|Year : 2014 | Volume
| Issue : 1 | Page : 3-10
Trauma care in Africa: The way forward
Charles Mock1, Robert Quansah2, Olive Kobusingye3, Jacques Goosen4
1 University of Washington, Seattle, USA
2 Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
3 WHO Regional Office for Africa, Brazzaville, Congo
4 Trauma unit, Johannesburg Hospital,Johannesburg, South Africa
|Date of Web Publication||26-Aug-2014|
Harborview medical center, 325 Ninth Avenue, Seattle, WA, 98104
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mock C, Quansah R, Kobusingye O, Goosen J. Trauma care in Africa: The way forward. Afr J Trauma 2014;3:3-10
(Reprinted from Afr J Trauma. 2004; 2: 53-58)
Road traffic injury and other forms of trauma have become major health problems throughout the world and especially in low- and middle-income countries. ,, Africa has been especially hard hit. This has come at a time when there is still a high burden from infection diseases. Some might say that attention should be focused on these infections diseases only because little can be done to address the problems of trauma, and indeed, that little is too expensive. Nothing could be further from the truth. Much that is affordable, feasible, and sustainable can be done to strengthen the prevention and treatment of injuries in Africa. This can be done by addressing the spectrum of injury (trauma) control activities in a comprehensive fashion, including surveillance, prevention and treatment, both inside and outside the hospital [Figure 1]. Organized, scientific approaches can be applied at each step of this continuum N B: In this paper, "trauma" and "injury" are used interchangeable.
All too often, efforts to improve the prevention and treatment of injuries have been carried out without adequate assessment of their effectiveness. In order to be maximally effective, we need to know which efforts have proven successful and hence should be promoted and scaled up, and which others have proven unsuccessful and hence should be amended or ceased. This implies having accurate and timely information on the occurrence and characteristic of injuries and the deaths they cause. Information on injuries usually comes from vital registries, police reports, and hospital records. In most African countries, there are considerable shortcomings in these sources, with at times, less than 100% of the series. , However, low-cost measures to improve such reporting are possible. The South African National Non-Natural Mortality Surveillance System is an example of an affordable system unit built upon mortuary data.  This has proven a valuable tool for those involved in injury control efforts in South Africa. Likewise, in Uganda, a simple intake form for trauma patients has assisted record keeping and patient care, as well as providing a database to monitor broader trauma care measure.  Similar improvement in information systems on injury need to be advocated for by trauma surgeons and those involved in injury control in all African countries. Although [Figure 1] shows surveillance as one point, it should be emphasized that surveillance is a continuous process - the means by which we monitor whether instituted improvements in injury prevention and trauma care have been successful.
Injury prevention is often misconstrued as merely admonitions to be careful. However, it is a scientific field, like that used to combat any other disease. It ascertains injury risk factors, develops scientifically sound prevention efforts to address these risk factors, assesses the outcome of these efforts, and promotes what can be proven to work. Injury prevention work usually involves three overlapping spheres of activities, including environment, vector (e.g. vehicle or other product or device), and a host (e.g., human behavior) [Figure 1]. To illustrate this for one of Africa's largest problems, road safety, these activities involve: (1) Roadways. Many features make a roadway safer or more dangerous, such as curvature, intersection design, signage, and shoulders. Promoting safer road infrastructure involves adequate engineering expertise in safety aspects of road design and maintenance and adequate surveillance data to know which section of roadways are, in fact having frequent crashes and need to be corrected.  (2) Vehicle design and maintenance. Many vehicles in use in Africa are old and in disrepair. Some of these issues such as brakes and tyres, have safety implications. Lowering import duties and other measures to increase the supply and decrease the cost of such safety-related spare parts have been suggested as a way to make vehicles safer.  (3) Driver behavior. There are many aspects of driver behavior that can lead to increased risk of crashes. Two stand out as the most significant to address: Alcohol use (drunk driving) and speed control. The African Ministerial Conference on Road Safety (Accra 2000) concluded that these should be emphasized in road safety efforts on the continent.
Although trauma care clinicians should obviously emphasize developing their own profession of caring for the injured, there is much that they can do to promote prevention efforts. This includes bearing witness to the human and financial cost of trauma and thus aiding those who do prevention work, as well as convincing politicians of the need to enact road safety and other injury prevention legislation. There is also a role for more direct involvement. For example, in the United State, trauma surgeons have developed program to screen injured drivers for alcohol abuse and to provide alcohol counseling to those who test positive. These programmed have been shown to decrease the rates of subsequent alcohol related crashes involving these drivers.  There is a need to develop similar versions of such program, oriented for the African context.
Trauma care should begin as soon as possible after the injury occurs, even in the field. The importance of the prehospital setting is made obvious by the fact that the majority of trauma victims die in the field. This is especially the case in Africa. A comparison of trauma mortality patterns among countries showed that 59% of all trauma deaths occurred in the field (e.g. outside the hospital) in Seattle, USA. These rose to 72% in Latin America and 81% in Kumasi, Ghana.  Thus, although improvement in hospital capabilities are obviously important, these improvements cannot do anything for those who die in the field. Many of these deaths are likely due to the condition that could be treated or quickly stabilized in the field, such as external bleeding and airway obstruction. The question arises on how to do this in the African setting, where there are, as of now, little formal emergency medical services (EMS) or ambulances. Middle-income South Africa has well-developed EMS systems in its cities. Many other countries have begun looking at developing ambulance services, primarily for cities and along major highways. This may ultimately prove very useful. However, the cost of such systems may be a limiting factors. In Malaysia, an economic analysis suggested that instituting a high-income country style ambulance services in Kuala Lumpur would only save seven lives per year, at a cost of US$2.5 million. obviously in this circumstance, funds cannot legitimately be diverted from other cost-effective-health program to such ambulance services.  Whether or not the exact figures of the Malaysian calculations are correct, the caution that this study urges is important. Any efforts to promote new ambulance services, especially in lower income countries, should be accompanied by rigorous evaluation of their costs and effectiveness.
Even while such formal EMS is being addressed, progress can also be made by building on existing, although informal, systems of prehospital care and transport. In every country, there is some system in place by which severely ill or injured persons are rushed to the hospital (at least about those who receive formal medical care). By system, we imply what has arisen by common usage in society, not necessarily the result of any formal planning. Such systems vary in different countries. In Ghana, this system primary consists of commercial drivers. A study in Kumasi showed that 71% of severely injured person were taken to hospital in commercial vehicle (taxis and buses), either by relative who hired the drivers or by the drivers themselves, oftentimes acting as Good Samaritans, taking injured persons away from the scenes of crashes that the drivers had come across in the course of the work.  A pilot program providing basic first - aid training to 400 commercial drivers increased the provision of first aid to injured persons, at an affordable cost. , Similar pilot program building on exiting patterns of prehospital care and transport need to be tried out, evaluated, and if successful, scaled up in other African countries.
We come now to the environment of most interest of trauma care clinicians. First, we need to ask what might need to be improved in such hospital based care and second how to do it. Concerning the need for improvement, a comparative study evaluated mortality rates for persons with life threatening, but treatable injuries. This showed that mortality in a hospital in Ghana (36%) was 6 times higher than mortality in a trauma center in the USA (6%).  This suggestion a high rate of death from medically preventable causes such as airway obstruction and bleeding from single abdominal organ injuries. Obviously, part of the reason for this discrepancy is resource availability, including high-cost, high-tech items such as computerized axial tomographic scans and angiography which will not be available routinely to all or even most injured persons in Africa for the foreseeable future, because of economic reality. We can nonetheless identify "weak links" in the chain of trauma care that can be targeted for low-cost and sustainable improvements. A variety of categories can be addressed:
In high-income countries, trauma care is usually envisioned as the domain of full trained surgeons and intensive care unit nurses. The availability of formally trained surgeons varies logarithmically across the world. There are estimated to be 50 surgeons per 100,000 persons in United State compared to seven per 100,000 in Latin America and 0.5/100,000 in Africa.  Thus, of necessity, trauma care in Africa, especially in rural areas, is provided primarily by generalist, often with limited capabilities for urgent referral of severely injured persons that cannot be adequate handle at rural hospital. Increasing the number of fully trained surgeons by developing and expanding surgical colleges in Africa countries clearly stands out as a priority. Even while this is being done, we also need to look at optimizing training for generalists in rural hospitals. For example, a study in Ghana looked at training for trauma care at the network of the district hospital. All of these were staffed exclusively by general doctors, without specialists. Most of these hospital received large numbers of casualties due to road traffic crashes. None of the doctors or nurses providing trauma care had any particular trauma training whether in the medical school, during the internship or postgraduate training or other continuing education courses. Moreover 30% of the doctors had not even done a rotation in surgery in their internship, yet were being called upon to perform major emergency surgery. , Locally designed continuing education courses, designed for the need of such general doctors, have been shown to be an effective method to improve the trauma care capabilities of rural hospital.  Furthermore, needing attention are the trauma skill of the nondoctor providers who staff the rural primary health care (PHC) clinics (more below, under access to care).
Low-cost items for trauma care are scarce at many hospitals in Africa, especially in rural areas. One study looked at 11 rural hospitals along major roads, all of which had high volumes of road traffic injuries. Equipment for trauma care was frighteningly scarce. None had chest tubes, and only four had airway equipment, all of which was kept locked in the operating theatre and was not immediately available for use in the casualty ward. These are all low-cost items, eminently affordable in the Africa context. The reason for their absence was not their cost, but lack of organization and planning to make sure they were there. 
Assuring adequate supplies is obviously one aspect of how the organization and administration for trauma care can be strengthened. One must also consider the proper utilization of resources. Here there are also problems that need to be addressed. A study at an urban teaching hospital revealed sustained problems with the process of trauma care. There was a mean of 12 h between presentation and start of emergency procedures. There was low utilization of chest tubes, even though they were physically present in the hospital. There was low utilization of fluid and blood resuscitation for patients in shock. This study identified quality improvement program (such as medical audit) was a possible means to address many of such problems in a comprehensive fashion.  Few African hospitals currently have such program.
Access to care
Many injured persons do not receive formal medical care. A household survey in Ghana revealed that 68% of injury person in the cities and only 51% in rural areas received formal medical care. The most frequent reason for not receiving such care was financial, related to the upfront user fees imposed for cost-recovery. Moreover, it is important to note that although we usually think of hospitals as being the site for trauma care, a great many rural people only receive care at nondoctor staffed PHC clinics. The same survey found that, of seriously injured (disability time >30 days) rural people, nearly equal numbers received care at only rural PHC clinic (36% of severely injured) as received care at hospital (38%). Thus, in addition to addressing care at hospitals, trauma care advocates must address the need of Africa's rural majority, many of whom will receive initial or even their only care at such minimally equipped PHC clinic. The optimal resources for trauma care at such facilities have only barely begun to be addressed.  The above example draw heavily from reports from Ghana. Similar problems are reported from most African countries. ,,, To meet the challenges these problem pose, we need to look at the examples of what has worked to improve trauma care in various setting and then consider how to make more progress in African and globally.
Effort to improve trauma care
Of course, many have been working hard to improve upon the problem noted above, both in Africa and around the world. Many have notable success stories to report. For example, Ali et al. in Trinidad improved trauma training by instituting the Advanced Trauma Life Support (ATLS) course in Trinidad. They reported a substantial decrease in mortality among the most severely injured group of patients, from 67% to 34% after most doctors staffing the casualty ward at the main trauma hospital in Trinidad been ATLS certified.  Similarly, in Thailand, trauma surgeons in Khon Kaen identified a high rate of medically preventable deaths due to correctable problems such as inadequate resuscitation for shocks, delayed surgery for head injuries, and problem with record keeping and communications. They took targeted corrective action, including improving communications with radios within the hospital, increasing staffing in the casualty ward by stationing fully trained attending (consultant/specialist) surgeons there during peak times, and improved monitoring of trauma cases, including the use of trauma registry and reporting on trauma care problems at hospital meetings. These improvements resulted in a decrease in mortality among all admitted trauma patients from 6.1% to 4.4%, all at an affordable and sustainable cost. 
Similarly, many high-income countries report improvements with the development of organized trauma systems. Such systems entail a region wide planning process to optimize trauma care, which addresses planning for prehospital care, hospital inspection and trauma services verification and relationships between hospitals at different levels of capability in the form of transfer protocols. Improved organization for trauma care along these lines has lowered death rates for all treated trauma patients by 15-20% and especially has lowered mortality from medically preventable cause (e.g. airway obstruction or death from isolated intra-abdominal organ injury) by over 50% usually with minimal additional expenditures. ,
The question arises on how to build on such isolated pilot program in developing countries and how to take the example of trauma system planning from high-income countries and combine them into a comprehensive approach to improve trauma care globally. This has been the aim of the Essential Trauma Care (EsTC) Project.
Essential trauma care
The World Health Organization (WHO) and the International Society of Surgery have developed a collaborative Working Group for EsTC, of which the authors of this paper are members. Working with trauma care clinicians and health service planner from every continent, this group has recently published Guidelines for Essential Trauma Care. These Guidelines put forth 11 EsTC services that the authors feel could and should be provided to every injured person worldwide, even in the poorest countries. These include medical straightforward services, such as "obstructed airways are opened and maintained before hypoxia leads to death or permanent disability. Although many of these may be obvious, they need to be clearly stated as a great many trauma patients worldwide currently do NOT receive these services. The Guidelines then go on to delineate 260 items of human resource (training and staffing) and physical resources (equipment and supplies) that are needed to assure the above noted trauma care services at the spectrum of health facilities, ranging from small rural PHC clinic to tertiary care facilities. These resources are designed as either essential or desirable. Essential items are the most important and most cost-effective. The authors of the Guidelines feel that every country could assure these to its population. Desirable items are those that add value, but also cost and are not as cost-effective as the essential items. They may be applicable more to middle-income countries or very high volume trauma care facilities. Generally, desirable items should not be emphasized until essential ones have been assured. A sample of one of the tables from the Guidelines is shown in [Table 1], for management of airway obstruction. The Guidelines also covers other aspect of initial resuscitation, as well as acute definitive care and rehabilitation. ,
Another important point to emphasize is that the designation of a recourse as essential does not merely mean that resource in physically present. Essential implies that the resource or related service is provided to all, who need it, in a timely fashion. Thus, user fees and cost-recovery schemes, important though they may ultimately be, cannot be allowed to interfere with the provision of essential emergency services.
The Guidelines also provide suggestions on ways to implement the above technical recommendations, including training program, quality assurance, hospital inspection and interaction among stakeholders. During their development, the Guidelines were reviewed by 40 experts from 20 countries, including representatives of 15 national and international organizations. In Africa, this included Ghana Medical Association and the trauma Society of South Africa.
The Guidelines are intended to be:
- Part planning guide for trauma care clinicians, hospital administrators, and planner in ministries of health. The matrices containing the 260 items for each of the four levels of the health care system are intended to provide a flexible template that countries, provinces or individual facilities can adjust to their own needs
- Part advocacy statement, putting forth those trauma care services that the WHO and the International Society of Surgery, as well as the other organizations and individuals involved, have endorsed as what countries worldwide can and should provide to their injured citizen.
Already, some progress has been made in using the guidelines in real world circumstances. They have been used for trauma care needs assessments in Ghana, India, Vietnam and Mexico. In India and in Mexico, WHO country offices, local government and other stakeholders have adapted the guidelines to local needs and developed preliminary implementation plans.
The authors of the current article highly recommend the Guidelines for Essential Trauma Care for consideration by trauma care clinicians and those organizing and administering health services that include trauma care in all countries throughout Africa. We feel that implementing the recommendations contained in these Guidelines will go a long way to strengthening trauma care throughout Africa by improved organization and planning at an affordable cost and in a sustainable fashion. More information about the EsTC project and the full text of the Guideline may be found on the WHO website: www.who.int/violenceinjury_prevention/publications/services/guildelines_traumacare/en/.
This site also contained forms that can be used in trauma care needs assessments, as have been done in Ghana, Vietnam and Mexico, as described above. The site also contains a brief policy statement that can be used to promote the recommendations contained in the Guideline. Paper copies of the Guidelines can be ordered from the WHO publications department (firstname.lastname@example.org).
| Capacity Building for Injury Control|| |
All of the above efforts for injury control involve the need for adequate capacity at a range of institutions, including ministries of health and transport, hospitals and clinics, universities and others. Such capacity includes adequate funding, requisites legal authority and adequate trained personnel. Expertise is needed in a range of discipline. For example, epidemiologist who can handle injury data, engineers who can deal with safety-related features of roads, vehicle and other project design; police, lawyer and policy makers who can assess traffic and other laws from a safety and health perspective. In addition, we need public health workers and media experts with capabilities in safety-related behavior change program. Finally, and most important for the readers of this journal, we need expertise in both clinical care and in administrating and planning trauma care services.
Africa obviously has many capable professionals in all of the above discipline. However, there are not nearly enough. We need to look at ways to increase the number and retention of the above professions. About trauma care, we need to better develop the surgical college of African countries, to train adequate numbers of qualified surgeons to meet the need of populations. We need to improve the trauma training received by general medical doctors, who will for the foreseeable future continue to be the backbone of the rural hospital serving the majority of Africans that live in rural areas. This also applies to nurses and other health care providers. Training for clinical care is not enough, we also needs to assure that administrators and planners have adequate understanding of trauma care issues. There needs to be sufficient experts, whether by clinicians or administrators/planners to design cost-effective and sustainable changes to really known what is working and what is not. This requires having adequate administrative, as well as research skills.  The model of having a cadre of trauma care clinicians with public health and administrative training needs to be promoted.
| Conclusions|| |
Trauma has become a massive health problem in Africa, progress can be made in lowering the burden of suffering from this disease by addressing the spectrum of injury control. This includes assuring adequate surveillance systems so as to have adequate information to make effective decisions on prevention and treatment strategies. It includes expanding currently rudimentary efforts for road safety and prevention of other forms of injury. It includes development of formal ambulance services in some locations. However, given the likely high-cost, such services should be developed cautiously and with adequate evaluation of their cost-effectiveness. There may be role for building on existing, although informal, systems of pre-hospital care and transport, such as providing first training for commercial drivers or others who already see, transport, and care for the injured person before they come to the hospital. In terms of clinic and hospital-based trauma care, considerable progress could be made by implementing the WHO and International Society of Surgery's Guidelines for Essential Trauma Care.
All of the above represent affordable, feasible and sustainable ways to strengthen the prevention and treatment of injuries throughout Africa. Given the high human and economic costs of trauma in Africa,  we cannot afford ignoring these steps. Surgeons and others providing trauma care have a role to play at all steps along this spectrum. This includes not only what they do with their hands in the operation theatre, but what they do in better organizing the entire trauma system in each country, and in bearing witness to the suffering of their patients, increasing the political will to attack the problem of injuries, and in advocating for improvement in the entire spectrum of injury control.
This example is for the skills and equipment for management of Airway obstruction in injured patients. Thirteen other matrices cover the spectrum of trauma care, including initial resuscitation, definitive acute care, and rehabilitations.
| What Trauma Surgeons and Other Trauma Care Clinicians Can Do|| |
Develop and promote standards for injury surveillance systems, so that efforts to improve injury prevention and treatment can be based on solid facts and can be monitored.
Assist those involve in prevention work by increasing political and popular will for road safety and other injury prevention strategies.
Develop African models for direct involvement of surgeons and other trauma care clinicians in injury prevention.
Develop and pilot test new formal EMS system (e.g. ambulance systems) in high impact areas, such as in cities and along major highways, with rigorous evaluation so as to know the cost-effectiveness of such new system.
Develop, pilot test and evaluate novels ways to improve upon existing although informal, patterns of prehospital care and transport, such as by first aid training for commercial drivers or other segments of the lay public who are likely to have frequency contact with injured persons.
Hospital based care
Promote the recommendations contained in the Guidelines for EsTC in individual facilities and within ministries of health.
Develop surgical colleges to meet the human resource needs for surgeons in African countries.
Develop and promote continuing education courses for trauma care pertinent for the Africa context, especially for the general doctors, who provide the majority of rural trauma care and for rural PHC workers at locations, where there are significant trauma volumes.
Develop and promote Truman quality improvement (such as medical audit) program for large hospitals with high trauma volumes, especially the teaching hospitals in major cities.
Promote improved access for trauma care by developing medical insurance or other payment methods so that user fees and cost-recovery schemes do not interfere with the provision of emergency care.
Increase the expertise and capacity for developing and administering organized trauma care systems, such as by developing a cadre of trauma care clinicians with extra training in administration and public health.
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