patterns, and long-term disability, should also be measured. Ultimately, methods of evaluation of leadership, access to care, prevention, and education and/or quality improvement, such as the Global Trauma System Evaluation Tool (G-TSET), could also be implemented [19]. This review does present limitations. Our findings are limited to published data; the availability of each criterion was limited by what was stated in the text or shown in the tables and/or graphs. Moreover, our findings rely on the validity of the data collection procedures in the initial studies; given the pressures to improve trauma care, it is possible that resources were overreported by hospital administrators or conversely, in an effort to attract increased funding, it is possible that certain resources were underreported by hospital personnel. However, as most studies included on-site visits by study authors to corroborate survey answers, we are confident of the validity of our findings. We made the assumption that improvements in material and human resources would necessarily equate improved trauma outcomes, which would be difficult to prove without proper outcomes of data. We also chose to focus on hospital-based trauma care. We did not
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address the other essential components of trauma systems. Nevertheless, we believe that the included studies provide a valid snapshot of shortages in hospital resources required for trauma care and that our review adequately provides alleys to guide future capacity-building efforts.
5.
Conclusions
Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs. As injury-related deaths are expected to rise, particularly in these settings, future efforts to improve trauma capacity should be prioritized.
Acknowledgment Authors’ contributions: All authors contributed to the study design. E.G.W., S.G., and A.L.K. acquired and analyzed the data. All authors helped interpret the data. E.G.W., S.G., and A.L.K. drafted the initial article and all authors critically revised it. All authors provided final approval of the submitted article.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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