Overview of the Essential Trauma Care Project

Abstract

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

Appendices

APPENDIX 1 INFORMATION ON THE INTRODUCTION AND PASSAGE OF A WORLD HEALTH ASSEMBLY RESOLUTION ON MODEL EMERGENCY AND TRAUMA CARE SYSTEM POLICY

This appendix seeks to promote the introduction and passage of a World Health Assembly (WHA) resolution to promote strengthening of health systems for the provision of trauma care and other aspects of emergency care globally. The foundation for this Resolution is the Model Emergency and Trauma Care System Policy, which follows. This Model Policy has been drafted, discussed, and edited by several consultation meetings involving the WHO and an international panel of experts.

The basic premise of the WHA Resolution on the Model Emergency and Trauma Care System Policy is that emergency and trauma care can be considerably strengthened worldwide at an affordable cost and in a sustainable fashion, primarily by improved organization and planning. Many lives could be saved by so doing. Technical details of how the Model Policy could be implemented are provided in several related WHO publications, as described on the following pages.

At this time, we are seeking to have this Resolution placed on the agenda for the WHA. The agenda for this meeting is usually formulated during July and August for the meeting that is held in April–May of the following year. The agenda and related formulation and eventual passage of WHA resolutions are typically done by ministers of health, or their designates. We are asking people who might be willing from any country to approach their Minister of Health to place this item on the agenda. It would be ideal for several countries to place the item on the agenda in a coordinated fashion. However, one country alone may request to have the Resolution placed on the agenda for the upcoming meeting.

MODEL EMERGENCY AND TRAUMA CARE SYSTEM POLICY

Revision: 2 July, 2005

These recommendations were developed at several consultation meetings, including:

• Meeting to Promote Implementation of the Guidelines for Essential Trauma Care, 10–11 June, 2004, WHO HQ, Geneva.

• Meeting to Promote the Development of Prehospital Care Systems in Low- and Middle-Income Countries, 6–7 December, 2004, WHO HQ, Geneva.

• Meeting to Formulate a Strategic Plan to Improve Prehospital and Emergency Care Systems in Low- and Middle-Income Settings, WHO HQ 28–29 June, 2005.

The recommendations represent a consensus of the participants as to what most countries should consider having in place within their overall health policy to assure minimum standards for care of the injured and other medical conditions requiring emergency care.

The purpose of this set of policy recommendations is to assure that all patients with severe injuries and other medical conditions requiring emergency care receive essential life and limb saving care in an appropriate and timely fashion. Essential items of care are defined in related WHO publications, including Guidelines for Essential Trauma Care and Prehospital Trauma Care Systems. Such essential services should be provided to all who need them without regard for ability to pay. This does not preclude the possible need for cost recovery, as appropriate, after essential services have been rendered.

1. OVERSIGHT

A responsible person or unit within the ministry of health or other appointed agency should be clearly defined as being in charge of assuring the minimum standards of trauma care and emergency care for that country. The personnel involved should have the necessary administrative skills and understanding of clinical trauma and emergency care issues. The department should have adequate resources and legal mandate to undertake its work. This department should work in a multi-sectoral, multi-disciplinary collaborative manner with other stakeholders in trauma care, including representatives of pertinent professional societies, other government agencies such as transport and justice, and communities.

2. PREHOSPITAL CARE

• A. In locations where there are currently no formal emergency medical services (EMS, or ambulance service):

  • 2.A.1. Governments should undertake systematic reviews of the prehospital trauma care and emergency care scenario, including identifying the unmet prehospital needs. This might include understanding the proportion of trauma-related deaths that occur in the prehospital setting and understanding the de facto prehospital transport system for severely ill and injured persons. Such reviews might reasonably also address non-traumatic emergency care needs.

  • 2.A.2. Alternative arrangements should be created for prehospital care in areas where formal EMS systems are not possible or practical. Governments should identify ways in which to build on existing, albeit informal de facto systems and harness community resources, such as by identifying high-yield groups of the lay public for basic first aid training. Such programs should be carefully evaluated as to their cost and effectiveness before being scaled-up or converted to a formal EMS system.

  • 2.A.3. Governments should explore the possibility of establishing formal EMS in high yield areas, such as in urban areas and along major inter-urban roadways. Such exploration should emphasize cost considerations, given the likely high cost of establishing such systems.

• B. In locations where there is formal EMS, governments should establish a monitoring agency to assure and promote minimum standards for training, equipment, infrastructure, and communication so as to assure delivery of prompt, quality, and equitable prehospital care. This agency should have mandate to regulate individual ambulance services, both private and governmental, to prevent unnecessary duplication of services and to assure adequate coordination among the services and between the services and other components of the emergency response system (e.g., fire, police, etc).

• C. The WHO’s Prehospital Trauma Care Systems should be used as a basis for developing all of the above. Systems that are developed should be locally sustainable and should fit with local culture, health care systems, and resources. Care should be taken not to follow high-income models, unless these really fit a given environment and its resources. Systems that are built should be available to all who need them without regard of ability to pay. This does not obviate the need for cost recovery eventually; but such cost recovery should not prevent the provision of emergency care.

3. FACILITY BASED TRAUMA CARE AND EMERGENCY CARE

Governments should establish the Guidelines for Essential Trauma Care (collaboratively developed by the WHO and the International Society of Surgery) as a basis for facility-based trauma care in the country, including hospitals and clinics that provide care to the injured.

Essential trauma care services should be provided to all who need them in a timely fashion without regard to ability to pay. This does not obviate the possible need for cost recovery, as appropriate, after essential services have been rendered. Such cost recovery should not prevent the provision of essential care.

These services and the related essential trauma care resource criteria could be promoted through several means, including:

A. Training

The knowledge and skills delineated in the Guidelines for Essential Trauma Care should form the basis for core competencies in the curricula of schools of medicine, nursing, and other pertinent allied health disciplines and in continuing education (in-service) courses. Such continuing education courses should be promoted and assured for all practitioners regularly providing trauma care.

B. Quality Improvement Programs

Quality improvement (QI) programs offer a means to assure the actual provision of quality essential services. It is to be emphasized that essential means not just the physical presence of resources, but that these resources are used to provide necessary care to all who need them in a timely and appropriate fashion. QI offers a means to assure this. Depending on the level of the facility, this might include monitoring of the structure, process, and/or outcome of trauma care. For smaller facilities that handle trauma cases, it would be reasonable to incorporate trauma related elements into more general QI programs. For larger facilities with high trauma volumes, specific trauma related QI programs would be reasonable, such as monitoring of preventable deaths using autopsy findings. Whatever QI processes are utilized, they should address the entire system, including prehospital care and rehabilitation.

C. Team approach and organization of initial resuscitation

Assuring the organization of the initial resuscitation can improve the prompt delivery of essential care. This often implies several providers working together in a team fashion with pre-assigned duties and responsibilities. This applies both to large urban centers with many providers as well as to smaller rural facilities with limited human resources. Improving the organization of the initial resuscitation by such means is an avenue to assuring the implementation of the Guidelines for Essential Trauma Care.

D. Facility inspection

Every health care system has some means of assuring and improving the provision of care at its facilities. The elements from the Guidelines for Essential Trauma Care should be incorporated into ongoing and new mechanisms for such review, especially for facilities with high trauma volumes.

E. Broader system considerations

The Guidelines for Essential Trauma Care are a means of promoting broader improvements in the health care system, including non-trauma care, such as surgical and other emergencies. It also should be linked with broader system issues, such as: surveillance; prevention; access; prehospital care; relations between facilities, including referral and reception; and reintegration of the injured person back into society. The Guidelines for Essential Trauma Care offers a means of assessment of the functioning of the broader health care system, for identification of weaknesses that could be strengthened in a cost-effective fashion.

4. SURVEILLANCE

Establishing affordable and sustainable improvements in care of the injured requires adequate, reliable, and timely information on injuries and related deaths. Improvements in systems for care of the injured need to be based on solid facts. Changes that are made need to be assessed so as to know which measures are effective, and hence should be continued and scaled-up, and which measures are ineffective, and hence should be modified or discontinued. Thus, all countries should have in place mechanisms for gathering the needed injury-related information, as a component of their broader health information systems. The WHO’s Injury Surveillance Guidelines should be used as a basis for assuring adequate information on injury to accurately guide injury-care policy.

Similar considerations apply to data sources for other conditions requiring emergency care. Such data sources should be sufficient to allow effective policy decisions.