Are Primary Trauma Care (PTC) courses beneficial in low- and middle-income countries - A systematic review.

BACKGROUND: Injuries remain an important public health concern, resulting in considerable annual morbidity and mortality. In low- and middle-income countries (LMICs), the lack of appropriate infrastructure, equipment and skilled personnel compound the burden of injury, leading to higher mortality rates. As Advanced Trauma Life Support (ATLS) courses remain uneconomical and inappropriate in LMICs, the Primary Trauma Care (PTC) course was introduced to provide an alternative that is both sustainable and appropriate to local resources. METHODS: A systematic review was performed in May 2019, utilising MEDLINE, EMBASE, Cochrane Library and Google Scholar. All studies reporting patient related outcomes (mortality and morbidity rates) and course participant related outcomes (knowledge, confidence and skills) in LMICs were included. PRISMA guidelines were adhered to throughout. RESULTS: Nine observational studies were identified (Level 3 evidence). Six studies reported improved knowledge in injury management post-PTC course (p < 0.05). Two studies reported improvements in confidence (p < 0.05) and one on skill attainment (p < 0.0001). One study reported a reduction in mortality rates post-PTC course (p < 0.01). CONCLUSION: Departmental, institutional and personal improvements may occur in clinical practice as a result of formal PTC training of trauma team members in LMICs. Further high-quality research is needed to evaluate this course's effects on observed change in clinical practice and patient outcomes. This may require long-term observational and epidemiological studies to assess improvements in morbidity and mortality. PROSPERO Registration Number: CRD42019133986.

Cost Analysis of the Mongolian ATLS© Program: A Framework for Low- and Middle-Income Countries.

BACKGROUND: Trauma is the leading cause of death among Mongolians aged 24-44. To improve initial management of injured patients, the Mongolian National University of Medical Sciences (MNUMS) implemented the American College of Surgeons' (ACS) Advanced Trauma Life Support (ATLS) training program in 2015. Cost analysis demonstrates that such programs can have clear pathways to self-sufficiency. METHODS: Costs associated with an ACS Mongolian ATLS program were quantified based on discussions with the Mongolian government, MNUMS, ATLS Australasia headquarters, and existing pricing data. Costs were then classified as either essential or contingencies. These classifications determined budgetary items for each program. Savings projections for contingencies included training Mongolian instructors and educators. Scenarios for funding the budget were then assessed. RESULTS: The minimum annual cost of ATLS in Mongolia, which includes 3 ATLS student courses/1 instructor course, is $10,709. A budget of $19,900 includes additional contingencies. The scenario that involves foreign instructors is the most expensive one. An initial investment of $85,000 to train Mongolian instructors reduces annual costs by $48,305 (71% reduction). An investment of $4050 to train a Mongolian educator will reduce costs by $1750 annually. ATLS can be sustained with 0.04% of Mongolia's current spending on public health and preventative services. CONCLUSIONS: Initial investment to train Mongolian ATLS instructors leads to substantial savings. Training a Mongolian educator lowers long-term costs. When minimum costs for ATLS courses are understood, these can be scaled up and supported with different contingencies and minimal funding by government or third-party stakeholders.

TEAM: A Low-Cost Alternative to ATLS for Providing Trauma Care Teaching in Haiti.

OBJECTIVE: Trauma resuscitation protocols have unified the care of trauma patients and significantly improved outcomes. However, the success of the Advanced Trauma Life Support course is difficult to reproduce in developing countries due to set-up costs, limitations of resources, and variations of practice. The objective of this study is to assess the Trauma Evaluation and Management (TEAM) course as a low-cost alternative for trauma resuscitation teaching in Low and Middle Income Countries (LMIC). DESIGN: As part of the Team Broken Earth initiative, TEAM course was provided to the health care professionals in Haiti. At its conclusion, participants were asked to complete a survey evaluating the course. Qualitative and quantitative data were analyzed to evaluate the perception of the course. SETTING: The course was provided in Port-au-Prince, Haiti. PARTICIPANTS: A total of 80 health care professionals participated in the course. Response was obtained from 69 participants, which comprised of 32 physicians, 10 Emergency Medical Technicians (EMT), 22 nurses, and 5 medical trainees. RESULTS: The course was well received by physicians, nurses, and EMT with an average score of 90.6%. Question analysis revealed a lower satisfaction of physicians for the course manual and teaching materials, and information related to decisions for transfer of patients. EMT consistently felt that the course was not tailored to their learning and practice needs. Written feedback demonstrated several areas of weaknesses including need for improvements in translations, hands-on practice, and educational materials. CONCLUSIONS: Overall, the TEAM course was well received. Analysis demonstrated a need for adjustments specific to LMIC including a focus on prehospital assessment, increased nursing responsibilities, and unavailability of specialist's referrals. Team Broken Earth intends to take these findings into consideration and continue to provide the TEAM course to other LMIC.

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