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Hospital level interventions to improve outcomes after injury in India, a LMIC
For correspondence: Dr Ajai K. Malhotra, Department of Surgery, University of Vermont, Burlington, Vermont 05401, USAemail: ajai.malhotra@uvmhealth.org
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Received: ,
Abstract
Background & objectives
Trauma is one of the leading causes of disability and death, worldwide. Ninety per cent of trauma related mortality occurs in low- and middle-income countries (LMICs). Despite this, there is paucity of literature emanating from LMICs with studies that present and/or evaluate feasible interventions that can have a measurable impact on outcomes after injury, primarily mortality. The current article aims at developing such interventions key elements of implementation and measures of compliance and impact.
Methods
A literature review was conducted to evaluate the status of injury care among LMICs worldwide. Based on this review, interventions were identified/developed, that (i) were feasible to implement within the constraints of available resources; (ii) could be implemented within a two year timespan; and (iii) would improve outcomes primarily, mortality. These interventions were then discussed at a symposium of experts and stakeholders from around the world.
Results
The literature review identified gaps across the entire spectrum of injury care at all levels – primary, secondary and tertiary prevention. Additionally, lack of data systems capable of ensuring quality of care and driving performance improvement was identified. Utilizing the review as the basis and focusing on hospital level interventions, one policy intervention, five in-hospital interventions and one major research question were identified/developed that met the defined criteria.
Interpretation & conclusions
Gaps in trauma care in LMICs at every level and in data systems were identified. Feasible interventions that can be implemented within the resource constraints of LMICs in a reasonable timeframe and that can have a measurable impact on injury related mortality were developed and are presented.
Keywords
Hospital
mortality
injury
intervention
outcome
Trauma is one of the leading causes of disability and death worldwide with annual deaths exceeding those caused by malaria, HIV/AIDS and tuberculosis, combined1,2. Reportedly, 90 per cent of trauma related deaths occur in low- and middle-income countries (LMICs)3 and are associated with tremendous economic hardships for the impacted family4. In most LMICs, trauma systems are rudimentary, with post-injury care often delayed and not up to standards. Estimates suggest that if the care provided in LMICs was similar to that in high-income countries (HIC), approximately two million lives would be saved annually5. In a Delphi study examining in-hospital trauma deaths across five major hospitals in India, ∼50 per cent of the deaths were deemed preventable6. Despite such grim statistics, there is paucity of research into resource appropriate interventions that can impact trauma mortality in LMICs7. The current study is a review of recent literature from LMICs specifically evaluating the gaps in care with the aims of (i) identifying/developing feasible hospital level interventions that could measurably impact outcomes, primarily mortality and (ii) identifying research area(s) that, if addressed, could help in furthering policy decisions in India.
A literature review focusing on the issues impacting trauma care/outcomes in LMICs demonstrates gaps in care at every level – primary, secondary and tertiary. The review organized by regions – Southeast Asia (excluding India), Central/South America, Europe/Central Asia and Africa is summarized in Table I8-19.
| Region | Study/key findings | Recommendations |
|---|---|---|
| SE Asia excluding India | ||
| Pakistan |
Khalil et al8: Evaluation of 22 secondary & Tertiary care hospitals in Karachi, Pakistan
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|
| Nepal |
Kharel et al9: Assessment of 7 tertiary care hospitals
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|
| Central/South America | ||
| Peru |
LaGrone et al10: Surgeons’ perceptions of trauma care in a globalized world
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|
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Lagrone et al11: Mixed methods assessment of quality improvement programmes
|
|
|
| Columbia |
Ramachandran et al12: Comparing outcomes at 2 first-level trauma centers
|
|
|
Munoz-Valencia et al13: A population-based analysis corelating blood banks per city & mortality from traumatic haemorrhage
|
|
|
| Europe/Central Asia | ||
| Turkey |
Squyer et al14: Comparing trauma mortality in Turkey vs US
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|
| Africa | ||
| Kenya |
Wesson et al15: Hospital compliance with WHO trauma checklist
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|
| Rwanda |
Ntakiyiruta et al16:Geo-spatial evaluation of trauma surgical procedures
|
|
| Sub-Saharan Africa |
Boschini et al17: Impact of direct vs indirect transfer on trauma mortality
|
Transport: Improve transport infrastructure |
| South Africa |
Clarke et al18: Gap between trauma workload & capacity in a rural health district, & Hardcastle et al19: Hospital disease burden & care in a heavily populated province
|
|
WHO, World Health Organization; HIC, high income countries; QI, quality improvement; SE, southeast
Material & Methods
Based on the preliminary review of literature (Table I8-19), common themes were identified. Next, an additional literature search was performed focusing on interventions that have proven to be successful in HICs that could be modified and implemented in the low resourced environment of LMICs. Based on these, interventions were developed by the authors. All interventions had to meet the following criteria: (i) implementable within the constraints of available resources; (ii) implementable in two-year time-frame; and (iii) have a measurable impact on outcomes. For each of the proposed interventions the SMART (Specific, Measurable, Achievable, Relevant and Time-bound) framework was utilized to ensure appropriateness of the intervention. Each intervention was drafted under four headings namely, (i) definition/description; (ii) key elements for effective implementation; (iii) measures of compliance to ensure effective implementation; and (iv) measures of impact to objectively evaluate effectiveness.
All proposed interventions were then presented and discussed at a symposium held at All India Institute of Medical Sciences (AIIMS), New Delhi on September 30-October 1, 2023. The symposium was organized by the Transdisciplinary Research, Action, and Implementation network for Trauma (TRAIN Trauma India). The symposium brought together a group of experts to discuss the current state, assess existing best practices, and explore future directions for research and intervention in trauma care using a system-level approach. The current report focussing on in-hospital interventions is from one of five working groups. The other four groups focussed on other areas of trauma care. The symposium was attended by >50 participants and saw representation from multiple institutions in the field of trauma surgery, including experts from academic centers across India, as well as a multidisciplinary multinational global health team from seven countries with a longstanding history of collaboration in India. Surgeons in attendance represented both rural and urban contexts, spanning levels of care from primary to tertiary hospitals. Disciplines represented at the conference included surgery, emergency medicine, anaesthesia, radiology, nursing, patient advocates, policy makers, and representatives from international non-governmental organizations (NGOs). On Day 1 of the symposium, the proposed interventions were presented to the attendees followed by a facilitated discussion for each specifically focusing on the applicability, and feasibility in the LMIC setting. All discussions/comments were recorded. These discussions/comments were collated and the proposed interventions modified accordingly. On Day 2 of the symposium, the modified interventions were again presented, discussed and finalized by consensuses which are presented in this article.
Results
Based on the literature review (Table I8-19), the broad themes identified are presented in Table II. Based on these, interventions at the hospital level were developed under three domains: (i) one relevant to policy; (ii) five relevant to the in-hospital setting; and (iii) one relevant to trauma readiness of Indian hospitals.
| Phase of care/systems | Common themes | Intervention area |
|---|---|---|
| Primary prevention (Pre-injury) |
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| Secondary prevention (Pre-hospital) |
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| Secondary prevention (In-hospital) |
|
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| Tertiary prevention (Post-hospital) |
|
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| Data systems |
|
|
Policy domain
At the policy level it is critical to establish a system of designating specific hospitals as ‘Trauma Centers’. A large number of studies20,21 and the experience in the US20,21 have demonstrated that when injured patients, especially those with major injuries, are managed at designated trauma centers, outcomes are better20,21. Trauma centers are hospitals that have elected to commit the needed resources – structure, personnel, data systems etc., to provide optimal care to the injured person. The World Health Organization (WHO) Guidelines for essential trauma care considers a process of designation/verification of trauma centers as a critical element of overall trauma system development22,23 (Supplementary Material: Box 1).
In-hospital domain
At the in-hospital level, five interventions were developed: (i) designated space for resuscitation; (ii) designated trauma team; (iii) utilizing WHO checklist; (iv) application of resource appropriate ‘trauma tool’ for initial evaluation; and (v) utilizing resource appropriate protocols for management of specific injuries.
Designated space
A polytrauma patient needs expeditious evaluation, diagnosis and treatment of immediately life-threatening conditions and plan for further management, imaging/intervention etc. In this regard, the WHO recommends that a designated area in the emergency department be created where all appropriate equipment for evaluation, monitoring, and lifesaving interventions is immediately available (Supplementary Material: Box 2). The details of what is immediately available within the designated resuscitation area will be dependent on the resources available at the hospital and hence each hospital will have to carefully evaluate what is appropriate in their environment.
Designated team
In addition to the designated resuscitation area, to rapidly evaluate a patient with major injuries, diagnose and treat immediately life-threatening conditions and make a plan for further management, imaging/intervention etc., the patient should be evaluated by a skilled ‘trauma team’ capable of performing these actions in an expeditious manner. In most developed trauma systems, this team is summoned to assemble, preferably prior to patient arrival24,25. The team consists of providers who have the requisite skill and training to rapidly assess the injured patient, diagnose immediately life-threatening conditions and provide lifesaving interventions, and develop a plan of care appropriate to the patient’s needs. Additionally, the team should have support staff (e.g. nurses, respiratory therapists, etc.) who can support the provision of care and also document the care process (Supplementary Material: Box 3).
WHO Checklist
Checklists are highly effective in ensuring that all essential elements of a process are actually completed. They have been utilized in multiple diverse fields/environments and have demonstrated improved compliance with the elements of the process which lead to reduction in missed elements and improved outcomes. The WHO has proposed a basic trauma checklist to be completed after the initial evaluation, primary and secondary survey is completed and before the trauma team disperses. Studies have demonstrated that using the WHO Trauma Checklist reduces mortality, improves care, and increases patient satisfaction with care21,26,27 (https://cdn.who.int/media/docs/default-source/emergencies-trauma-care/trauma-congress-630_a3e8707b-6cd6-4482-a3cf-70019f677abe.pdf?sfvrsn=3a553ced_8&download=true).
To be effective, the WHO checklist has the following assumptions: a) there is a designated resuscitation area/space for the initial management of a major trauma patient; b) resuscitation area/space is equipped with monitoring equipment eg., oximeter, etc.; c) a trauma team evaluates all major trauma patients; and d) the trauma team has the requisite training to identify and intervene for immediately life-threatening conditions eg., tension pneumothorax, etc. If a hospital has all of these in place, the WHO checklist is an effective intervention (Supplementary Material: Box 4).
Resource appropriate ‘trauma tool’
The WHO checklist is a highly effective and well validated tool to improve trauma team performance and reduce the incidence of missed essential steps in the early management of an injured patient21,26,27. However, as mentioned above, for the WHO checklist to be effective, the hospital has to have a certain degree of maturity in terms of managing injured patients; have a designated resuscitation area with appropriate equipment and a designated trauma team with requisite training. In LMICs many hospitals do not have that level of maturity and the initial evaluation and management of a trauma patient is often performed by basic physicians or at times by non-physician providers who do not have specialized training in early evaluation and management of an injured patient. In such environments the most obvious and prominent injury e.g., a fracture, becomes the dominant injury and occult injuries within body cavities (chest, abdomen, and pelvis) are often missed. A simple resource appropriate trauma tool that ‘forces’ the provider to look for occult injuries may be highly effective in reducing missed injury and improving outcomes, even in the hands of providers without specialized training (Supplementary Material: Box 5). An example of such a tool with resource appropriate strategies for high resourced, resource constrained and low resourced environments is presented in Supplementary Table.
Resource appropriate protocols
Once the initial evaluation of the patient is complete, immediately life-threatening conditions have been addressed and all injuries have been diagnosed through resource appropriate imaging, the identified injuries need to be managed. Protocols are evidence-based management practices that lead to optimal outcomes. Implementation of protocols or practice management guidelines have demonstrated improved outcomes in varying settings including LMIC28-31. However, many of the protocols in the literature were developed in HIC and are highly resource intensive. These resources, specifically imaging, blood products etc., may not be available in hospitals in LMICs. Each hospital should endeavour to develop its own protocols that may be based on the ones developed in HICs but then are modified based on the available resources (Supplementary Material: Box 6). A detailed discussion of specific protocols is beyond the scope of the current study, and will be highly dependent upon the available resources.
Trauma readiness domain
There is wide variation among Indian hospitals with regard to readiness and ability to adequately evaluate and manage patients brought in to the Emergency department including those with injuries as demonstrated by a recent report conducted by AIIMS, New Delhi, under the auspices of NITI Aayog32. That report focused on the Emergency department only and included readiness for all emergencies. We propose a RedCap based assessment tool based on the American College of Surgeons, Committee on Trauma pre-review questionnaire (ACS COT PRQ), modified to Indian context that will assess injury care in depth and across the entire continuum from Primary, through Secondary to Tertiary prevention. The tool assess structure (physical plant; resources including personnel), processes of care (including performance improvement), and data systems devoted to the care of the injured patient. The primary aim of the intervention would be to identify strengths and weaknesses at Indian hospitals at various levels – primary, secondary, tertiary and quaternary – in terms of their ability to take care of patients with major injury. This will allow future interventions to be developed that could improve outcomes.
Discussion
Recent literature (as reviewed in this study) from LMICs with regard to the status of trauma care indicates weaknesses across entire continuum of care from primary, through secondary to tertiary prevention. Additionally, a severe lack of effective data systems to assess the care provided and to drive performance improvement also emerged. No single study can possibly address all of these issues. The current study focused on hospital level interventions in India, a LMIC, that are feasible within the available resource constraints; can be implemented over two-year timespan; and predicted to have a measurable impact on risk-adjusted outcomes, primarily mortality.
In the Indian context, the Delphi study of preventable deaths by Roy et al6 demonstrated that early deaths were primarily related to airway issues and haemorrhage control. The study recommended standardized care pathways and management protocols. More recently, a study by Amato et al33 compared risk adjusted mortality in India and USA and demonstrated that among injured adults brought to the hospital alive, risk-adjusted mortality in India was much higher than the crude difference and treatment location, was by far the greatest independent predictor of mortality among similarly injured patients. Additionally, the authors demonstrated that the odds of increased mortality in India were higher for the young vs the old; less injured vs the more injured; and less physiologically compromised vs the more compromised33.These findings were later duplicated among the paediatric population34. While troubling, these findings, taken together with the Delphi study, suggest that low fidelity and relatively ease to implement interventions that do not require major additional resources, can have a major impact on trauma related mortality7. The present study proposes specific feasible in-hospital interventions that can be implemented within the constraints of available resources and that can directly lead to measurable improvement in risk adjusted outcomes, primarily mortality. The study also identified a specific research question that can inform policy development by identifying the areas of greatest need at various hospital levels.
Overall, despite 90 per cent of trauma deaths occurring in LMICs, research into feasible interventions that can reduce trauma related mortality in LMICs is severely lacking. The current study evaluates the major challenges and describes six feasible interventions that can improve trauma related mortality. Additionally, it proposes a research question and a methodology to evaluate in great detail, the state of readiness of hospitals to provide care for the injured.
Declaration
All the information in the Supplementary Boxes 1-6 were developed exclusively by the authors and modifications were done purely based on the discussions held at the symposium. The RedCap based trauma readiness tool is available with the corresponding author, who can be reached by email. The symposium was funded by the Rick and Sadhana Downs Foundation and Boston Children Hospital, Boston, USA (project number: 010-1184-302).
Financial support & sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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