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Can Focused Trauma Education Initiatives Reduce Mortality or Improve Resource Utilization in a Low-Resource Setting?

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Abstract

Background

Over 90 % of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization.

Methods

Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October–November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ 2 and Fisher’s exact test.

Results

A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3 %, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3–8 had the highest injury-related mortality, which significantly decreased from 58.5 % (n = 55) to 37.1 % (n = 23), (p = 0.009, OR 0.42, 95 % CI 0.22–0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3–5 in the post-intervention period had higher utilization of head CT scans and chest X-rays.

Conclusions

The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.

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Acknowledgments

Support for the Rwanda Injury Registry (local staff stipends, training, and registry printing) comes from a Fogarty International Clinical Research Fellowship, NIH and International Clinical Research Fellows Program at Vanderbilt University, USA (R24 TW007988) from February 2011–August 2012. Maintenance of the Rwanda Injury Registry is currently funded by the University of Virginia Department of Surgery. Salary for RTP (author) was funded by NIH 5-T32-AI-078875-03, PI: Robert G. Sawyer from July 1, 2012, to June 30, 2013.

Conflict of interest

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Authors and Affiliations

  1. Department of Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA

    Robin T. Petroze, Robert G. Sawyer & J. Forrest Calland

  2. Department of Accident and Emergency, Kigali University Teaching Hospital, Butare, Rwanda

    Jean Claude Byiringiro

  3. School of Medicine, University of Rwanda, Butare, Rwanda

    Jean Claude Byiringiro

  4. Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Butare, Rwanda

    Georges Ntakiyiruta & Patrick Kyamanywa

  5. Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

    Susan M. Briggs

  6. Centre for Global Surgery, McGill University Health Centre, Montreal, Canada

    Dan L. Deckelbaum & Tarek Razek

  7. Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

    Robert Riviello

  8. School of Medicine, University of Virginia, Charlottesville, VA, USA

    Jennifer Reid

Authors
  1. Robin T. Petroze
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  2. Jean Claude Byiringiro
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  3. Georges Ntakiyiruta
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  4. Susan M. Briggs
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  5. Dan L. Deckelbaum
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  6. Tarek Razek
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  7. Robert Riviello
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  8. Patrick Kyamanywa
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  9. Jennifer Reid
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  10. Robert G. Sawyer
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  11. J. Forrest Calland
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Corresponding author

Correspondence to J. Forrest Calland.

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Petroze, R.T., Byiringiro, J.C., Ntakiyiruta, G. et al. Can Focused Trauma Education Initiatives Reduce Mortality or Improve Resource Utilization in a Low-Resource Setting?. World J Surg 39, 926–933 (2015). https://doi.org/10.1007/s00268-014-2899-y

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  • DOI: https://doi.org/10.1007/s00268-014-2899-y

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