Strengthening care of injured children globally
Charles Mock a, Francis Abantanga b, Jacques Goosen c, Manjul Joshipura d & Catherine Juillard e
a. Department of Violence and Injury Prevention and Disability, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland.
b. Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
c. Department of Surgery, Johannesburg Hospital, Johannesburg, South Africa.
d. Academy of Traumatology (India), Ahmedebad, India.
e. Department of Surgery, University of California at Los Angeles, Los Angeles, CA, United States of America.
Correspondence to Charles Mock (e-mail: firstname.lastname@example.org).
(Submitted: 01 October 2008 – Revised version received: 23 February 2009 – Accepted: 27 February 2009.)
Bulletin of the World Health Organization 2009;87:382-389. doi: 10.2471/BLT.08.057059
Injury has become a leading cause of death and disability globally. The two age groups most affected are older children (aged 5–14 years) and adolescents and younger adults (aged 15–44). For every person injured, many more are left with temporary or lifelong disabilities. The burden of injury is especially pronounced in low- and middle-income countries (LMICs), where 95% of all childhood injury deaths occur.1
To decrease this burden, a spectrum of activities are needed, including injury surveillance, injury prevention and improvements in care of the injured (e.g. trauma care). Obviously, a major emphasis should be on prevention. However, much can also be accomplished by improvements in trauma care. To gauge the potential extent of such gains, we can examine existing discrepancies in outcome of injured patients in different countries. One study comparing outcomes of severely injured patients in three countries at different economic levels showed that case-fatality rates among seriously injured persons (i.e. with an Injury Severity Score ≥ 9) increased from 35% in high-income United States of America to 55% in middle-income Mexico to 63% in low-income Ghana. These results show that people injured to a similar extent are nearly twice as likely to die in a low-income setting as in a high-income setting.2 If these inequities could be eliminated, an estimated 2 million of the 5 million injury deaths each year could be averted.
In addition to mortality, there is also a large burden of avoidable disability globally. The majority of injury-related disability in LMICs is due to extremity injuries, as opposed to high-income countries where there is a relatively higher burden from more difficult to treat head and spinal cord injuries. The disability from extremity injuries should be eminently amenable to low-cost improvements in orthopaedic care and rehabilitation.3,4
There is often a misperception that improvements in trauma care would be expensive and impractical in LMICs. However, the Disease Control Priorities Project has shown that several interventions that need to be promoted to improve trauma care are among the most cost-effective in the health-care armamentarium. Among these, the following interventions were identified as having cost-effectiveness ratios of below 100 (US$ 100 per disability-adjusted life year averted): strengthening of prehospital care through training of community-based paramedics and village lay-first responders; community ambulances; and basic surgical care (including care of injuries) at district hospitals. Thus, these interventions are considered extremely cost-effective when assessed on a scale ranging from 1 (most cost-effective) to 100 000 (least cost-effective).5
In this paper, we address how to better implement the array of cost-effective and sustainable trauma care improvements globally, especially regarding care of the injured child. First, we review some of the recent individual country efforts that specifically address care of the injured child in the LMIC setting. We show that there are many capable individuals successfully confronting barriers and difficulties in their own institutions, some with innovative solutions from which others around the world can learn. We will then discuss how to build on such individual examples to make more progress globally. We conclude with practical steps that can be taken to reduce the currently unacceptable burden of death and disability from childhood injury.
Progress in individual institutions and countries
It has long been recognized that injured children are not just small injured adults. Although some of the same general principles of trauma care do apply, there are many specific considerations for children that need to be addressed, such as paediatric-size equipment, modifications in technique for airway maintenance, differences in calculation of fluid requirements for shock resuscitation, among many others. Likewise, care of the injured child necessitates an appreciation of the special psychological, emotional and developmental needs of the child and his/her family. Thus, special attention is indeed needed in development of trauma care services for injured children.
A variety of authors have addressed such issues in the LMIC setting, several have reviewed the overall scenario with paediatric trauma care at their institutions. Shen et al. looked at the patterns of injury and major interventions required among injured children in Gambia.6 Gurses et al. looked at similar issues, including cost of care in Turkey.7 Some authors have expanded on such reviews, looking at structural issues that influence care in their systems. Van As and Rode reviewed the history of the development of the paediatric trauma unit at their hospital in South Africa.8 Inon & Haller looked at systems issues for paediatric trauma care in several countries, focusing on Argentina. After the initiation of the national Argentine Paediatric Trauma Registry, they identified deficits in paediatric trauma care that were then addressed through training and standardization of initial paediatric trauma management. These measures were associated with a decrease in mortality among seriously injured children from 14.1% to 5.9%.9
Some studies have demonstrated the role that specific interventions could play in reducing mortality and morbidity. Gaudeuille et al. looked at the barriers faced in managing a particularly difficult type of fracture (supracondylar humerus fractures) in the Central African Republic. They commented that the currently poor functional results could be improved upon by a specific type of X-ray equipment (image intensifier).10
A few studies have reported on the results of innovative strategies. Obaidullah et al. confronted the issue of maintaining joint mobility after release of axillary burn contractures in Pakistan. Commonly used splints were too hot and uncomfortable for their environment and had low compliance. They used a low-cost innovative solution of a cloth figure-of-eight sling. This resulted in a good range of shoulder motion, comparable to other methods, as well as high skin graft take.11 Similarly, Hudson et al. demonstrated the effectiveness and safety of the use of tissue expanders in reconstructive surgery after burns in children in South Africa.12
Karkiner et al. in Turkey and Landau et al. in South Africa evaluated changes in protocols for management of children with blunt hepatic trauma. They found that selective non-operative management (versus routine surgery) was safe in their environment. Selective non-operative management has been widely used in high-income countries, resulting in fewer unnecessary surgeries. However, its applicability and safety in LMICs had thus far not been well addressed. These studies from Turkey and South Africa did demonstrate that this technique could be used effectively and safely in their environment, but such use was dependant on somewhat expensive imaging technology.13,14
As already mentioned, many special considerations apply to the care of injured children. Nonetheless, broader efforts to improve training, resources, or organization and planning for all trauma patients may also improve care of injured children. Several studies from LMICs have shown improvements in outcome for both children and adults with such measures. For example, in the prehospital setting, most people in the world currently do not have access to formal emergency medical services (EMS) or ambulance services, especially in rural areas. One programme specifically addressed this scenario. In mine-infested areas of Cambodia and northern Iraq, this programme created a two-tiered response system. The first tier included lay-first responders who had first aid training. The second tier consisted of a smaller number of paramedics with more advanced training. Equipment and supplies were provided, but not ambulances. They continued to rely on the existing transport system of private and commercial vehicles, as well as non-motorized transport. This program greatly improved timely care for victims of mine blasts and other forms of trauma. Mortality among severely injured persons decreased substantially from 40% to 9%.15
In Mexico, Arreola-Risa et al. reported on training programmes designed to strengthen the performance of an existing, basic EMS. In this locale, few prehospital providers had formal certification as emergency medical technicians. An effort by local government provided better training for existing staff and tightened requirements for newly hired staff so that all full-time staff were eventually certified. As a result, mortality for all trauma patients treated by the EMS decreased from 6.3% to 2.5%.16
In the hospital setting, the main trauma hospital in Khon Kaen, Thailand instituted a trauma audit committee to better oversee trauma care. This committee identified a high rate of medically-preventable deaths, i.e. those that could be prevented by improvements in care. In trauma, these are often from airway obstruction or single organ intra-abdominal injuries, which should be treated well in most environments. Correctable problems identified by the committee included inadequate resuscitation for shock, delayed surgery for head injuries and communication problems. Low-cost, corrective action was instituted to target these problems, including improved communication within the hospital by use of radios, better supervision of junior doctors through increased senior staffing in the emergency department at peak times, and improved reporting and monitoring of trauma cases at hospital meetings (i.e. better use of techniques of quality improvement). These improvements resulted in a decrease in mortality among all admitted trauma patients from 6.1% to 4.4%.17
Thus, much is indeed being done well to strengthen the care of injured children in many institutions and locations worldwide. This includes efforts that specifically address the care that children receive and broader efforts to strengthen trauma care systems that benefit children and adults alike. The question now becomes how to build on such local and national efforts to make more comprehensive progress globally.
Global efforts to improve care
To expand the individual efforts mentioned, we have two additional foundations on which to build. Both of these foundations emphasize improving health care through improved organization and planning. The first is the essential services approach of international public health. Essential services are those that are high-yield, but low-cost, and which realistically could be assured to almost everyone in a given population. Programmes have included defining the core services to promote, identifying barriers to such services, and providing technical input and assistance to countries and high-need areas to improve capacity to deliver these services. Examples of programmes that have successfully done this include the Expanded Programme on Immunizations, the Essential Medicines Programme, the Global TB Programme, and the Safe Motherhood Initiative and related programmes to make pregnancy safer. Until recently, this approach had not been applied to trauma care.
The second foundation to build on is the trauma system development from high-income countries. This has entailed improving the spectrum of care for the injured in both prehospital and hospital-based settings, as well as streamlining referrals between hospitals. Such improvements in organization and planning for system-wide trauma care have resulted in 15–20% reductions in mortality of treated trauma patients and 50% reductions in medically preventable deaths.18,19 Thus far, similar system-wide approaches have been only minimally applied in LMICs.
The Essential Trauma Care Project has sought to combine these two different perspectives. It has sought to promote improved trauma system planning in LMICs by applying a public health approach. This project has been a collaborative effort of WHO and the International Society of Surgery. Representatives of these two organizations, working with other groups and with trauma care clinicians and administrators from many countries globally, have created the Guidelines for essential trauma care.20 This defines 11 core essential trauma care services, that every injured person in the world should realistically be able to receive (Box 1). These are the most cost-effective and high-yield trauma care services.
Box 1. Essential trauma care services20
- Obstructed airways are opened and maintained before hypoxia leads to death or permanent disability.
- Impaired breathing is supported until the injured person is able to breathe adequately without assistance.
- Pneumothorax and haemothorax are promptly recognized and relieved.
- Bleeding (external or internal) is promptly stopped.
- Shock is recognized and treated with intravenous fluid replacement before irreversible consequences occur.
- The consequences of traumatic brain injury are lessened by timely decompression of space occupying lesions and by prevention of secondary brain injury.
- Intestinal and other abdominal injuries are promptly recognized and repaired.
- Potentially disabling extremity injuries are corrected.
- Potentially unstable spinal cord injuries are recognized and managed appropriately, including early immobilization.
- The consequences to the individual of injuries that result in physical impairment are minimized by appropriate rehabilitative services.
- Medications for the above services and for the minimization of pain are readily available when needed.
Box 2. Summary table of recommendations on ways in which to strengthen care of the injured child globally
Policy and planning
- Each country should define core, minimum essential trauma care services that every injured child should realistically be able to receive. Key WHO guidance documents20,21 provide input on what these services should entail and how they can be modified to fit a country’s particular situation.
- Countries (or provinces and districts) should undertake needs assessments to identify high priority ways in which the above-noted minimum essential trauma care services can be better assured to every injured child.
- Capacity for organization and planning for trauma care should be strengthened in both individual facilities and in ministries of health.
- Trauma-related quality improvement programmes should be established to identify and address correctable factors in preventable deaths, appropriate for local conditions.
- Key human resources (skills, training and staffing) should be defined as part of the resources needed to assure minimum essential trauma care services. These skills should include those specifically needed for care of the injured child, such as different techniques for trauma resuscitation and an appreciation of the special psychological, emotional and developmental needs of the child and his/her family.
- Adequate human resources for trauma care should be promoted through assuring appropriate core competencies in schools of medicine, nursing and other relevant professions. They should also be promoted by increased capacity for conducting continuing education on trauma.
- Each country should define trauma-related equipment and supplies that are essential at different levels of the health care system. These resources should include those specifically needed for care of the injured child, such as the range of paediatric sizes for equipment.
- Availability of such essential items should then be promoted by measures such as tightening up procurement and repair processes and should be assured through appropriate monitoring processes, such as quality improvement programmes and hospital inspection.
- Links to child injury prevention should be promoted such as by using hospital data to better inform community injury prevention strategies and by counselling of injured children and their families on actions that they can undertake to prevent future injuries, when appropriate.
To assure the availability of these services, the guidelines delineate 260 individual items of human resources (skills, training, staffing) and physical resources (equipment, supplies) that should be in place in the range of health-care facilities globally. These recommendations cover the breadth of trauma care, including initial resuscitation, definitive care of injuries to all body regions and long-term rehabilitation. An example of one of the sets of resources guidelines, for airway management, is shown in Table 1. Recommendations are given for a range of facilities, from small rural clinics to tertiary care facilities. Likewise, individual resources are designated as either essential or desirable. Essential items are felt to be the most cost-effective and widely applicable, being relevant to countries at all economic levels. When they are not present at a given facility, they could be assured primarily through improved organization and planning, at no or minimal additional cost. Desirable items help to strengthen the provision of trauma care but are not as cost-effective. They are more amenable to middle-income countries or to specific facilities that have particularly high volumes of trauma patients.
One of the sections of the guidelines addresses special considerations for care of the injured child. It shows how the human and physical resources recommendations need to be adjusted to assure optimal care of the injured child. For example, these special skills include the ability to recognize and manage specific paediatric orthopaedic injuries that are highly prone to disability, also the ability to interpret spinal X-ray films taking into account the anatomy of the childhood spine as it varies with age. Among the special equipment and supplies needed are the range of paediatric sizes for airway equipment, intravenous cannulas, nasogastric tubes, etc., as well as laboratory facilities that are able to perform tests on small samples of blood.
In similar fashion to the above-noted recommendations for trauma care at fixed facilities (clinics and hospitals), WHO has developed Prehospital trauma care systems21 to give guidance on ways to strengthen care of the injured in the field, before arrival at fixed facilities. This addresses several scenarios, such as how to improve existing basic formal EMS (including ambulances); how to start new basic EMS systems in locations where none currently exist; and, in locations where instituting a formal EMS would not be feasible, how care of the injured can be improved by building on existing, although informal, systems of prehospital care and transport. These recommendations cover a wide variety of prehospital issues, including medical care, logistics, transport, communication, quality improvement, information systems and records and legal/ethical considerations.
These two publications are intended as planning tools for ministry of health planners and for administrators and clinicians at individual facilities or in individual institutions. They provide flexible templates, to be adjusted as needed based on local circumstances. Likewise, both are meant to serve as advocacy statements, to be used by who ever wishes to push for affordable and sustainable improvements in trauma care in their own environment. Their legitimacy for advocacy is further increased by the fact that they were developed with the input of a wide range of experts, including representation from at least two countries on each continent. Likewise, representatives of a wide range of professional societies were involved in creating the recommendations, including, among others, international specialty organizations such as the International Society of Surgery, the World Federation of Neurosurgical Societies and the International Committee of the Red Cross, as well as country organizations such as the Ghana Medical Association and the Academy of Traumatology (India).
The true usefulness of these publications lies in whether they are able to actually promote and stimulate improvements in care of the injured on the ground. Since their release, there has been progress in this regard (Table 2). Several ministry of health stakeholder meetings have been called to examine how the recommendations contained in these publications can be adjusted to national circumstances and implemented within national policy. In some cases, actual national policy changes have directly resulted from these publications. Likewise, the publications have been used as the basis for needs that have uncovered deficiencies in human and physical resources that could be remedied by affordable and sustainable measures, especially by greater attention to detail in planning and administration.
A particularly interesting example of the use of the publications to improve care comes from Viet Nam. A needs assessment of trauma care capabilities in the Hanoi area was conducted in 2002 using the Guidelines for essential trauma care as a template. This demonstrated several important deficiencies in resources, especially at commune health stations and smaller hospitals. Some of these deficiencies were in low-cost, but critical, supplies and equipment. This assessment led to increased attention to trauma care by the Hanoi Health Department. A repeat assessment the following year demonstrated a notable improvement in capabilities. This had come about primarily through improved organization and planning, with no increased budget having been allotted to trauma care.28 Similar accomplishments are eminently achievable worldwide.
Finally, increased global attention has been focused on trauma care through World Health Assembly Resolution 60.22: “Health systems: emergency-care system”. The WHA is the governing board of the WHO. It consists of every minister of health, or their designee, from 193 Member States. Its resolutions direct WHO’s activities and carry considerable influence on actions of individual countries, as well as non-government organizations and funders. In 2007, for the first time the World Health Assembly passed a resolution encouraging governments worldwide to increase their efforts at providing care for trauma and other emergency conditions. The resolution listed 10 actions that Member States could take to achieve this, including measures like: “Identifying a core set of trauma services and developing methods to assure and document that such services are provided to all who need them”. The resolution adds further endorsement to the above-noted guidance documents and global efforts to promote and implement them.29,30
There are many dedicated people working hard to strengthen care of the injured in general and care of injured children particularly, in the circumstances of LMICs. They have reported several practical, innovative solutions to overcome resource restrictions for a range of clinical issues. Their efforts have recently been aided by increased international attention to this problem. Although there are no major, well-funded global programmes to improve trauma care yet, recent WHO guidance publications and the broad network of collaborators who have worked on them have stimulated increased global attention to improving planning and resources for trauma care. This has in turn led to increased national attention, including conduct of needs assessments and implementation of WHO recommendations in national policy.
Most of these global efforts, however, have not yet specifically addressed children. Given the special needs of the injured child and given the high burden of injury-related death and disability among children, clearly greater emphasis on childhood trauma care is needed. There are several practical steps that can be taken to achieve this goal. These are summarized in Box 2 and primarily include low cost and affordable steps to improve the organization and planning for trauma care services for children. By taking these practical steps, countries worldwide can lower the unacceptably high and tragic rates of childhood death and disability from injury. ■
Competing interests: None declared.
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