Manjul Joshipura

Emergency medical systems in low- and middle-income countries: recommendations for action

Emergency medical care is not a luxury for rich countries or rich individuals in poor countries. This paper makes the point that emergency care can make an important contribution to reducing avoidable death and disability in low- and middle-income countries. But emergency care needs to be planned well and supported at all levels--at the national, provincial and community levels--and take into account the entire spectrum of care, from the occurrence of an acute medical event in the community to the provision of appropriate care at the hospital. The mix of personnel, materials, and health-system infrastructure can be tailored to optimize the provision of emergency care in settings with different levels of resource availability. The misconception that emergency care cannot be cost effective in low-income settings is demonstrably inaccurate. Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. With better planning, the ongoing costs of emergency care can result in better outcomes and better cost-effectiveness. Every country and community can and should provide emergency care regardless of their place in the ratings of developmental indices. We make the case for universal access to emergency care and lay out a research agenda to fill the gaps in knowledge in emergency care.

Evaluation of Trauma Care Capabilities in Four Countries Using the WHO-IATSIC Guidelines for Essential Trauma Care

BackgroundWe sought to identify affordable and sustainable methods to strengthen trauma care capabilities globally, especially in developing countries, using the Guidelines for Essential Trauma Care. These guidelines were created by the World Health Organization (WHO) and the International Society of Surgery and provide recommendations on elements of trauma care that should be in place at the range of health facilities globally.MethodsThe guidelines were used as a basis for needs assessments in 4 countries selected to represent the world’s range of geographic and economic conditions: Mexico (middle income; Latin America); Vietnam (low income; east Asia); India (low income; south Asia); and Ghana (low income; Africa). One hundred sites were assessed, including rural clinics (n = 51), small hospitals (n = 34), and large hospitals (n = 15). Site visits utilized direct inspection and interviews with administrative and clinical staff.ResultsResources were partly adequate or adequate at most large hospitals, but there were gaps that could be improved, especially in low-income settings, such as shortages of airway equipment, chest tubes, and trauma-related medications; and prolonged periods where critical equipment (e.g., X-ray, laboratory) were unavailable while awaiting repairs. Rural clinics everywhere had difficulties with basic supplies for resuscitation even though some received significant trauma volumes. In all settings, there was a dearth of administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and regular in-service training.ConclusionsThis study identified several low-cost ways in which to strengthen trauma care globally. It also has demonstrated the usefulness of the Guidelines for Essential Trauma Care in providing an internationally applicable, standardized template by which to assess trauma care capabilities.

An Estimate of the Number of Lives that Could be Saved through Improvements in Trauma Care Globally

BackgroundReducing the global burden of injury requires both injury prevention and improved trauma care. We sought to provide an estimate of the number of lives that could be saved by improvements in trauma care, especially in low income and middle income countries.MethodsPrior data showed differences in case fatality rates for seriously injured persons (Injury Severity Score ≥9) in three separate locations: Seattle, WA (high income; case fatality 35%); Monterrey, Mexico (middle income; case fatality 55%); and Kumasi, Ghana (low income; case fatality 63%). For the present study, total numbers of injury deaths in all countries in different economic strata were obtained from the Global Burden of Disease study. The number of lives that could potentially be saved from improvements in trauma care globally was calculated as the difference in current number of deaths from trauma in low income and middle income countries minus the number of deaths that would have occurred if case fatality rates in these locations were decreased to the case fatality rate in high income countries.ResultsBetween 1,730,000 and 1,965,000 lives could be saved in low income and middle income countries if case fatality rates among seriously injured persons could be reduced to those in high income countries. This amounts to 34–38% of all injury deaths.ConclusionsA significant number of lives could be saved by improvements in trauma care globally. This is another piece of evidence in support of investment in and greater attention to strengthening trauma care services globally.

The burden of musculoskeletal injury in low and middle-income countries: challenges and opportunities

The global burden of injury is substantial, and injuries are predicted to be a leading cause of death and disability over the next few decades1-6. The majority of this burden will be borne by low and middle-income countries, where preventive strategies are often nonexistent and barriers to the timely and appropriate care of the injured include absent or inefficient systems for the delivery of trauma care, inadequacies in the number and the distribution of health-care facilities and workers, a lack of infrastructure and/or physical resources, and a lack of education and training. Addressing the burden of injury in low and middle-income countries has become a public health priority. So-called essential services, which are low-cost, high-yield, and target major health problems, should be made available to every person in the world7-10. While surgery has been traditionally viewed as a high-cost treatment lying outside the realm of the traditional public health model, evidence is emerging that the burden of surgical diseases such as trauma is substantial, and that essential surgery may be a cost-effective addition to the health system in low and middle-income countries11,12. The goals for this review were (1) to provide a public health perspective on the burden of injury in low and middle-income countries, (2) to discuss the delivery of musculoskeletal trauma care in resource-challenged environments, (3) to highlight deficiencies in physical resources and human resources for health care, (4) to outline approaches to teaching and training, and (5) to describe the information flow between economically developed and underdeveloped regions. ### Background The World Bank classifies countries in July of each year on the basis of per capita gross national income. As of 2005, countries have been classified (in U.S. dollars) as low income (<

Trauma registries in developing countries: A review of the published experience ☆

875 per year), lower-middle income …

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

BACKGROUND The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries. METHODS A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis. RESULTS There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the Kampala Trauma Score (KTS). CONCLUSION Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed.

Strengthening trauma and critical care globally

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

Purpose of reviewTrauma is an increasingly significant health problem globally, especially in low-income and middle-income countries. Trauma care is often compromised by economic restrictions. Many capable individuals are attempting to meet this challenge in their own countries, however. This review summarizes such efforts and assesses how they might be expanded in a comprehensive, global fashion. Recent findingsOptions for improving trauma care in the prehospital setting have been explored, including strengthening existing, basic formal emergency medical services (including ambulances); instituting new formal emergency medical services, where none had previously existed; and exploring novel ways to strengthen existing, although informal, systems of prehospital care when formal emergency medical services would be infeasible. Affordable ways by which to strengthen hospital care have been addressed for several specific injuries, including open fractures, burns, and vascular injuries. Especially notable are growing efforts to better monitor outcomes and address factors contributing to preventable deaths. The Essential Trauma Care Project has defined and promoted core essential trauma care services that every injured person in the world realistically can and should be able to receive. This project is a collaborative effort of the World Health Organization and the International Society of Surgery. SummaryIndividual efforts must be built upon to make progress in a comprehensive, global fashion. This review summarizes the background, achievements, and future potential of the Essential Trauma Care Project and several related efforts.

Preventing death and disability through the timely provision of prehospital trauma care

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.

Assessment of the availability of technology for trauma care in India

Injury remains a major cause of death and disability worldwide, and places an enormous burden on countries with limited resources. The optimal way to reduce life-threatening injuries is through primary prevention efforts that decrease the incidence and severity of injuries. When prevention fails, however, it is often possible to minimize the consequences of injury through effective prehospital and hospital-based trauma care. Unfortunately, much of the worlds population does not have access to prehospital trauma care, particularly in low income countries. In many parts of the world, few victims receive treatment at the scene and fewer still receive safe transport to the hospital in an ambulance. Transport, when available, is usually provided by relatives, untrained bystanders, commercial drivers (minibus, taxi or truck drivers), or by public safety officers (police and firefighters). Many high-income countries have developed technically complex and costly prehospital trauma care systems to provide care for acutely ill or injured patients. While these systems are impressive and they undoubtedly benefit some patients, there is little evidence that they are inherently superior to less costly systems that provide a more basic level of prehospital care. The start-up and maintenance costs of advanced life support systems place them out of the reach of all but a few countries, effectively eliminating them as a practical, sustainable option in many parts of the world. Expensive systems are not necessarily the best. With few exceptions, most advanced prehospital interventions have not been scientifically proven to be effective because the necessary randomized trials have not been conducted. In fact, most of the benefits of prehospital trauma care can be readily realized if basic, vital interventions are quickly and consistently applied, utilizing a countrys existing resources and health-care infrastructure. Considerable good may be accomplished by ensuring that victims receive life-sustaining care within a few minutes of injury. Even in countries with limited resources, many lives may be saved and disabilities prevented by teaching individuals what to do at the scene of an injury. The foundations of an effective prehospital system can be laid by recruiting carefully selected volunteers and non-medical professionals, and providing them with training as well as the basic supplies and equipment they need to provide effective prehospital care. Most severely injured patients who die in the first few hours after injury succumb to airway compromise, respiratory failure or uncontrolled haemorrhage. All of these conditions can be treated using basic first aid measures. The challenge, however, is to promote sustainable and affordable prehospital trauma care systems that provide services to everyone. To do this, each system must be defined by local needs and capacity and must be developed with due regard for local culture and health-care capacity. …