Improving Initial Management of the Injured at Ghanaian District and Regional Hospitals with a Trauma Intake Form

Kwame Nkrumah University/Science/Tech, Kumasi

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Abstract

ABSTRACT Injuries cause millions of deaths each year, with the vast majority in low- and middle-income countries. Improving care of the injured (trauma care) is a way to lower this burden. The initial period of trauma care is especially important, but is often chaotic and prone to errors. The World Health Organization created a Trauma Care Checklist (TCC), which improved key performance indicators of care and lowered mortality at tertiary hospitals in multiple countries. As with any checklist, it requires a team of providers to go through the checklist as a group, which decreases its uptake. A model Trauma Intake Form (TIF) has potential to achieve the benefits of the TCC, but with automatic usage and with accompanying improvements in documentation. The TIF is a 2 page form, filled out by health care providers as part of the medical record, with built-in memory prompts for key elements of care. It is especially oriented for smaller hospitals. Our broad goal is to assess the effectiveness of the TIF to improve trauma care at non-tertiary hospitals. We propose a pragmatic randomized clinical trial with introduction of the TIF at 8 hospitals sequentially, with start times randomized by stepped-wedge design. We propose three Specific Aims: 1. To determine the effectiveness of a model Trauma Intake Form (TIF) to function as a checklist for increasing the appropriate use of key performance indicators (e.g. airway maintenance, pulse oximeter placed, tests to exclude internal bleeding) during care of the injured in emergency units in district (first level) and regional (second level) hospitals in Ghana, as assessed by independent observers. Hypothesis: The TIF will increase use of key performance indicators by significant and clinically meaningful levels. For example, the TIF will increase the percent of all injured patients who have their consciousness level checked by at least 9% (50% to 59%). 2. To determine the percent of injured patients with adequate data on initial assessment before vs. after introduction of the TIF in emergency units in district and regional hospitals in Ghana. Hypothesis. The TIF will increase documentation of important clinical data on injured patients (including all of the following: time of injury, mechanism of injury, respiratory rate, heart rate, blood pressure, consciousness level, temperature, and time of disposition) by at least 5% (10% to 15%). 3. To increase the capacity of the Kwame Nkrumah University of Science and Technology and the network of district and regional hospitals in southern Ghana to undertake high-quality trauma care research, including clinical trials. The proposal is innovative as it employs the novel idea of a checklist for trauma care (the TIF) that is built into the clinical chart. The proposal is significant as it will advance scientific knowledge on checklists and will evaluate an intervention that is feasible to use in non-tertiary hospitals in countries at all economic levels.