Simple changes save lives: a multi-centre clinical audit of the management of trauma patients on arrival at the emergency room in the Gaza Strip, occupied Palestinian territory

Abstract

BackgroundThe WHO trauma checklist reduces morbidity and mortality. This study evaluates adherence of three hospitals in Gaza to the basic WHO checklist standards in order to promote set standards of care. MethodsA multi-centre clinical audit was conducted at the three major hospitals in Gaza (Nasser Hospital, European Gaza Hospital, and Alshifa Hospital), which we refer to as hospitals A, B, and C. A prospective observational study was carried out to assess current trauma care practice and to compare this with the WHO trauma care checklist, which was used as a data collection sheet. A team member selected the sample prospectively and randomly from patients with trauma in the emergency department of each of the hospitals over a 3-month period (June to September 2017), and data were analysed using SPSS. FindingsIn each hospital, 50 patients were included, with mean ages of 9·5 years (SD 4·1 years), 21·3 years (7 years), and 13 years (9 years) in hospitals A, B, and C, respectively. The majority of these patients were male; 38 out of 50 patients (76%) in hospital A, 44 of 50 patients (88%) in hospital B, and 37 of 50 patients (74%) in hospital C. Road traffic accidents were the most common cause of trauma in hospitals A and C, whereas falling from a height of 2 m or greater was the most common in hospital B. All patients reached the emergency room within 30 min, mainly by ambulance in hospital A (28 of 50 patients; 56%), whereas private cars were the most frequent type of transportation to hospital B (28 of 50 patients; 56%) and hospital C (30 of 50 patients; 60%). Pre-hospital care was provided by non-trained first responders in all cases. In the emergency room, airway devices and chest drains were provided in all cases when indicated, but intravenous fluids and oximeters were not always used. Intravenous fluids were used in 32%, 34%, and 60% of indicated cases in hospitals A, B, and C, respectively. Oximeters were used in 72%, 74%, and 76% of indicated cases in hospitals A, B, and C, respectively. All patients were checked for internal and external bleeding and pelvic fractures, with immobilisation when indicated. In hospitals A and B, urinary catheters were used in some cases despite no appropriate indication (for 8% and 16% of patients with no indication in hospitals A and B, respectively). In hospital C, urinary catheters were only used when indicated. The broader treatment plan was discussed with patients' families, with good communication with units to which the patients were referred after the emergency room. In the majority of cases (126 of 150 patients), the treatment plan was not documented on the patient's trauma chart. InterpretationThe findings show that adherence to trauma care standards and emergency room care provision vary by hospital. Areas requiring improvement include pre-hospital care and documentation on the patient's trauma chart. Universal use of the WHO checklist, a simple adaptable tool, should facilitate the necessary improvements, and a re-audit should be carried out after this improvement are made. FundingNone.