Delivery Of Trauma Care Research Articles

Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway

BackgroundTrauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016–July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts.MethodologyA qualitative study design was used to examine the Mosul civilian trauma response. From August–December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified.ResultsThe Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system.ConclusionsThe Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.

Challenges to trauma care delivery for Australian and New Zealand trauma clinicians

IntroductionThe availability and implementation of evidence-based care is essential to achieving safe, quality trauma patient outcomes. Little is documented, however, about the challenges trauma clinicians face in their day-to day practice, or their views on the availability of evidence. This paper presents the most significant clinical practice challenges reported by multidisciplinary trauma care professionals in Australia and New Zealand, in particular those that may be resolved with focussed research or enhanced implementation activity. MethodsAn exploratory survey of trauma professionals from relevant Australia and New Zealand professional organisations was conducted between September 2018 and February 2019 using the Snowballing Method. Participants were recruited via a non-random sampling technique to complete an online survey. Thematic analyses were conducted. ResultsThere were nine significant clinical practice challenge themes in trauma care, arising from 287 individual clinical practice challenges reported. The most reported being clinical management (bleeding, spinal, older patients) and operationalisation of the trauma system. There was no consensus as to the availability of evidence to guide each theme. ConclusionFuture research should seek to address the clinical practice challenge of Australian and New Zealand trauma community to enable safe, quality trauma patient outcomes.

Managing the multiply injured patient: the impact of multidisciplinary teams.

Management of trauma has been tackled at a national level to improve patient care and mortality. Decision making through a multidisciplinary team approach has resulted in improved patient outcomes through a complex combination of changes. While the focus of trauma care delivery has been towards establishing an effective multidisciplinary trauma service, there are still improvements which can be made. This article reviews the history of trauma care in the UK, and the impact that multidisciplinary teams have had on the management of the multiply injured patient.

Determining the priorities for change in paediatric trauma care delivery in NSW, Australia

BackgroundInjury remains the leading cause of death and disability for Australian children. There is known variability in the quality of care delivered to injured children in Australia. This study prioritises recommendations developed from an expert review of paediatric trauma cases, for implementation with the aim of improving health service delivery to children sustaining severe injury. MethodsA modified-Delphi study was conducted between October 2018 and February 2019. Two rounds of an online survey to rank the suitability and importance of each of the 26 recommendations was conducted. Final decisions on the priorities for change in the paediatric trauma system was determined by a consensus of ≥80% for importance and/or suitability. ResultsOne hundred and one participants completed Round 1, and 60 participants completed Round 2 of the modified-Delphi. In Round 1, 13 recommendations reached ≥80% and in round 2, 11 recommendations reached ≥80%. Those ranked highest focussed on pre-hospital airway management, streamlining retrieval and transfer processes, improving hospital nursing ratios and radiology reporting. ConclusionThis modified-Delphi study identified the priority areas for recommended change to the NSW paediatric trauma system. Work to address these areas has the potential to provide more coordinated and timely care to children sustaining severe injury.

What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units?

The Trauma network was established in April 2012 in England to improve the care of patients with trauma. The care of major trauma was centralised to major trauma centres. This article aims to survey trauma team members (TTM) to compare perceptions of trauma care delivery in major trauma centres (MTC) and trauma units (TU) from where major trauma care has been diverted. Trauma team members (TTM) from six hospitals were interviewed between June and July 2016. This included three MTCs and their neighbouring TU. Data were also gathered to determine appropriate trauma qualifications of TTMs. TTMs in MTCs perceived the standard of trauma service improved (90% increased, 10% same) since April 2012 in comparison to TUs (10% increased, 63% same, 27% decreased) (p ≤ 0.001). In MTCs, TTMs felt their skills improved more (66% improved, 34% unchanged) compared to TU's (24% improved, 64% unchanged, 12% regressed) (p ≤ 0.001). TTM's in MTCs were more satisfied with their trauma teams training (p ≤ 0.001), leader's communication (p ≤ 0.001) and handover process (p ≤ 0.01) in comparison to TTMs in TUs. 69% of doctors in MTCs held valid trauma qualifications as compared to only 37% in TUs (p ≤ 0.001). The centralisation of major trauma care to MTCs allows care for severely injured patients in specialised hospitals with allocated resources. This survey shows the effect of this reorganisation where diversion of major trauma from TUs may have led to their TTMs perceiving their standard of care to be less than TTMs in MTCs. This study recommends training support for TUs using modalities such as simulation-based training and regular audits to ensure improved perceptions and adequate qualifications. Multidisciplinary meetings between MTCs and TUs can allow information to be exchanged and shared to ensure reciprocal support and engagement to improve perception of trauma care delivery.

A Data-Driven Approach to Team Training for Nurses in a Level II Trauma Center.

This prospective investigation describes the process of designing a targeted, data-driven team training aimed at reducing identified process inefficiencies or flow disruptions (FDs) that threaten the optimal delivery of trauma care. Trained researchers observed and classified FDs during 34 trauma cases in a Level II trauma center. Multidisciplinary trauma personnel generated interventions to identified issues using the human factors intervention matrix (HFIX). This article focuses on one intervention: a formal trauma nurse training program centered around leadership, teamwork, and communication. The training was well perceived and was found to have a significant impact on participant knowledge of course content; t (65) = -13.92, p ≤ .01. By using hospital-specific data to drive intervention development from multidisciplinary team members, it is possible to develop effective solutions aimed at addressing individual threats.

The "Top 10" research and development priorities for battlefield surgical care: Results from the Committee on Surgical Combat Casualty Care research gap analysis.

The US Military has achieved the highest casualty survival rates in its history. However, there remain multiple areas in combat trauma that present challenges to the delivery of high-quality and effective trauma care. Previous work has identified research priorities for pre-hospital care, but there has been no similar analysis for forward surgical care. A list of critical "focus areas" was developed by the Committee on Surgical Combat Casualty Care (CoSCCC). Individual topics were solicited and mapped to appropriate focus areas by group consensus and review of Eastern Association for the Surgery of Trauma (EAST) and Joint Trauma System guidelines. A web-based survey was distributed to the CoSCCC and the military committees of EAST and the American Association for the Surgery of Trauma. Topics were rated on a Likert scale from 1 (low) to 10 (high priority). Descriptives, univariate statistics, and inter-rater correlation analysis was performed. 13 research focus areas were identified (eight clinical and five adjunctive categories). Ninety individual topics were solicited. The survey received 64 responses. The majority of respondents were military (90%) versus civilians (10%). There was moderate to high agreement (inter-rater correlation coefficient = 0.93, p < 0.01) for 10 focus areas. The top five focus areas were Personnel/Staffing (mean, 8.03), Resuscitation and Hemorrhage Management (7.49), Pain/Sedation/Anxiety Management (6.96), Operative Interventions (6.9), and Initial Evaluation (6.9). The "Top 10" research priorities included four in Personnel/Staffing, four in Resuscitation/Hemorrhage Management, and three in Operative Interventions. A complete list of the topics/scores will be presented. This is the first objective ranking of research priorities for combat trauma care. The "Top 10" priorities were all from three focus areas, supporting prioritization of personnel/staffing of austere teams, resuscitation/hemorrhage control, and damage-control interventions. This data will help guide Department of Defense research programs and new areas for prioritized funding of both military and civilian researchers. Study design, level IV.

Current Status of Musculoskeletal Trauma Care Systems Worldwide.

Although general trauma care systems and their effects on mortality reduction have been studied, little is known of the current state of musculoskeletal trauma delivery globally, particularly in low-income (LI) and low middle-income (LMI) countries. The goal of this study is to assess and describe the development and availability of musculoskeletal trauma care delivery worldwide. A questionnaire was developed to evaluate different characteristics of general and musculoskeletal trauma care systems, including general aspects of systems, education, access to care and pre- and posthospital care. Surgical leaders involved with musculoskeletal trauma care were contacted to participate in the survey. Of the 170 surveys sent, 95 were returned for use for the study. Nearly 30 percent of surgeons reported a formalized and coordinated trauma system in their countries. Estimates for the number of surgeons providing musculoskeletal trauma per one million inhabitants varied from 2.6 in LI countries to 58.8 in high-income countries. Worldwide, 15% of those caring for musculoskeletal trauma are fellowship trained. The survey results indicate a lack of implemented musculoskeletal trauma care guidelines across countries, with even high-income countries reporting less than 50% availability in most categories. Seventy-nine percent of the populations from LI countries were estimated to have no form of health care insurance. Formalized emergency medical services were reportedly available in only 33% and 50% of LI and LMI countries, respectively. Surgeons from LI and LMI countries responded that improvements in the availability of equipment (100%), number and locations of trauma-designated hospitals (90%), and physician training programs (88%) were necessary in their countries. The survey also revealed a general lack of resources for postoperative and rehabilitation care, irrespective of the country's income level. This study addresses the current state of musculoskeletal trauma care delivery worldwide. These results indicate a greater need for trauma system development and support, from prehospital through posthospital care. Optimization of these systems can lead to better outcomes for patients after trauma. This study represents a critical first step toward better understanding the state of musculoskeletal trauma care in countries with different levels of resources, developing strategies to address deficiencies, and forming regional and international collaborations to develop musculoskeletal trauma care guidelines.

Electronic referrals for virtual fracture clinic service using the National Integrated Medical Imaging System (NIMIS).

Virtual fracture clinics (VFC) are now prevalent across many orthopaedic services in the UK and Ireland. The management of a variety of musculoskeletal injuries using the VFC model has been demonstrated to be safe, cost-effective and associated with high levels of patient satisfaction. Referrals were made available through the National Integrated Medical Imaging System (NIMIS). NIMIS allows for electronic movement of patient images throughout the Irish health service. A retrospective review of 157 orthopaedic fracture referrals from a regional hospital was performed. The referrals were received during a 6-week period between May 2016 and June 2016. Each of these referrals was sent electronically. These referrals were reviewed each day by a consultant-led multi-disciplinary team. Thirty (93%) patients agreed or strongly agreed that they received adequate information in relation to the VFC when they attended the emergency department (ED). All patients except for one either agreed or strongly agreed that they were satisfied with their recovery (97%). Fifteen parents advised us that they would have had to take time off to attend fracture clinic with their child. Two patients attended their general practitioner (GP) or ED to seek further pain relief following their injuries. Only one patient reported a poor clinical outcome. Nine (28%) patients reported that they would have preferred a face-to-face appointment rather than being treated by the VFC. Virtual review of orthopaedic trauma patients results in satisfactory patient outcomes. Clinical outcomes were acceptable with minimal additional medical attention required following injury. Electronic transfer of information allows for the virtual service to operate from sites long distances from the primary orthopaedic centre. The NIMIS is a safe and confidential means of collaborating with other institutions and has huge potential in the areas of trauma care delivery, clinical conferencing and other image-based disciplines.

Achieving Better Integration in Trauma Care Delivery in India

Interdependencies among healthcare providers result in complex healthcare supply chains with fragmented healthcare processes characterized by coordination failure and incentive misalignment. In developing countries where resources are scarce such coordination failures can have a severe impact on patient health. However, limited knowledge exists about how coordination takes place across and within the different healthcare service providers and how this influences hospital transfer time and length of stay. This article research this gap by studying trauma care delivery in India using a patient survey ( n = 104). The Indian healthcare system is insightful because India has to provide low-cost care to large populations living in geographically big areas and the healthcare infrastructure struggles to meet increasing demands. The findings suggest mechanisms to better integrate the processes from the accident site to the hospital which include setting up referral processes, 24-hour ambulance services, using third-party coordinators and process improvement within the hospital following lean principles.

Cultivating Global Surgery Initiatives Abroad and at Home.

Cultivating Global Surgery Initiatives Abroad and at Home.

PD02-01 IMPACT OF TRAUMA CENTER DESIGNATION ON RENAL TRAUMA OUTCOMES: EVIDENCE FOR UNIVERSAL MANAGEMENT

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I1 Apr 2018PD02-01 IMPACT OF TRAUMA CENTER DESIGNATION ON RENAL TRAUMA OUTCOMES: EVIDENCE FOR UNIVERSAL MANAGEMENT Marc Bjurlin, Audrey Renson, Richard Jacob Fantus, and Richard Joseph Fantus Marc BjurlinMarc Bjurlin More articles by this author , Audrey RensonAudrey Renson More articles by this author , Richard Jacob FantusRichard Jacob Fantus More articles by this author , and Richard Joseph FantusRichard Joseph Fantus More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.226AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tiered delivery of trauma care has resulted in improved trauma outcomes at level I trauma centers compared to non-level I centers. In the era of conservative management of kidney injuries, comparison of outcomes of renal trauma by hospital designation is not well studied. Our study objective was to evaluate the initial management of renal trauma, assess patterns of management based on hospital trauma level designation, and analyze management trends over time. METHODS This retrospective cohort study included renal trauma from the National Trauma Data Bank 2010-2015. We examined the association between hospital trauma level designation (level I vs transferred to level I vs non-level I), and renal trauma management including nephrectomy, angioembolization, and nonoperative management, along with presence of any annual linear time trends in management. RESULTS We analyzed 51,798 renal trauma records; 44,838 low grade (AAST I-III) and 6,359 high grade (IV-V) injuries. After adjusting for comorbidities, demographics, and hospital characteristics, odds of nephrectomy, angioembolization, and nonoperative management were similar in patients transferred to a level I and directly admitted to level I centers, compared to those treated at non-level I for both high and low grade injuries (Table 1), although mortality was lower in those transferred to level I centers (OR 0.70, 95% Cl 0.61-0.80, p<0.001). Change over time of management of high grade renal injuries demonstrated a decrease in the use of nephrectomy (p=0.007) while rates of angioembolization remained constant (p=0.33) (Figure 1). CONCLUSIONS In this contemporary trauma analysis, outcomes of both low and high grade renal trauma are similar across those patients managed in tiered trauma centers, signifying dissemination of collective renal trauma management. The rate of nephrectomy has decreased for high grade renal injury over our study period suggesting new adoption of kidney sparing management. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e64-e65 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Marc Bjurlin More articles by this author Audrey Renson More articles by this author Richard Jacob Fantus More articles by this author Richard Joseph Fantus More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Value of Regional Collaboratives

This review examines the framework and current evidence regarding regional collaboratives in the delivery of trauma care. The evolution of the learning health system challenges traditional quality improvement teachings. This vision calls for agile, evidence-based, best practice sharing across all stakeholders. A regional collaborative model answers the call for collaboration, assessment, and accountability. This framework enables participants to easily identify variability in care delivery and collaborate with multidisciplinary positive deviants. The fundamental hallmarks of a regional collaborative are data submission and aggregation, benchmark reporting, and peer-to-peer discussion. Advanced collaboratives may also offer unblinded benchmarking, risk- and reliability-adjusted analyses, provider-level feedback, and external data validation. Participation in a regional collaborative is associated with improved data quality, outcomes, and mortality. Processes of care and cost savings in trauma care delivery are optimized. Collaborative data sharing can also be applied to gain insights on the impact of legislative changes and public health challenges of a region. Future research should examine the implications of collaboratives across all phases of the patient care experience to broadly leverage the power of collaborative momentum.

Delivering emergency and trauma care in Sri Lanka in 2017 – a decade of change and leadership by the Emergency Treatment Unit of Teaching Hospital Karapitiya

Following the 2004 tsunami in Sri Lanka, the Health for the South Project was initiated by the Sri Lankan Ministry of Health, Teaching Hospital Karapitiya in Galle, and the Government of Victoria. With support from the Australian and Victorian Governments, the Alfred Hospital delivered the Capacity Building Component. The aim of the overall Project was to construct a fully equipped and staffed Emergency Trauma Centre; the aim of the Capacity Building Component was to increase the capacity of Teaching Hospital Karapitiya staff to deliver effective emergency and trauma care. The program included training in the systematic and team approach to trauma care plus triage, trauma quality improvement and disaster response. Following the formal completion of the Project, local medical and nursing champions have continued to improve the level of emergency and trauma care provided by Teaching Hospital Karapitiya; the facility is now a national and regional leader in the training and delivery of excellent emergency and trauma care.

Forward surgical care: Emerging issues and challenges

War strategies have been evolving with time and battlefield casualty care services have been trying to keep pace with the changing demands. Technological advances in the field of trauma care have revolutionised the way in which erstwhile ‘non-salvageable’ lives and limbs are managed with more favourable outcome. The quality of Pre-Hospital Trauma Care Services will largely determine the survival statistics of battle casualties. The surgeon has to acknowledge the various resource constraints imposed upon him in the course of delivery of expert trauma care in the battlefield. The philosophy of Tactical Field Care and TACEVAC has, to a great extent, standardized point-of-care services and the manner in which combat casualties are managed. This has resulted in increasing favourable clinical outcome in a demanding, resource restricted and challenging environment. Training of Military Surgeons prior to induction into theatres of combat is an operational imperative and has to be based on validated guidelines promulgated by apex institutes specialised in Combat Casualty Care. CASEVAC hurdles, resource paucity, command and tactical decisions, govern casualty care and impose serious constraints that are not present in an urban setting. This article highlights the basic tenets of battlefield care, the challenges associated with it and the way forward.

Incidence and Outcomes of the Psychiatric Population among Acute Trauma Victims

Psychiatric illnesses (PI) are common, and they negatively affect medical/surgical diseases. Reasons include presentation delays, altered immune responses, and provider prejudice. Traumatic injuries, also common, remain leading causes of death. We hypothesized that pretrauma PI negatively affects trauma care and outcomes. We performed a 10-year review of patients age ≥ 18 years with PI vs without PI (non-PI), including socioeconomics, Injury Severity Score (ISS), hemodynamics, and medical comorbidities including DSM-defined psychiatric illnesses. Potential provider bias was measured by time to CT, operating room, or ICU, and placement in rehabilitation. Among 23,220 trauma admissions, PI patients (n = 559) were younger (50.7 vs 53.1 years, p = 0.004), white (94% vs 86.6%, p < 0.001), and less likely to have private insurance (12.3% vs 17.3%, p < 0.001). With respect to physiologic response, PI had lower ISS (9.5 vs 10.5, p = 0.015) but more likely tachycardic (44% vs 37.4%, p = 0.002). PI were less likely to have nonpsychiatric medical comorbidies (43.8% vs 54.6%, p < 0.001). However, among those with a comorbidity, PI patients had a greater average number of comorbidities (5.5 vs 1.2, p < 0.001). With respect to trauma-related care, no difference existed in time to first CT, time to first operative procedure, or ICU placement. Further, there was no difference in discharge to either home or rehabilitation facilities. Adjusting for age, sex, and ISS, pre-trauma PI did not affect the risk of death (odds ratio1.4, 95% CI 0.92 to 2.4). Pre-trauma PI patients had more medical comorbidities and, despite lower ISS, more likely presented with tachycardic responses. Despite PI patients having worse overall health status, and counter to other observations in nontrauma medical conditions, the presence of PI did not affect delivery of trauma care. Our findings support the effectiveness of standardized American College of Surgeons trauma care systems.

Feasibility of and Rationale for the Collection of Orthopaedic Trauma Surgery Quality of Care Metrics.

Reproducible metrics are needed to evaluate the delivery of orthopaedic trauma care, national care, norms, and outliers. The American College of Surgeons (ACS) is uniquely positioned to collect and evaluate the data needed to evaluate orthopaedic trauma care via the Committee on Trauma and the Trauma Quality Improvement Project. We evaluated the first quality metrics the ACS has collected for orthopaedic trauma surgery to determine whether these metrics can be appropriately collected with accuracy and completeness. The metrics include the time to administration of the first dose of antibiotics for open fractures, the time to surgical irrigation and débridement of open tibial fractures, and the percentage of patients who undergo stabilization of femoral fractures at trauma centers nationwide. These metrics were analyzed to evaluate for variances in the delivery of orthopaedic care across the country. The data showed wide variances for all metrics, and many centers had incomplete ability to collect the orthopaedic trauma care metrics. There was a large variability in the results of the metrics collected among different trauma center levels, as well as among centers of a particular level. The ACS has successfully begun tracking orthopaedic trauma care performance measures, which will help inform reevaluation of the goals and continued work on data collection and improvement of patient care. Future areas of research may link these performance measures with patient outcomes, such as long-term tracking, to assess nonunion and function. This information can provide insight into center performance and its effect on patient outcomes. The ACS was able to successfully collect and evaluate the data for three metrics used to assess the quality of orthopaedic trauma care. However, additional research is needed to determine whether these metrics are suitable for evaluating orthopaedic trauma care and cutoff values for each metric.

Military Resuscitation: Lessons from Recent Battlefield Experience

This review will discuss the current methods employed in military trauma systems to care for combat casualties, with emphasis on what is referred to in NATO doctrine as “Role 1” and “Role 2” medical support—that is, care of the war-injured patient at the point of injury and, slightly further “upstream” in the trauma system in a forward, mobile trauma system. Tactical Combat Casualty Care is continuously updated by the Joint Trauma System in a rigorous manner. New technologies and procedures are constantly being investigated and adapted to the tactical demands of the battlefield. The most significant recent developments are the introduction of tranexamic acid, the advent of 1:1:1 blood product therapy, widespread use of tourniquets, and lyophilized or “freeze-dried” plasma to overcome the barriers inherent in frozen plasma. Current doctrine in military medicine is the ultimate expression of damage control resuscitation. Realities of the modern battlefield often necessitate novel approaches to care that emphasize mobility over robustness and temporizing measures over definitive. While these methods would perhaps seem suboptimal to the civilian trauma surgeon, the preventable mortality in the recent conflicts in Iraq and Afghanistan was lower than for any other modern war [1], and fell after the lessons of the early phases of the wars lead to development of the prehospital guidelines developed by the Committee on Tactical Combat Casualty Care (TCCC), now overseen by the Joint Trauma System (JTS) [2, 3]. The JTS oversees the delivery of trauma care to war-wounded personnel from point of injury to convalescence in the continental USA. It regularly updates its clinical practice guidelines [3]. Controlling hemorrhage, the primary cause of preventable battlefield deaths (>80%) [4, 5] is the primary goal in TCCC and the JTS. Far from being applicable only to combat trauma, the lessons learned in the recent wars have tangible benefits in disaster response and mass civilian trauma, particularly in this age of seemingly random mass shootings in the US and assorted terror attacks in Europe and throughout the world. This review will describe the system in which the US Armed Forces delivers care to patients injured on the modern battlefield, the tenants that guide that care, and the scientific basis for the most current developments in the field.

Cost of Trauma Care in Secondary- and Tertiary-Care Public Sector Hospitals in North India.

Several initiatives to provide trauma care, including ambulance services, creation of a network of trauma hospitals and insurance schemes for cashless treatment, are currently being implemented in India. However, lack of information on the cost of trauma care is an impediment to the evidence-based planning for such initiatives. In this study, we aim to bridge this gap in evidence by estimating the unit cost of an outpatient consultation, inpatient bed-day of hospitalization, surgical procedure and diagnostics for providing trauma care through secondary- and tertiary-level hospitals in India. We undertook an economic costing of trauma care in a secondary-care district hospital and a tertiary-level teaching and research hospital in North India. Cost analysis was undertaken using a health system perspective, employing a bottom-up costing methodology. Data on all resources-capital or recurrent-on delivery of trauma care during the period of April 2014 to March 2015 were collected. Standardized unit costs were estimated after adjusting for bed occupancy rates. Sensitivity analysis was performed to account for the uncertainties due to differences in prices and other assumptions. The cost of trauma care in the tertiary care hospital was INR 9585 (US$147.4) per day-care consultation; INR 2470 (US$37.7) per bed-day hospitalization (excluding ICU), INR 12,905 (US$198.5) per bed day in ICU and INR 21,499 (US$330.8) per surgery. Similarly, in the secondary-care hospital, the cost of trauma care was INR 482 (US$7.4) per outpatient consultation, INR 791 (US$12.2) per bed day of hospitalization, INR 186 (US$2.9) per minor surgery and INR 6505 (US$100.1) per major surgery. The estimates generated can be used for planning and managing trauma care services in India. The findings may also be used for undertaking future research in estimating the cost effectiveness of trauma care services or models of care.

Trauma care in India: A review of the literature

We reviewed the published literature related to prehospital and hospital trauma care in India to identify how trauma care is defined in the literature and what factors limit the delivery of appropriate trauma care. In summarizing the evidence and recommendations regarding trauma care, this review identifies essential research and development goals to address the burden of injury in India. A review of the literature was conducted between August 2014 and September 2014. The literature was sorted into 3 categories: prehospital care, hospital clinical care, and hospital administrative care. The characteristics of trauma care were explored using the Essential Trauma Care Project of the World Health Organization. A total of 38 studies were included. Prehospital care lacked care provided at the scene of the injury, timely transport to a hospital, and transport via ambulance. With regard to hospital care, we found a lack of capabilities of basic clinical care, such as airway management, insertion of chest tubes, and efforts at resuscitation. There was a lack of administrative capabilities, including trauma data systems, trauma-specific training, quality improvement, and development of designated trauma teams. The high rate of injury-related deaths and disabilities in India could be in part due to the absence of integrated and organized systems of trauma care. In the prehospital setting, a multisector approach must be implemented to address the training of emergency medical service providers and community members. Prehospital transport time can be decreased through improved communication and transport modalities. The Indian trauma care system could also be strengthened through hospital-based training programs and trauma response teams.