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Enhancing Training Capacity to Strengthen Pre-hospital Trauma Care in Developing Countries

By Sarah Arnquist | 12 Jun, 2011 Last edited by Robert Szypko on 02 Aug 2011

Injury is a major cause of death and disability worldwide. Prompt provision of emergency care and rapid movement of injured victims to a health care facility can save lives, decrease short-term disability, and improve long-term outcomes.

While trauma system development requires wide-ranging considerations, this GHDonline panel discussion from June 13-17 will focus on training programs. Emergency medicine and trauma care experts with experience working on every continent will lead a discussion around designing, implementing, and evaluating pre-hospital care training courses.

Panelists will begin the discussion by briefly introducing themselves and answering the following questions. We invite the community to join in the discussion and ask the panelists questions through Friday June 17.

Framing Questions:

1. What factors should be considered when selecting and developing an appropriate training curriculum for different audiences or cadres in pre-hospital care work force?

2. Which stakeholders should be involved in the training and capacity building process?

3. What program aspects should be measured and over what time frame?

4. What factors should be considered throughout the process to promote institutionalization and long-term viability of the training programs and ensure high quality trainees?

Panelists:

Manjul Joshipura, MBBS, MS, is a technical advisor to the WHO on global trauma systems development.

Paul Bollinger, MPH, oversees the Emergency Medical Care Train the Trainer education and systems development programs for Medical Teams International.

Ross Donaldson, MD, MPH, is the global head of International Medical Corps' emergency and disaster care development programming and a UCLA medical and public health professor.

Amado Alejandro Báez, MD, MPH, is the chair a department of emergency medicine and critical care in the Dominican Republic General Hospital and co-director of the Operational Medicine Institute.

Junaid Abdul Razzak, MD, is the chair of emergency medicine at Aga Khan University Hospital in Karachi, Pakistan.

Replies

 

Ross Donaldson Replied at 3:19 AM, 13 Jun 2011

Please introduce yourself and briefly describe your background/work in this area, including where you’ve worked:

I'm the global head of International Medical Corps' emergency and disaster care development programming. I also serve as the director for the emergency medicine global health program at the Harbor-UCLA Medical Center, as well as faculty at the UCLA schools of medicine and public health.

Although I've worked around much of the globe at various times, current ongoing programs in emergency care development include Iraq, Haiti, and Armenia. For example, over the last four years in Iraq we have trained thousands of personnel spanning the full spectrum from community to prehospital to hospital-based emergency care. We have also focused heavily on systems-building on multiple levels, supporting the development of a universal phone number, nation-wide emergency care health information systems, mass casualty response protocols, and many other system improvements, to build a modern emergency care system out of the ashes of conflict.

1. What factors should be considered when selecting and developing an appropriate training curriculum for different audiences or cadres in prehospital care work force?

There are three main keys to developing appropriate prehospital training materials for low- and middle-income countries. First, the curriculum should be for general emergency care training, as opposed to a specific vertical focus on trauma or another disease/injury process. Although specific processes are frequently the impetus for such programs, prehospital emergency care is a classic area for synergy; it should ideally address the many divergent illnesses that benefit from rapid treatment and transport.

Second, the curriculum should be evidence-based. Although the exact needs varies by locale, this almost always includes a strong focus on basic emergency care, as demonstrated by the Canadian OPALS Studies and other literature. Developers need to resist the tendency towards thinking that a higher level of prehospital care is always better and rather focus on first providing quality basic care in a rapid, accessible and systematic manner.

Third, the curriculum needs to be adapted to the local environment with local buy-in. Disease processes and emergency systems vary by country; the standard operating procedures of their prehospital personnel, as well as the training programs for these personnel also need be adapted to these differences, normally in partnership with national counterparts.

2. Which stakeholders should be involved in the training and capacity building process?

As the delivery of prehospital emergency care varies widely by country, it is not possible to give universal answers as to the choosing initial stakeholders. However, it is invariably true that the key to the long term success any emergency care development program is the buy-in of national stakeholders. Traditional stakeholders include the general community, medical community, and government, as well as humanitarian groups.

Our standard approach is to establish a local Emergency Medicine Working Group, in the initial stages of any emergency care development program. This can include high-level members of the government (e.g. Ministry of Health, Ministry of Transport, Ministry of Interior, etc., depending on country), national medical leaders, community leaders, representatives from other NGOs, as well as other identified individuals or groups.

3. What program aspects should be measured and over what time frame?

There are a host of possible indicators, depending on the emergency care development program focus and environment. These can include program indicators (e.g. training numbers, test scores), community indicators (e.g. using emergency care KAP studies), operational indicators (e.g. response time, call volume), and hard indicators (e.g. changes in morbidity and mortality).

Preferably, indicators should be measured before program onset, throughout the program, and at its termination. Such indicators should also ideally be incorporated into the capacity building of the prehospital system and continued to be measured in a sustainable manner far after the termination of any specific development project.

4. What factors should be considered throughout the process to promote institutionalization and long-term viability of the training programs and ensure high quality trainees?

Sustainability and institutionalization of program gains are of primary importance for successful prehospital emergency care development programs. To avoid misadventure, programs should have strong buy-in at multiple levels throughout society. Developers also need to give intensive thought to the cost-effectiveness of the program they are implementing, as well as to the long-term financial arrangements that will support the system into the future. Local government and/or community cost-sharing is a good way of establishing this early on in program development. System development and ongoing quality assurance/improvement is as important, or more important, than the initial training program. Experience shows that short-term trainings of prehospital personnel in the absence of local buy-in, financial support, and an overall system, are rarely sustainable or of long-term utility.

Manjul Joshipura Replied at 3:26 AM, 13 Jun 2011

• As a trauma care scientist at WHO HQ I provide scientific leadership and technical support in the field of trauma care to WHO departments and Member States. I support trauma system development, capacity building and quality improvement activities across countries. I have over 25 years of experience working as a Trauma Surgeon in both developed and developing countries.

1. Most short training courses will be off shoots of PHTLS or similar programmes. Long term programmes would follow more or less EMT (B) or EMT (A) type of curriculum. However in low and middle income countries the knowledge and skills imparted should match the resources that are going to be available to them. e.g. if there are no resources for advance airway management in the prehospital setting , will there be value in including ventilator management in the curriculum. The skills and knowledge will need to be retained in absence of it s regular use. WHO publication Prehospital trauma care systems (2005) clearly defines what knowledge and skills will be important based on the sophistication of the EMS in a given setting. Creating awareness and imparting basic life saving basic training in the community has a big role.

2. Trainers and EMS leaders will be the key stakeholders. Centres of Excellence in a country can take a lead to start the capacity building process. There are number of examples where university programmes in high income countries have played hand holding role to such institutions in low and middle income countries. Where available, professional associations (Emergency Medicine Physicians) can also play a central role. One important stakeholder in the setting of low and middle income country will be Ministry of Health. They are not easy to engage in the process however they can be encouraged to participate in this process then they can institutionalize the capacity building with a legislation in the country.

3. The training programmes should be measured over medium to long term only. Generally structure and process indicators are easy to measure.

4. Support from the Government is vital for a long term sustainability of such programmes , especially in low and middle income countries. Governments can make legislations, rules and set standards for such training. It can make mandatory such training for all EMS providers. Obviously the quality of such training would be critical too. Another important factor to ensure sustainability would be periodic re-certification of EMS providers which is can be considered only at a next stage development after introducing and then stabilizing the training programme.

Paul Bollinger Replied at 7:59 AM, 13 Jun 2011

I oversee the Emergency Medical Care (EMC) Train the Trainer education and systems development programs for Medical Teams International based in Portland Oregon. These programs focus on the reduction of secondary injury from trauma related incidents and enhancing EMS and trauma systems in developing countries (Cambodia, Moldova, Sri Lanka, Uganda, Uzbekistan and Vietnam). Program focus includes small community driven programming to nationalized system development from point of entry into the EMS system to discharge from hospital setting. I hold a master's degree in public health with a focus in international health. I have worked in the EMS field in both urban and rural settings for more than 25 years and have extensive field experience in Asia.

1. A key factor when introducing training curriculum is to provide curriculum that is in the local language. The curriculum should not just be a translation of an existing curriculum but a contextualization for use in the project area. This should include pictures, video and diagrams depicting the people within the service area actually demonstrating the skills and concepts being taught.

2. The key to a successful training program is to include all members of the first responder community. This includes both the pre-hospital and receiving hospital personnel. Additionally when introducing a “new” pre-hospital training program be sure that the local healthcare policy makers are aware that the training includes the provision of “non-physicians” providing healthcare outside of the hospital setting. The earlier that the key stakeholders are involved the more successful the project will be.

3. Each program is unique. Easy indicators to measure include both direct (# of students taught, curriculum developed, patients treated in a pre-hospital setting etc...) and indirect beneficiaries (# of potential trauma patients, service area catchment, etc...). Most projects will take at least three years to fully develop in areas where there has not been a previous EMS system.

4. Early engagement with key personnel within the medical education system is paramount to establish long term sustainability. Additionally identification of a local “champion” who has a passion and understanding of the program will help promote the project within respective ministries or local agencies.

Sarah Arnquist Replied at 9:02 AM, 13 Jun 2011

Posting on behalf of Dr. Razzak:

My name is Junaid Razzak. I am a board certified Emergency Medicine specialist with training in Public Health. I founded the first department of Emergency Medicine in Pakistan at the Aga Khan University and established the first organized residency training program in emergency medicine. I am also director of WHO Collaborating Center on Emergency Medicine and Trauma in Pakistan. I am currently working with a not-for-profit organization to establish prehospital emergency care system in the city of Karachi.

1. What factors should be considered when selecting and developing an appropriate training curriculum for different audiences or cadres in prehospital care work force?

a. Affordability
b. Relevance to the local setting and talent
c. Availability
d. Acceptability in the local licensing milieu
e. Acceptability in the international market in countries where many people are interested in enhancing their skills to make themselves more marketable in international market.

2. Which stakeholders should be involved in the training and capacity building process?

a. Local medical University/teaching institution
b. Local Licensing authorities
c. Government agencies that define medical care standards
d. Nursing societies
e. International partners

3. What program aspects should be measured and over what time frame?

a. Ability to enhance skills and the level of retention of such skills in obviously the key. A program with a good balance of theoretical training and skills enhancement needs to be looked at.
b. The program guidelines and training standards should be based on evidence especially when in countries where resources are scarce and doing interventions with questionable effectiveness, out of research, can take away resources from more pressing issues.
c. Affordability in the low income setting
d. Ability to teach more than medical care which is to enhance skills in patient and scene handling in out-of-hospital environment.
e. Training in soft skills such as communication, team work etc


4.What factors should be considered throughout the process to promote institutionalization and long-term viability?

a.A non-profit mandate helps in areas such as EMS.
b.Creating market for skills and knowledge in EMS by ensuring that jobs are available for trained staff and there is a career track.
c. Developing local or regional training hubs or perhaps centers of excellence in Pakistan context when travel for people have become very difficult
d. Ability to market the courses at a price which ensure local financial viability without making them unaffordable

Amado Alejandro Baez Replied at 1:38 PM, 13 Jun 2011

Please introduce yourself and briefly (few sentences) describe your background/work in this area, including where you’ve worked.
Amado Alejandro Baez. I am a US trained board certified emergency physician with fellowships in clinical research and critical care with masters degrees in Health Care Management (MSc) and Public Health MPH). I lived and worked in the USA for 11 years including residency at the Mayo Clinic and fellowship and a attending physician work at the Brigham and Womens in Boston. At the BWH, I served as associate director of emergency medical services leading administrative, research and development efforts in the fields of trauma, disaster and prehospital care. I have been involved in EMS/ Prehospital care for close to 18 years and have lectured, advised and consulted in EMS/ EM and Tauma in more than a dozen countries mostly low and middle income. Currently I chair a department of emergency medicine and critical care in the Dominican Republic at www.hgps.com.do, and where I consult and run projects with government and NGOs (PAHO, Interamerican Development Bank among others). I also am Co-Director of the Operational Medicine Institute (www.opmedinstitute.org).


What factors should be considered when selecting and developing an appropriate training curriculum for different audiences or cadres in prehospital care work force?
current state of EMS Education, previous experiences with training programs
Workforce (education, level of providers, number of providers)
current infrastructure (hospitals, access to ambulance services)
EMS system model (medicalized, paramedic-based) also known as Franco-German Based vs US-British Based

Which stakeholders should be involved in the training and capacity building process?
Public such as ministry of health, hospitals, universities, industry (tourism, free trade zones with required standards
Telephone companies
Public safety departments (police, fire)
Public works and road management companies
Private universities
Current ambulance providers

What program aspects should be measured and over what time frame?
Short term- clinical knowledge improvement (not just exam passing)
Knowledge translation with clinical effectiveness
Provider/ Population ratios to meet service demand
User/ patient satisfaction

What factors should be considered throughout the process to promote institutionalization and long-term viability?
Job security
Staff retention
Evolution of training schemes
Quality management programs

Regan Marsh Replied at 10:02 PM, 13 Jun 2011

Thank you to the discussants for their thoughts. I am an emergency physician in Boston and have worked in Haiti, Malawi and Zambia.

In my experience, EMS in resource-poor settings is limited to the wealthy, who can pay for private insurance and medical care; or, to intrafacility transfers, taking patients from health centers and district hospitals to higher levels of care.

Given that prehospital EMS can be costly to provide for staff, vehicles and fuel, what can be done to make these services widely available and avoid marginalizing the poor? [At the same time, understanding that there is a need for triage of truly emergent cases.] Are there ways to engage the community around triage using health workers or other community leaders?

Jason Friesen Replied at 10:09 PM, 13 Jun 2011

Good evening,
My name is Jason Friesen. I'm a paramedic from the US, and an MPH student, and I started a non-profit a few years ago that is dedicated to developing prehospital care in LMICs - Trek Medics International. I am currently working full-time for Project HOPE in Haiti, where we're involved in a very exciting, albeit extremely challenging emergency care development program (for both in-hospital and prehospital care).

While I have had the pleasure of meeting both Mr. Bollinger and Dr. Donaldson in the past, I would like to first thank you all for your invaluable work in a field where reliable, published literature is scant, and forums like this one even more so. Thank you very much for supporting this, and thanks to GHDonline.org as well, for bringing it all together.

I have a number of questions, so I'm going to try to keep them comparatively brief. Though my questions are directed at a particular panelist, I'd appreciate any thoughts or comments from the entire group however they see fit.

1. Dr. Joshipura - WHO's "Prehospital Trauma Care Systems" presents an extremely useful and practical framework for developing/improving prehospital care in LMICs. It's also the most comprehensive attempt to approach this field systematically, as is the entire Essential Trauma Care project. However, in terms of follow up materials, revisions, updates etc., it has not had quite as much "press" as other areas in the ETC program - and understandably so. Nonetheless, I wanted to know if there are any plans, projects or plans specifically by WHO-VIP to expand upon prehospital initiatives in the near future, whether in regards to publishing, or in terms of actual program implementation, especially in light of the "Decade of Action"? It's been well documented by everyone that prehospital care (and trauma/emergency care, in general), does not receive anywhere near the funding that other global health initiatives receive despite the clear benefit. Do you foresee this changing? And if so, how? What role do, or can collaborating centers have in this?


2. Dr. Razzak - To follow on my comments about expanding upon the work of WHO-VIP, you and your colleagues at Aga Khan University have written extensively on trauma care, and specifically on Monitoring & Evaluation, QA/QI, Surveillance, Prevention, Trauma Registries, and Peer-Reviewed Audits, among other topics. In the Aug. 2010 article you co-authored, "Placing Emergency Care on the Global Agenda", you wrote:

"Research on essential health care that is time sensitive and emergent has suffered from a relative neglect in the global health agenda, both in terms of health systems and research to guide system development and management."

I was hoping to see if you could elaborate upon that point - including the other research studies and analyses you discussed in that article - inasmuch as they relate specifically to prehospital care - i.e, What specific data, research or analyses would you consider "priorities" in prehospital care? More generally, what would the "Research Agenda" be for prehospital care? If you could get your hands on three definitive studies for prehospital care, what would they be? (and why?)

3. Dr. Baez - given your multi-disciplinary/cross-cutting work with the Operational Medicine Institute, as well as your work in formal clinical and prehospital settings, what would your suggestions be for incorporating disaster preparedness capacity building into prehospital care programs in developing countries? One of the unfortunate patterns that we're beginning to see develop here in Haiti with the second round of cholera is a clear emphasis on short-term "emergency/rapid response teams", and what seems to be a general lack of development for any long-term emergency care systems, which, theoretically at least, would be able to address disaster response "in stride", as it were (I'm going on the assumption that in either case you need trained responders, readily-available transport and functioning communications in the prehospital setting). I ask this specifically about Haiti because this appears to be the current approach, based on the RFAs that are being issued, and assuming that cholera will be here for a little while still, it is puzzling that donors at least appear more keen to devote short injections of funding to quick-fix rapid response teams without much attempt at developing emergency care for the long-term. So I guess my question is two-fold: 1) How might you develop a prehospital care system to incorporate disaster preparedness from the outset, and 2) What would your approach be to address the situation in Haiti as it is now from a prehospital care perspective, especially as many of the rapid response teams that are being funded are only funded until the rainy season ends? Follow up questions would be: What are the merits to differing approaches in developing capacities in prehospital access, treatment and transportation for an outbreak such as this one? What kind of case can/should be made by the "emergency care" sector to donors and the "communicable/infectious disease" sector, including the logisiticians who typically guide program design?

4. Dr. Donaldson, given your organization's involvement in both aspects, I'd also be interested to hear your thoughts, as International Medical Corps has extensive experience in both of these sectors, and is already involved in such programs here. Do you see a line being drawn between "Cholera Response" and "Emergency Care" in the eyes of donors? How much leeway is there in using funds for cholera response to develop long-term programs? Perhaps you also had experiences with this in Iraq during their cholera outbreak? (Assuming the IMC program was going on at the same time, and in the same place as their outbreak.)

5. Mr. Bollinger, I was wondering if you could share a bit about your experiences in Asia, particularly with Medical Team International's program in Sri Lanka. I think it would be very beneficial to hear more about how that program developed. Did it begin with the intentions of creating as expansive of a system as you did, or was that a result of process/"scaling up"? What were the factors that encouraged you to continue expanding, and what were some of the obstacles that got in the way (at least, the most notable or trying ones).

I would also be grateful for any thoughts on your experiences with the eRanger motorcycle ambulances in Mozambique, as Project HOPE is presently awaiting the arrival of two initial eRanger motorcycles here in Haiti.



While I have a few other questions, particularly in regards to a new communications system we're implementing here, I think that that has probably been enough for now.

Thank you for your time, and also for all of the admirable work each of you are making great contributions to.


Best regards,
Jason Friesen


www.trekmedics.org | www.projecthope.org

Manjul Joshipura Replied at 9:30 AM, 14 Jun 2011

WHO is currently in process of exploring possibility of creating a "Global Alliance for the care of the injured" to take these initiatives forward globally in a collaborative fashion. There are some specific country request for support in setting up systems on the basis of these guidance and documents. Recently launched UN Decade of Action for Road Safety also asks countries to scale up their work and improve the systems for the care of the injured.

Robert Szypko Replied at 2:35 PM, 14 Jun 2011

I have attached a chapter from the book "Disease Control Priorities in Developing Countries" that deals specifically with emergency medical services in resource-limited settings. The authors discuss ways by which emergency medical care can be improved in a cost-effective manner through better organization and planning. These improvements encompass changes to training and personnel, equipment and supplies, communications systems, and transportation systems. The authors also provide examples of emergency care delivery in the absence of an established emergency care system, and make recommendations for research and development.


Olive C. Kobusingye, Adnan A. Hyder, David Bishai, Manjul Joshipura, Eduardo Romero Hicks, and Charles Mock, "Emergency Medical Services." 2006. Disease Control Priorities in Developing Countries (2nd Edition),ed. , 1,261-1,280. New York: Oxford University Press. DOI: 10.1596/978-0-821-36179-5/Chpt-68.

Attached resource:
  • Emergency Medical Services (download, 692.9 KB)

    Summary: I have attached a chapter from the book "Disease Control Priorities in Developing Countries" that deals specifically with emergency medical services in resource-limited settings. The authors discuss ways by which emergency medical care can be improved in a cost-effective manner through better organization and planning. These improvements encompass changes to training and personnel, equipment and supplies, communications systems, and transportation systems. The authors also provide examples of emergency care delivery in the absence of an established emergency care system, and make recommendations for research and development.


    Olive C. Kobusingye, Adnan A. Hyder, David Bishai, Manjul Joshipura, Eduardo Romero Hicks, and Charles Mock, "Emergency Medical Services." 2006. Disease Control Priorities in Developing Countries (2nd Edition),ed. , 1,261-1,280. New York: Oxford University Press. DOI: 10.1596/978-0-821-36179-5/Chpt-68.

    Source: World Bank

    Keywords: Acute Trauma, Emergency medical system, EMS, first responders, Innovations for Resource-Limited Settings, pre-hospital care, trauma care

Robert Szypko Replied at 2:56 PM, 14 Jun 2011

This attached resource is a collection of graphs and charts that use the Global Burden of Disease 2000 database to document the breadth and nature of various measures of injury mortality and morbidity. The document contains an overview of injuries worldwide, which is followed by charts and graphs documenting road traffic accidents, fire-related burns, drowning, fall-related injuries, poisoning, interpersonal violence, and suicide. The available data is broken down by categories such as gender, age, region, and income level.


Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva, World Health Organization, 2002.

Attached resource:
  • The injury chart book: a graphical overview of the global burden of injuries (download, 495.8 KB)

    Summary: This attached resource is a collection of graphs and charts that use the Global Burden of Disease 2000 database to document the breadth and nature of various measures of injury mortality and morbidity. The document contains an overview of injuries worldwide, which is followed by charts and graphs documenting road traffic accidents, fire-related burns, drowning, fall-related injuries, poisoning, interpersonal violence, and suicide. The available data is broken down by categories such as gender, age, region, and income level.


    Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva, World Health Organization, 2002.

    Source: World Health Organization - WHO

    Keywords: Acute Trauma, Emergency medical system, EMS, first responders, Innovations for Resource-Limited Settings, pre-hospital care, trauma care

Robert Szypko Replied at 3:04 PM, 14 Jun 2011

Here is a works cited compiled by the organization Global Partners in Anesthesia and Surgery. It includes a variety of readings from scholarly journals and the World Health Organization, covering topics such as prehospital care, trauma care, injuries, and surgery in developing countries.

Attached resource:
  • Bibliography (download, 74.5 KB)

    Summary: Here is a works cited compiled by the organization Global Partners in Anesthesia and Surgery. It includes a variety of readings from scholarly journals and the World Health Organization, covering topics such as prehospital care, trauma care, injuries, and surgery in developing countries.

    Source: Global Partners in Anesthesia and Surgery - GPAS

    Keywords: Acute Trauma, Emergency medical system, EMS, first responders, Innovations for Resource-Limited Settings, pre-hospital care, trauma care

Robert Szypko Replied at 3:17 PM, 14 Jun 2011

Attached here is a set of guidelines compiled by the World Health Organization for health care administrators who seek to improve organized efforts to treat injuries (or trauma). Conscious of the differences in resource availability across regions, the authors make recommendations for improvements to training, trauma team organization, and hospital inspection. The report also includes a list of services essential to the needs of trauma patients, and a description of methods of emergency care.

Attached resource:
  • WHO Guidelines for essential trauma care (download, 763.4 KB)

    Summary: Attached here is a set of guidelines compiled by the World Health Organization for health care administrators who seek to improve organized efforts to treat injuries (or trauma). Conscious of the differences in resource availability across regions, the authors make recommendations for improvements to training, trauma team organization, and hospital inspection. The report also includes a list of services essential to the needs of trauma patients, and a description of methods of emergency care.

    Source: World Health Organization - WHO

    Keywords: Acute Trauma, Emergency medical system, EMS, first responders, Innovations for Resource-Limited Settings, pre-hospital care, trauma care

Robert Szypko Replied at 3:35 PM, 14 Jun 2011

This document, also compiled by the World Health Organization, seeks to outline key concepts for developing trauma care systems at the policy level. The authors discuss the design and administration of such a prehospital system, and outline the range of different trauma care providers and how to recruit and train them. Recommendations for resource acquisition, documentation, and quality improvement are also included, as are ethical and legal considerations that play into developing trauma care administration.

Sasser S,Varghese M, Kellermann A, Lormand JD.
Prehospital trauma care systems. Geneva,World Health Organization, 2005

Attached resource:
  • WHO Prehospital Trauma Care (download, 552.7 KB)

    Summary: This document, also compiled by the World Health Organization, seeks to outline key concepts for developing trauma care systems at the policy level. The authors discuss the design and administration of such a prehospital system, and outline the range of different trauma care providers and how to recruit and train them. Recommendations for resource acquisition, documentation, and quality improvement are also included, as are ethical and legal considerations that play into developing trauma care administration.

    Sasser S,Varghese M, Kellermann A, Lormand JD.
    Prehospital trauma care systems. Geneva,World Health Organization, 2005

    Source: World Health Organization - WHO

    Keywords: Acute Trauma, Emergency medical system, EMS, first responders, Innovations for Resource-Limited Settings, pre-hospital care, trauma care

Amado Alejandro Baez Replied at 3:46 PM, 14 Jun 2011

So I think that educational\ training needs, have to be looked at from a global perspective. One needs to take into account the system as a whole, available hospitals, levels and numbers of medical providers, funding-compensation.
A few years ago we wrote a basic paper outlining needs assessment system elements, based on the proposed components of the 1973 EMS Act, with education being a key component.
Here is the article link:
http://www.emsworld.com/web/online/Operations/What-a-Prehospital-Care-System-...

Alejandro Baez MD, MPH, FAAEM, FCCP
Emergency Medicine / Critical Care
Enviado desde mi dispositivo BlackBerry®

Junaid Razzak Replied at 1:27 AM, 15 Jun 2011

If you look at the global research and practice agenda, pre-hospital or hospital based emergency care is still in light of the usual "disease based" model. WHO's publications of Prehospital Care of Trauma would be one such example. A lot of work has been carried out by the Maternal Health researchers on Prehospital Care for patients with complications of pregnancy. Interestingly the investments in terms of human resources and equipment would be somewhat similar in prehospital arena for most diseases.

I think one of the studies that needs to be done is to asses the impact of setting pre-hospital care system on rates of deaths or disability/morbidity. Secondly, if we can show the cost-effectiveness of pre-hospital care intervention. DCPP document as highlighted above identified the interventions by lay-rescuers as a cost-effective intervention for trauma. But Pre-hospital care is much more than that.

Paul Bollinger Replied at 10:18 AM, 16 Jun 2011

Mr. Friesen,

It is good to hear from you. Here is a brief overview of the development of our programming in Sri Lanka.
Medical Teams International (MTI) is an international, nongovernmental organization based in the United States of America that works with more than 30 countries. MTI arrived in Sri Lanka after the 2004 devastating Tsunami and, after its initial response activities, started to work towards the development of pre-hospital care in Sri Lanka with the collaboration of the Trauma Secretariat of the Ministry of Health Care and Nutrition.

The Trauma Secretariat of Sri Lanka was established by the Ministry of Health Care and Nutrition in September 2006 and officially launched on January 1, 2007. Its vision is to provide timely, appropriate, quality and cost-effective medical care to trauma victims by a coordinated, sustainable trauma system with improved preparedness. The Trauma Secretariat is working toward establishing a comprehensive trauma care system by integrating prevention, pre-hospital care, hospital care and rehabilitation into one system that includes surveillance and policy development.

Medical Teams International trains EMTs in three categories under a Memorandum of Understanding (MOU) with Ministry of Health Care and Nutrition. They are:
• Emergency Medical Technician Level 1 which is equal to the standards of Medical First Responder in the USA.
• Emergency Medical Technician Level 2 which is equal to level of Emergency Technician-Basic in the USA.
• Emergency Medical Technician Level 3 which is equal to level of Emergency Technician-Intermediate in the USA.

Medical Teams International has also trained more than 2000 Emergency Medical Technicians to support the pre-hospital l care systems under MOUs with Ministry of Health and Nutrition and Ministry of local Governments of Sri Lanka.

Out of these trained EMTs, 46% have received training on EMT level 1, 20% have received training on Level 2, and 32% have received training on both Level 1 and 2. Only 2% of EMTs have, however, received training on Level 3.

Regan Marsh Replied at 3:08 PM, 16 Jun 2011

Dear panelists,

Thanks again for your comments. In your experiences, have EMS programs by run primarily by hospitals/teaching institutions or by governments (local or national)? And given resource limitations, and often transport difficulties, what processes were in place to 'triage' the use of the EMS services to the most appropriate?

Dr Razzak,
In response to your question above about cost effectiveness, at the recent SAEM meeting, there was an abstract presented about a recently established EMS program in rural Uganda -- as part of the Millennium Villages project. Around 75% of their transports were for maternal complications. They did cost effectiveness analysis, finding an extremely low dollar-value per each life saved. If I can find a link to the abstract, I will post it shortly.

Paul Bollinger Replied at 9:20 AM, 17 Jun 2011

Many of the EMS programs developed and implemented by MTI have been in direct partnership with the Ministry of Health or a local/national academic institution. Early integration into the national health education system, recognition and adoption of EMS as part of the healthcare delivery system is essential to long term programmatic sustainability. At the recent WADEM congress in Beijing I presented a poster about our project in Jaffna, Sri Lanka that was nearly sustainable within the first year by utilizing a limited fee (based on ability to pay) for service model. The abstract can be located in Prehosp Disaster Med 2011;26(Suppl. 1):s144-145.

Maureen McCunn Replied at 9:56 AM, 17 Jun 2011

Thank you for initiating this discussion. I am a trauma anesthesiologist
that has worked in trauma care training in low and middle income countries,
and emerging economies, for over 10 years. I focus on care of the trauma
patient at admission to hospital, not specifically on pre-hospital care.

I am faculty for the *Comprehensive Trauma Life Support course* in
*India*(in co-ordination with the International Trauma Anesthesia and
Critical Care
Society); and *the Sequential Trauma Education ProgramS (STEPS) *in* Egypt*.
STEPS was developed with an NIH grant and initially taught through the MOH
in Cairo, and for the past several years has transitioned to Ain Shams and
Alexandria Universities. STEPS is now required by the Egyptian Board of
Emergency Medicine for all residency graduates.

I have been working on a *systematic review of global trauma training
courses* for 2 years (in manuscript preparation). We have identified 47
courses that are taught globally, most of which were developed in HIC and
taught in HIC, as opposed to where the greatest need lies. 63% of the
courses were identified in the literature review and the remaining 27%
courses were found through agencies, societies, and professional contacts.
67% of courses are given in high-income countries (HIC); 8% upper-middle
income countries (UMIC); 8% lower-middle income countries (LMIC); 17% lower
income countries (LIC). Few courses are designed specifically for
physicians; most include health care providers with variable levels of
education and training. LMIC tend to have region-specific trauma courses as
opposed to courses that are offered globally.

We have also completed a database query to define *anesthesia capacity in 22
LMIC* (590 facilities) by using the WHO Global Initiative for Emergency and
Essential Surgical Care (GIEESC) Situational Analysis tool. The majority of
facilities were district/rural/community hospitals (34.7%), followed by
health centres (23.2%), private/NGO/missions hospitals (16.6%), provincial
hospitals (11.7%), and general hospitals (13.1%). All facilities reported
presence of an anaesthesia provider, most often a nurse or clinical
assistant. Hospitals with > 200 beds reported a range of 2-10 providers.
Forty percent of hospitals had no anaesthesia machine and 35% of facilities
had no access to oxygen. Most facilities used ketamine (71.5%); spinal
anaesthesia was offered by 65.5% of facilities surveyed, regional
anaesthesia by 56% and inhalational anaesthesia by 58.5%. We have
demonstrated that the delivery of safe anaesthesia is impaired by
deficiencies in basic infrastructure: human resources, equipment
availability and system capacity.

I agree with comments that the material that is taught should be
country/region-specific, in the local language (often difficult), determined
by host nationals, and skills should utilize equipment that is available in
the area. Cost is also a challenge and should be figured in local currency;
per diem expectations can add to cost for both visiting faculty and
attendees. Didactic material can certainly include additional knowledge and
techniques. We are hoping to expand emergency, anaesthesia and trauma
training at a site in Kenya.

Maureen McCunn, MD, MIPP, FCCM
Anesthesiology and Critical Care Medicine
University of Pennsylvania
3400 Spruce Street, Dulles 6
Philadelphia, PA 19104
215-662-7832 (office)
215-301-2374 (iPhone)

Doruk Ozgediz Replied at 11:57 PM, 19 Jun 2011

Thanks to all the panelists for sharing their experiences and for the creation of this forum. I am a general and pediatric surgeon working with the group Global Partners in Anesthesia and Surgery. Our focus has primarily been on supporting the post-graduate programs in anesthesia and surgery in Kampala Uganda through a host of projects, for the last seven years. With local leaders, three years ago we delivered a trauma course for lay first responders based on international guidelines, published literature, and modified for the local context by stakeholders. Attached is one paper explaining our experience with need, design, and implementation. Another paper was on the short term follow up, including estimates of cost-effectiveness ($0.12-36/capita to deliver; $25-150/life-year saved). This can be found at PLOS One as a free download at http://tinyurl.com/5rks7t

Robust estimates of effectiveness were difficult, as good data on injury morbidity and mortality were lacking, as in other similar settings. Our curriculum, evaluation forms, the local kit that was assembled etc. are all in the papers and on our website (www.globalpas.org) in case they may be useful to other groups. Sustainability has been a major challenge, due to many of the factors cited in comments above. We have also worked with the local surgeons to design a hospital-based trauma course adapted to the local context, for post-graduate trainees, which has since been independently delivered by local surgeons. It would be useful to see how such programs, in both prehospital and hospital based trauma care, succeed and perhaps more importantly, fail, in other settings so we can continue to learn from each other’s work.

Attached resource:
  • Prehospital design (download, 329.7 KB)

    Summary: Thanks to all the panelists for sharing their experiences and for the creation of this forum. I am a general and pediatric surgeon working with the group Global Partners in Anesthesia and Surgery. Our focus has primarily been on supporting the post-graduate programs in anesthesia and surgery in Kampala Uganda through a host of projects, for the last seven years. With local leaders, three years ago we delivered a trauma course for lay first responders based on international guidelines, published literature, and modified for the local context by stakeholders. Attached is one paper explaining our experience with need, design, and implementation. Another paper was on the short term follow up, including estimates of cost-effectiveness ($0.12-36/capita to deliver; $25-150/life-year saved). This can be found at PLOS One as a free download at http://tinyurl.com/5rks7t

    Robust estimates of effectiveness were difficult, as good data on injury morbidity and mortality were lacking, as in other similar settings. Our curriculum, evaluation forms, the local kit that was assembled etc. are all in the papers and on our website (www.globalpas.org) in case they may be useful to other groups. Sustainability has been a major challenge, due to many of the factors cited in comments above. We have also worked with the local surgeons to design a hospital-based trauma course adapted to the local context, for post-graduate trainees, which has since been independently delivered by local surgeons. It would be useful to see how such programs, in both prehospital and hospital based trauma care, succeed and perhaps more importantly, fail, in other settings so we can continue to learn from each other’s work.

    Source: Global Partners in Anesthesia and Surgery - GPAS

    Keywords: Acute Trauma, Emergency medical system, EMS, first responders, Innovations for Resource-Limited Settings, pre-hospital care, trauma care

Sarah Arnquist Replied at 10:05 AM, 22 Jun 2011

On behalf of GHDonline, I would like to thank the participants in this discussion. Building capacity for prehospital care is critically important and cuts across multiple aspects of global health system development.

GHDonline hopes to host organized panel discussions like this on a regular basis in each community. If you have an idea for a discussion topic or are interested in helping organize a panel, please email me at . Also, if you have any suggestions on ways we can improve the format, email me.

I just uploaded a video to the site of a Pakistani man driving a motorcycle laden with his eight children coming home from school. http://bit.ly/lFnbKf Nine people on one motorcycle!

GHDonline moderator Lubna Samad's husband took the video with his iPhone while driving home from work one afternoon in Karachi. Unfortunately, the video won’t be shocking to those of you working on developing trauma care systems. You've already seen the frightening consequences of the failing transportation systems in many countries. Hopefully, by sharing lessons and knowledge through GHDonline and other platforms, your efforts can reduce the morbidity and mortality from road traffic accidents.

Thanks again for all your hard work.

sarah

Sarah Arnquist Replied at 12:30 PM, 15 Aug 2011

Hi Everyone,

Thanks again for participating in this discussion on training and capacity building for pre-hospital care. We've summarized the discussion into a two-page brief available here: http://bit.ly/nwnLYn

If you come across additional resources related to pre-hospital care that the community would find useful, please post them.

This Community is Archived.

While this community is no longer active, we invite you to review and recommend past posts and resources. Membership for this community is closed, but we hope you'll join us in one of the many other communities on GHDonline.

Moderators of Global Surgery & Anesthesia and GHDonline staff