Developing Emergency and Trauma Systems Internationally: What is Really Needed for Better Outcomes?

Regionalization of trauma care has long been established in the United States and other developed countries.[1] Several studies reported reduced mortality and improved patients’ outcomes with organized systems of care for trauma resulting from standardized prehospital triage, rapid transport, and treatment at designated trauma centers.[123] More recently, the designation of specialty centers such as percutaneous coronary intervention centers for ST-elevation myocardial infarction, stroke centers, and cardiac arrest centers was also linked to improved outcomes including survival.[45]

This categorization of health-care facilities based on acute care capabilities and ability to treat patients with different emergency medical conditions is an essential structural component that when tied to the right processes and the right personnel can lead to improvement in clinical outcomes. Other important elements of an effective system of care include accountability, communication, and coordination: Accountability involves monitoring performance and quality and having key measures or metrics for the different phases of care. Communication consists of ensuring clear linkage between emergency medical services, hospitals, trauma and specialty centers, and the system's leadership. Coordination involves the appropriate use of existing resources in a coordinated fashion to achieve common objectives with improved efficiency and reduced redundancy within the system. A clear vision is therefore needed to provide the framework for a plan to integrate existing resources including human and physical resources into a well-coordinated and highly effective system of care. With this in mind, the reality is that several countries mainly developing and low- and middle-income countries have constraints related to resources, to the availability of properly trained personnel, and availability of adequately equipped health-care facilities mainly hospitals. This in addition to the fact that the trauma burden is higher in such countries in terms of an overall number of reported injuries, younger age of victims, and costs to society.[6]

A good start toward improving outcomes would, therefore, require an initial assessment of the different components of a system using a standardized framework to identify areas of need and inform policymakers on the required interventions and legislations that would propel things forward toward the end goal of improving patient care. The World Health Organziation Guidelines for Essential Trauma Care[7] is one example of standardized assessment frameworks used to assess the emergency and trauma care in developing countries. Main elements to evaluate include system leadership and organization, resource management (financial, human resources, facilities, and transportation), public access, communication and linkage, public information and education, clinical care and surge capacity.

An initial assessment should be followed by data collection and continuous performance measurement and improvement. This requires collecting standardized data elements that allow for comparison with international benchmarks. Highlighting current performance, even if poor, and using outcome related data are helpful to drive the capacity building of the different essential structural elements (facilities, personnel, equipment) and to establish processes that would lead eventually to good outcomes. The next step would require establishing research registries or large system databases focused on few tracer conditions such as trauma or out of hospital cardiac arrest that allows for examining overall performance of the system.[89] The Utstein template is a good template for building out of hospital cardiac arrest registries internationally.[10] This template has been used successfully in several developing countries to report outcomes in a standardized manner.[11] Outcome research using these registries is useful to create a sense of urgency and mobilize policy makers and other stakeholders to act. Translating this knowledge into policy allows for setting general guidelines such as an overall plan organization and legal framework for the system. Launching small pilot projects of quality improvement affecting different aspects of care is important. Building on small successes would be pivotal for sustaining efforts toward improving outcomes.