Improving Trauma Care in Low- and Middle-Income Countries by Implementing a Standardized Trauma Protocol

Abstract

Standardized trauma protocols (STPs) have reduced morbidity and mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not yet implemented such protocols, often due to financial and logistic limitations. We report preliminary findings from a trauma quality improvement (QI) initiative, using and evaluating the impact of a low-cost STP in an LMIC university hospital. We developed an STP based on generally accepted best practices and damage control resuscitation. It was designed for the resources available at the test institution. The Neiva University Hospital (NUH) is a tertiary care hospital and level I trauma center in Neiva, Colombia. As in most LMIC hospitals, there was no trauma information data system at NUH. Therefore, we adapted an administrative electronic database to capture clinically relevant information of adult patients who were hospitalized or died in the emergency department (ED) between August 2010 and June 2012 with an International Classification of Diseases, 10th revision (ICD-10) diagnoses indicating trauma (S00-Y98). Interventions that were recommended in the STP were compared in these two groups. Length of hospital stay (LOS) and mortality were also examined. A total of 4,324 patients were included, of whom, 2,457 patients were in the pre-protocol period and 1,867 were in the post-protocol period. The use of several interventions increased: blood product transfusions in the ED (1.0 vs. 2.7%; p < 0.001), use of hypertonic fluids in hypotensive patients (3.2 vs. 8.9 %; p < 0.001), placement of Foley catheters (11.1 vs. 13.8%; p = 0.007), arterial blood gas draws (16.6 vs. 26.4%; p < 0.001), tetanus vaccinations (19.3 vs. 26.0%; p < 0.001), placement of multiple large bore peripheral catheters (29.5 vs. 34.7%; p < 0.001), prophylactic antibiotics (34.9 vs. 38.0%; p = 0.035), and the use of analgesics (64.5 vs. 68.0%; p = 0.016). Other interventions also trended upwards. Length of stay (LOS) decreased for both surgical and non-surgical patients (surgical 13.4 vs. 11.8 days; p = 0.017; non-surgical 4.4 vs. 3.8 days; p = 0.059). All-cause mortality of trauma patients decreased (3.9 vs. 2.9%; p = 0.088). The institution of an STP at a university hospital in an LMIC has increased the use of vital interventions while decreasing overall LOS for all-cause trauma patients.