May, 2017 - SUPPORT Summary of a systematic review | print this article |

Do pre-hospital trauma systems reduce mortality?

The majority of trauma deaths in low and middle income countries occur outside of hospitals. Improving pre hospital trauma care, such as emergency care through first responders and timely transport to an appropriate facility, has been suggested as a mechanism for reducing mortality and morbidity.

 

Key messages

  • Pre hospital trauma systems may reduce mortality.
  • Pre hospital trauma systems may reduce the response time from injury to first medical contact in the field.
  • Most of the included studies were conducted in middle income countries.

 

Background

The immediate period after injury is when resuscitation and stabilization is most beneficial to the patient. There is therefore a brief window of time in which to provide emergency care and rapid transport to hospital of people with injuries, in order to reduce mortality and morbidity.

The capacity to provide this immediate, basic level of care is lacking in many poor countries. Pre hospital trauma care involves a set of interacting elements that includes triage, airway management, oxygen administration, intravenous fluid administration, splinting, spinal immobilization, wound care and patient transport. Pre hospital trauma care can be categorised into two approaches: (1) first responders, and (2) ambulance services.


 



About the systematic review underlying this summary

Review objectives: To assess the effectiveness of pre hospital trauma systems in developing countries.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non randomised trials, controlled before after studies, uncontrolled before after studies and cohort studies assessing the effectiveness of pre hospital trauma systems.
14 included studies of which 8 were included in a meta analysis (3 non randomised trials, 4 before after studies and 1 retrospective cohort study).
Participants (1) Community members; and (2) professionals delivering pre hospital trauma care for communities.
Communities of rural areas (4 studies) and urban areas (4 studies).
Settings Developing countries (International Monetary Fund’s World Economic Outlook Report 2010).
Mexico (2 studies), Iran (2) and one each from Afghanistan, Brazil, Cambodia, Iraq and Trinidad and Tobago.
Outcomes Mortality (primary outcome), injury severity, physiologic severity, and pre hospital time.
Mortality and pre hospital time analysed by injury severity.
Date of most recent search: December 2010
Limitations: This is well conducted systematic review with only minor limitations.

Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta analysis. The journal of trauma and acute care surgery. 2012;73(1):261-268.

 


Summary of findings

14 studies were included in the review of which eight were included in a meta analysis.

Four of the eight studies included in the meta analysis were conducted in rural areas without an ambulance system. In three of these studies, a two tiered response system with lay (non professional) first responders was established. The fourth study was conducted in a combat zone where paramedics were trained to provide advanced trauma life support.

The remaining four of the eight studies included in the meta analysis were conducted in urban areas. In three of these studies, an uncoordinated ambulance system was in place and these systems were re organized as part of the studies and training provided to ambulance personnel. In one study, firefighters were trained to provide trauma care and an ambulance system was established.

 

  • Pre hospital trauma systems may reduce mortality. The certainty of this evidence is low.
  • Pre hospital trauma systems may reduce the response time from injury to first medical contact in the field. The certainty of this evidence is low.

Pre hospital trauma systems compared to no pre hospital trauma system

People: Patients from rural areas and urban areas.
Settings
:  Community
Intervention
: Pre hospital trauma systems.
Comparison
: No pre hospital trauma system.
Outcomes Impact Certainty of the evidence
(GRADE)
Mortality

Relative risk reduction of 25% (95% CI 15 to 34%)

- Rural areas 29% (95% CI 14 to 41%)

- Urban areas 21% (95% CI 6 to 35%)

 

Low

 


Response time from injury to first medical contact in the field
May be reduced in both rural (without an ambulance system, reduction of 66 minutes (95% CI 24 to 108 minutes)) and urban (with an ambulance system, reduction of 6 minutes (95% CI 5.47 to 6.53 minutes)) settings

 

Low

 


CI: Confidence interval

GRADE: GRADE Working Group grades of evidence (see above and last page


 


 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
All studies included in the systematic review were conducted in low and middle income countries (most were in middle income countries)

These findings are likely to be applicable in many low income country settings. However all of these interventions require the availability of lay or professional health workers who can be trained to provide first response care following trauma.

 

  • In resource poor settings, the costs of additional training and trauma response infrastructure, as well as wider human resource for health constraints, may be obstacles to implementing these interventions.
EQUITY

There is limited evidence that pre hospital trauma systems may have larger impacts on mortality and response times in rural areas

 

  • There was little further information in the included studies regarding the differential effects of the interventions on different levels of resource disadvantaged populations

 


The training of lay (non professional) people as first responders may help to reduce inequities if these lay people are drawn from and then work in resource poor areas.

 

  • Rural areas with poor trauma response systems may benefit particularly from interventions to improve pre hospital trauma systems. This probably relates to the distances that people in rural areas need to travel to reach a hospital that can provide appropriate trauma care.
ECONOMIC CONSIDERATIONS
The systematic review did not address economic considerations

Scaling up of these interventions may require considerable resources.

 

  • Using lay (non professional) rather than professional first responders and focusing on basic life support may require fewer resources. Such approaches may therefore be more appropriate in settings where resources are very constrained.
  • Local costings should be undertaken to inform decisions on implementation and on the sustainability of these interventions.
MONITORING & EVALUATION
The available evidence on the impacts of pre hospital trauma systems is of low certainty

Larger and more rigorous studies are required to determine the effects and the cost effectiveness of pre hospital trauma systems, particularly in low income countries.

 

  • Future studies should provide details of the interventions used, describe the contexts in which they were delivered and assess standardized trauma outcomes.
  • Attention needs to be paid to the sustainability of these interventions over time.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods


 

Additional information

Related literature

These systematic reviews provide complementary information:

Beuran M, Paun S, Gaspar B, et al. Prehospital trauma care: a clinical review. Chirurgia. 2012;107(5):564-570.

 

Callese TE, Richards CT, Shaw P, Schuetz SJ, Issa N, Paladino L, Swaroop M. Layperson trauma training in low and middle income countries: a review. J Surg Res. 2014;190(1):104-10.

 

Callese TE, Richards CT, Shaw P, Schuetz SJ, Paladino L, Issa N, Swaroop M. Trauma system development in low and middle income countries: a review. J Surg Res. 2015;193(1):300-7.

 

Jayaraman S, Sethi D, Wong R. Advanced training in trauma life support for ambulance crews. Cochrane Database of Systematic Reviews 2014; 8: CD003109.

 

Obermeyer Z, Abujaber S, Makar M, Stoll S, Kayden SR, Wallis LA, Reynolds TA; Acute Care Development Consortium. Emergency care in 59 low and middle income countries: a systematic review. Bull World Health Organ. 2015;93(8): 577-586G.

 

Sun JH, Shing R, Twomey M, Wallis LA. A strategy to implement and support pre hospital emergency medical systems in developing, resource constrained areas of South Africa. Injury. 2014;45(1): 31-8.

 

This manual describes the core strategies, equipment, supplies, and organizational structures needed to create effective pre hospital trauma systems:

Sasser S, Varghese M, Kellermann A, Lormand JD. Prehospital Trauma Care Systems. Geneva: World Health Organization; 2005.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Timothy Craig Hardcastle and Jaymie Henry.

 

This review should be cited as

Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta analysis. The journal of trauma and acute care surgery. 2012;73(1):261-268.

 

The summary should be cited as

Ciapponi A. Do pre-hospital trauma systems reduce mortality? May 2017. www.supportsummaries.org

 

Keywords

All Summaries:

evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care.

Prehospital; rural trauma system; first responder; developing countries; advanced trauma life support.

 

 

 

 

 

 

 

 



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