A single-site pilot implementation of a novel trauma training program for prehospital providers in a resource-limited setting

Abstract

BackgroundPrehospital (ambulance) care can reduce morbidity and mortality from trauma. Yet, there is a dearth of effective evidence-based interventions and implementation strategies. Emergency Medical Services Traumatic Shock Care (EMS-TruShoC) is a novel bundle of five core evidence-based trauma care interventions. High-Efficiency EMS Training (HEET) is an innovative training and sensitization program conducted during clinical shifts in ambulances. We assess the feasibility of implementing EMS-TruShoC using the HEET strategy, and feasibility of assessing implementation and clinical outcomes. Findings will inform a main trial.MethodsWe conducted a single-site, prospective cohort, multi-methods pilot implementation study in Western Cape EMS system of South Africa. Of the 120 providers at the study site, 12 were trainers and the remaining were eligible learners. Feasibility of implementation was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Feasibility of assessing clinical outcomes was assessed using shock indices and clinical quality of care scores, collected via abstraction of patients’ prehospital trauma charts. Thresholds for progression to a main trial were developed a priori.ResultsThe average of all implementation indices was 83% (standard deviation = 10.3). Reach of the HEET program was high, with 84% learners completing at least 75% of training modules. Comparing the proportion of learners attaining perfect scores in post- versus pre-implementation assessments, there was an 8-fold (52% vs. 6%) improvement in knowledge, 3-fold (39% vs. 12%) improvement in skills, and 2-fold (42% vs. 21%) increase in self-efficacy. Clinical outcomes data were successfully calculated—there were clinically significant improvements in shock indices and quality of prehospital trauma care in the post- versus pre-implementation phases. Adoption of HEET was good, evidenced by 83% of facilitator participation in trainings, and 100% of surveyed stakeholders indicating good programmatic fit for their organization. Stakeholders responded that HEET was a sustainable educational solution that aligned well with their organization. Implementation fidelity was very high; 90% of the HEET intervention and 77% of the implementation strategy were delivered as originally planned. Participants provided very positive feedback, and explained that on-the-job timing enhanced their participation. Maintenance was not relevant to assess in this pilot study.ConclusionsWe successfully implemented the EMS-TruShoC educational intervention using the HEET training strategy in a single-site pilot study conducted in a low-resource international setting. All clinical outcomes were successfully calculated. Overall, this pilot study suggests high feasibility of our future, planned experimental trial.

Ambulance ramping predicts poor mental health of paramedics.

“…Programs known to increase job-related self-efficacy typically provide training to assist workers to master specific skills of their occupation. For example, a recent pilot implementation of the Emergency Medical Services Traumatic Shock Care (EMS-TruShoC) intervention resulted in a 100% increase in self-efficacy among South African ambulance staff (Mould-Millman et al, 2019). EMS-TruShoC includes five components that focus on controlling on-scene hemorrhage control, keeping time at the scene time below 10 minutes, inserting large bore intravenous catheters, administering high-flow oxygen, and transporting to a trauma center.…”

Validity and reliability of the South African Triage Scale in prehospital providers

“…At the time of this study, foundational education for WCG EMS providers from across the Western Cape Province included a 6-week certificate courses for BLS (recently discontinued), a 12-week course for ILS (soon to be replaced with a 1-year certificate), and a 2-year (diploma) and 4-year (degree-earning) training for ALS providers [14]. WCG EMS providers responded to over 500,000 calls per year, of which approximately 40% are trauma cases [11,12]. Providers often staff ambulances as a mixed-tier crew (e.g., BLS with ILS, or BLS with ALS).…”

“…ALS providers, however, can deliver a wide variety of drugs and may perform advanced cardiac, trauma, and critical care life support and procedures, including endotracheal intubation and ventilator management. ILS providers' scope of practice lies between BLS and ALS, and ILS providers can perform several invasive interventions and deliver a narrow selection of intravenous drugs [12].…”

“…Vignettes were purposefully selected to represent a mixture and balance of case types and SATS distributions that are representative of those seen by WCG EMS. The case context in the original hospital-based vignettes were lightly edited by study investigators (NM, TB, JD) to reflect the prehospital context, but the core clinical scenario and gold standard TEWS, discriminator, and final SATS were unchanged [10][11][12][13][14]. Twomey and co-investigators from the hospital-based study re-scored all 50 vignettes by re-providing gold standard TEWS, discriminators, and SATS answers for each vignette.…”

“…The WCG EMS system is a public EMS system that provides 24/7 ambulance services to a catchment population of over 6 million in the Western Cape Province of South Africa [11]. In 2017, WCG EMS employed approximately 2000 operational EMS providers in across three cadres: basic, intermediate, and advance life support (BLS, ILS, and ALS, respectively); they executed approximately 450,000 ambulance responses, and providers are expected to use SATS in all clinical cases [11,12].…”