Jacques Goosen

Establishing the Evidence Base for Trauma Quality Improvement: A Collaborative WHO-IATSIC Review

BackgroundQuality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.MethodsThe review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.ResultsThirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.ConclusionsTrauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Overview of the Essential Trauma Care Project

The Essential Trauma Care (EsTC) Project represents an effort to set reasonable, affordable, minimum standards for trauma services worldwide and to define the resources necessary to actually provide these services to every injured person, even in the lowest-income countries. An emphasis is improved organization and planning, at minimal cost. The EsTC Project is a collaborative effort of the World Health Organization and the International Association for Trauma Surgery and Intensive Care, an integrated society within the International Society of Surgery-Société Internationale de Chirurgie. A milestone of the project has been the release of Guidelines for Essential Trauma Care. This establishes 11 core Essential Trauma Care services that can be considered “The Rights of the Injured.” To assure these services, Guidelines delineates 260 items of human and physical resources that should be in place at the spectrum of health facilities globally. These are delineated in a series of flexible resource tables, to be adjusted based on an individual country’s circumstances. Guidelines is intended to serve as both a planning guide and an advocacy statement. It has been used to catalyze improvements in trauma care in several countries. It has stimulated five national-level consultation meetings on trauma care, which constituted the highest governmental attention yet devoted to trauma care in those countries. At these meetings, the EsTC resource templates were adjusted to local circumstances and implementation strategies developed. Future efforts need to emphasize more on-the-ground implementation in individual countries, greater linkages with prehospital care, and wider political endorsement, such as by passage of a World Health Assembly resolution.

Evolving concepts in the management of colonic injury

PURPOSE The management of colonic injury has changed in recent years. This study sought to evaluate current surgical management of injuries to the colon in a busy urban trauma centre, in the light of our increasing confidence in primary repair and evolving understanding of the concepts and practice of damage control surgery. METHODS A retrospective analysis was made of consecutive patients presenting with colonic injury from January 1 to December 31 1998. Patients without full-thickness lesions of the colon were excluded, as were patients who died within 24 h of admission. Demographic data, wounding patterns and clinical course were studied. RESULTS One hundred twenty-seven patients were analyzed. Management without colostomy was achieved in 84% of cases. Patients who underwent diversion of the faecal stream had increased morbidity and hospital stay compared to equivalent patients who were repaired primarily. The important subgroup of patients who underwent damage control or abbreviated laparotomy is discussed. CONCLUSION This study further strengthens the validity of direct repair or resection and primary anastomosis for colonic injury. Strategies to deal with the subgroup of patients at very high risk of postoperative complications are suggested.

Strengthening care of injured children globally

Part of the solution to the growing problem of child injury is to strengthen the care that injured children receive. This paper will point out the potential health gains to be made by doing this and will then review recent advances in the care of injured children in individual institutions and countries. It will discuss how these individual efforts have been aided by increased international attention to trauma care. Although there are no major, well-funded global programmes to improve trauma care, recent guidance documents developed by WHO and a broad network of collaborators have stimulated increased global attention to improving planning and resources for trauma care. This has in turn led to increased attention to strengthening trauma care capabilities in countries, including needs assessments and implementation of WHO recommendations in national policy. Most of these global efforts, however, have not yet specifically addressed children. Given the special needs of the injured child and the high burden of injury-related death and disability among children, clearly greater emphasis on childhood trauma care is needed. Trauma care needs assessments being conducted in a growing number of countries need to focus more on capabilities for care of injured children. Trauma care policy development needs to better encompass childhood trauma care. More broadly, the growing network of individuals and groups collaborating to strengthen trauma care globally needs to engage a broader range of stakeholders who will focus on and champion the improvement of care for injured children.

What World Health Assembly Resolution 60.22 Means to Those Who Care for the Injured

On May 23, 2007, the World Health Assembly (WHA) adopted WHA Resolution 60.22, “Health Systems: Emergency Care Systems,” which called on the World Health Organization (WHO) and governments to adopt a variety of measures to strengthen trauma and emergency care services worldwide. This resolution constituted some of the highest level attention ever devoted to trauma care worldwide. This article reviews the background of this resolution and discusses how it can be of use to surgeons, emergency physicians, and others who care for the injured, especially in low- and middle-income countries.

Global Strengthening of Care for the Injured

Road traffic injuries and injuries from other causes have become significant public health problems throughout the world, particularly in low- and middle-income countries (1). Each year, about 20 million people are killed or injured on the roads (2). This increasing burden of death, disability and pain can be averted through appropriate preventive measures, if taken together with acces-sible and affordable care of the injured.Reviews of trauma care capacity in several low- and middle-income coun-tries have shown that, even in hospitals handling large volumes of trauma cases, many doctors and nurses providing care have had little training in this field. Many hospitals do not have essential low-cost supplies for trauma care, such as chest tubes and airway equipment; the lack of such supplies is often not attribut-able to their cost and could be overcome by better planning. Few facilities caring for injured patients have protocols for trauma care, and in many hospitals there are prolonged delays before emergency surgery. Low utilization of several funda-mental resources has been documented, even when the resources are physically present (3–6).These difficulties lead to worsened outcomes. Evidence indicates that people with life-threatening but potentially treatable injuries are six times more likely to die in a low-income country than in a high-income country (7). On the treatment side, therefore, much can be done to lower this overwhelming toll, and inexpensive improvements in trauma care are a promising and sustainable solu-tion. Efforts are needed to develop and standardize injury surveillance systems and to promote improvements in trauma care so as to ensure a minimum level of care for those in need.Many of the injury-related dis-abilities and deaths in low- and middle-income countries would be readily amenable to low-cost measures such as simple changes in training, better orga-nization and planning of services, and the availability of the right skills and the right equipment at the right places. As local needs differ, situation assess-ments are necessary. Defining what is needed to ensure care is the first step: requirements include human resources, physical resources and logistic capacity.It is with these goals in view that WHO and the International Association for the Surgery of Trauma and Surgical Intensive Care established a joint Essential Trauma Care Project. A collabo-rative Working Group for Essential Trauma Care, composed of members of both these organizations and stake-holders from several countries, includes trauma care clinicians from Africa, Asia and Latin America. Various national bodies are involved, such as the Academy of Traumatology (India), the Mexican Association for the Medicine and Sur-gery of Trauma, and the Ghana Medical Association.Over the past three years, the Working Group has defined 14 core trauma care service guidelines, such as “obstructed airways are opened and maintained before hypoxia leads to death or permanent disability”. To deliver trauma these care services worldwide, 260 items of human and physical resources have been designated as either “essential” or “desirable” at different levels, ranging from rural clinics to tertiary care facilities. Desirable items are useful resources but are not as cost-effective as those desig-nated as essential. Guidelines for essential trauma care (8) have been compiled, which detail these resources and contain recommendations on training, quality assurance, hospital inspections and interactions among stakeholders, together with practical suggestions for implementation.It is hoped that these guidelines and the Essential Trauma Care Project will become integral components of efforts to strengthen the activities of health systems. The guidelines may be used to define the human and physical resources needed at various levels of the health-care system and to identify low-cost ways to promote and ensure the availability of such resources. Progress in improving capabilities for trauma care will be likely to assist in and benefit from related efforts being made to strengthen health systems in general.Some progress has already been made in using the guidelines for trauma care needs assessments in Ghana, Mexico and Viet Nam. In India, the WHO office in Gujarat, local government and other stakeholders have adapted the guidelines to local needs and have devel-oped preliminary implementation plans. Through their use in the provision, administration and planning of trauma care services, the guidelines can be instrumental in lowering the unaccept-ably high burden of death and disability resulting from injury. O

Advancing Essential Trauma Care through the Partner Organizations: IATSIC, ISS-SIC, and WHO

The publication Guidelines for Essential Trauma Care offers an opportunity to improve trauma care services in an affordable and sustainable fashion, primarily through improved organization and planning. The publication will be useful, however, only if it actually catalyzes improvements in trauma care in health care facilities in individual countries, especially those low- and middle-income countries with the greatest needs. There is much that can be done to make this happen on the part of the partners that created these recommendations, including IATSIC (International Association for Trauma Surgery and Intensive Care); ISS-SIC (International Society of Surgery–Société Internationale de Chirurgie); and WHO (World Health Organization). This includes such activities as organizing multi-sectoral stakeholders’ meetings to adapt the Essential Trauma Care (EsTC) criteria to local needs; conducting trauma care needs assessments to identify priorities for low-cost improvements; having surgical colleges and societies throughout the world endorse the Guidelines; lobbying ministries of health to incorporate the EsTC recommendations into health policy; and seeking to integrate the EsTC recommendations into the 2-year action plans of WHO country offices. In all of these activities, surgeons and others who care for the injured can play a pivotal role, especially working collaboratively with their own ministries of health and WHO country offices.

Preparing and responding to mass casualties in the developing world

Disasters, albeit on a small scale, are an everyday event in Africa. They contribute to depriving millions of Africans of access to basic services, often considered rights in more affluent societies. The massive amounts of aid donated during disasters, could be limited by strengthening systems of disaster preparedness beforehand. Current, disease-specific programs can not achieve this goal. The Essential Trauma Care Program of the WHO, and the International Association of Trauma Surgery and Intensive Care provides a template on which to build affordable systems of disaster preparedness.

A 10-year experience of complex liver trauma (Br J Surg 2002; 89: 1532–1537)

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Fortalecimiento mundial de la asistencia a las lesiones infantiles

Introduction Injury has become a leading cause of death and disability globally. The two age groups most affected are older children (aged 5-14 years) and adolescents and younger adults (aged 15-44). For every person injured, many more are left with temporary or lifelong disabilities. The burden of injury is especially pronounced in low- and middle-income countries (LMICs), where 95% of all childhood injury deaths occur. (1) To decrease this burden, a spectrum of activities are needed, including injury surveillance, injury prevention and improvements in care of the injured (e.g. trauma care). Obviously, a major emphasis should be on prevention. However, much can also be accomplished by improvements in trauma care. To gauge the potential extent of such gains, we can examine existing discrepancies in outcome of injured patients in different countries. One study comparing outcomes of severely injured patients in three countries at different economic levels showed that case-fatality rates among seriously injured persons (i.e. with an Injury Severity Score [greater than or equal to] 9) increased from 35% in high-income United States of America to 55% in middle-income Mexico to 63% in low-income Ghana. These results show that people injured to a similar extent are nearly twice as likely to die in a low-income setting as in a high-income setting. (2) If these inequities could be eliminated, an estimated 2 million of the 5 million injury deaths each year could be averted. In addition to mortality, there is also a large burden of avoidable disability globally. The majority of injury-related disability in LMICs is due to extremity injuries, as opposed to high-income countries where there is a relatively higher burden from more difficult to treat head and spinal cord injuries. The disability from extremity injuries should be eminently amenable to low-cost improvements in orthopaedic care and rehabilitation. (3,4) There is often a misperception that improvements in trauma care would be expensive and impractical in LMICs. However, the Disease Control Priorities Project has shown that several interventions that need to be promoted to improve trauma care are among the most cost-effective in the health-care armamentarium. Among these, the following interventions were identified as having cost-effectiveness ratios of below 100 (US