Clinical impact of a prehospital trauma shock bundle of care in South Africa

Mould‐Millman, Nee‐Kofi; Dixon, Julia; Ster, Bradley van; Moreira, Fábio Tanzillo; Bester, Beatrix; Cunningham, Charmaine; Vries, Shaheem de; Beaty, Brenda; Suresh, Krithika; Schauer, Steven G; Maddry, Joseph K.; Wallis, Lynne; Bebarta, Vikhyat S.; Ginde, Adit A.

doi:10.1016/j.afjem.2021.10.003

Cited by 3 publications

(10 citation statements)

References 33 publications

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“…To improve the accuracy of capturing this critical data point, we added a new variable, an “estimated injury event date/time,” to capture the date/time using time statements commonly documented in the medical record. It is also plausible that more CRIs were performed but not documented in the medical record, which is a known limitation of the patient chart abstraction methodology, especially in LMICs 39–42 …”

Section: Discussionmentioning

confidence: 99%

“…It is also plausible that more CRIs were performed but not documented in the medical record, which is a known limitation of the patient chart abstraction methodology, especially in LMICs. [39][40][41][42] However, a more likely reason for low proportion of CRIs is the change in local trauma epidemiology consequent to the COVID-19 pandemic. 43,44 There were two main effects attributed to local alcohol bans, lockdown periods, and public curfews: fewer than usual trauma cases, and lower injury severity and fewer trauma deaths.…”

Section: Discussionmentioning

confidence: 99%

“…The Western Cape of South Africa is an ideal and exceptional setting to gather evidence relevant to prolonged care, partly because it has one of the largest populations of severe patients facing prolonged care and documentation that is readily accessible 11 . In collaboration with civilian partners in the United States and South Africa, the US Department of Defense (DOD) has funded a multicenter, prospective observational, large-scale epidemiologic study in South Africa, called “Epidemiology and Outcomes of Prolonged Trauma Care: A Prospective Multi-Center Observational Study in the Western Cape of South Africa” (EpiC) 14 . Upon its conclusion in late 2024, the EpiC study will uniquely assess the effects of early resuscitation on postinjury mortality and morbidity in patients experiencing prolonged care 11,15,16 .…”

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confidence: 99%

“…In collaboration with civilian partners in the United States and South Africa, the US Department of Defense (DOD) has funded a multicenter, prospective observational, large-scale epidemiologic study in South Africa, called “Epidemiology and Outcomes of Prolonged Trauma Care: A Prospective Multi-Center Observational Study in the Western Cape of South Africa” (EpiC) 14 . Upon its conclusion in late 2024, the EpiC study will uniquely assess the effects of early resuscitation on postinjury mortality and morbidity in patients experiencing prolonged care 11,15,16 . The Western Cape trauma system is particularly military relevant because critically injured patients undergo sequential transportation to successive echelons of trauma care, similar to the military deployed setting 12,17–20 .…”

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confidence: 99%

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Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Mould‐Millman

Dixon

Lategan

et al. 2023

J Trauma Acute Care Surg

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BACKGROUND The Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study is a 4-year, prospective, observational, large-scale epidemiologic study in South Africa. It will provide novel evidence on how early resuscitation impacts postinjury mortality and morbidity in patients experiencing prolonged care. A pilot study was performed to inform the main EpiC study. We assess outcomes and experiences from the pilot to evaluate overall feasibility of conducting the main EpiC study. METHODS The pilot was a prospective, multicenter, cohort study at four ambulance bases, four hospitals, and two mortuaries from March 25 to August 27, 2021. Trauma patients 18 years or older were included. Data were manually collected via chart review and abstraction from clinical records at all research sites and inputted into Research Electronic Data Capture. Feasibility metrics calculated were as follows: screening efficiency, adequate enrollment, availability of key exposure and outcome data, and availability of injury event date/time. RESULTS A total of 2,303 patients were screened. Of the 981 included, 70% were male, and the median age was 31.4 years. Six percent had one or more trauma relevant comorbidity. Fifty-five percent arrived by ambulance. Forty percent had penetrating injuries. Fifty-three percent were critically injured. Thirty-three percent had one or more critical interventions performed. Mortality was 5%. Four of the eight feasibility metrics exceed the predetermined threshold: screening ratio, monthly enrollment, percentage with significant organ failure, and missing injury date/time for emergency medical services patients. Two feasibility metrics were borderline: key exposure and primary outcome. Two feasibility metrics fell below the feasibility threshold, which necessitate changes to the main EpiC study: percentage with infections and missing injury date/time for walk-in patients. CONCLUSION The EpiC pilot study suggests that the main EpiC study is overall feasible. Improved data collection for infections and methods for missing data will be developed for the main study. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level V.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Mould‐Millman

Dixon

Lategan

et al. 2023

J Trauma Acute Care Surg

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“…[28][29][30][31][32] We previously published findings of our primary outcome using changes in patient's SI which demonstrated no significant difference between the intervention and control groups. 33 In this paper, we conduct a preplanned secondary analysis using the SIxAge outcome in the intervention group compared with the control group. An SIxAge ≥36 is the cut-off point for shock in younger trauma populations characteristic of the Western Cape.…”

Section: Clinical Effectiveness Outcomesmentioning

confidence: 99%

Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting

et al. 2023

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ObjectivesThis project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.DesignWe conduct a two-arm, controlled, mixed-methods, hybrid type II study.SettingThis study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.InterventionsWe pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measuresWe assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).ConclusionsIn this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.

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Prolonged casualty care: Extrapolating civilian data to the military context

Mould‐Millman

Baidwan

Beaty

et al. 2022

J Trauma Acute Care Surg

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BACKGROUND:Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource limitations, and system configuration to US military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations. METHODS:We conducted a 6-month analysis of an ongoing, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape (Epidemiology and Outcomes of Prolonged Trauma Care [EpiC]). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using χ 2 and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models. RESULTS:Of 995 patients, 146 experienced PCC. The PCC group, compared with non-PCC, were more critically injured (66% vs. 51%), received more critical interventions (36% vs. 29%), and had a greater proportionate mortality (5% vs. 3%), longer hospital stays (3 vs. 1 day), and higher Sequential Organ Failure Assessment scores (5 vs. 3). The odds of 7-day mortality and a Sequential Organ Failure Assessment score of ≥5 were 1.6 (odds ratio, 1.59; 95% confidence interval, 0.68-3.74) and 3.6 (odds ratio, 3.69; 95% confidence interval, 2.11-6.42) times higher, respectively, in PCC versus non-PCC patients. CONCLUSION:The EpiC study enrolled critically injured patients with PCC who received resuscitative interventions. Prolonged casualty care patients had worse outcomes than non-PCC. The EpiC study will be a useful platform to provide ongoing data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care.

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Clinical impact of a prehospital trauma shock bundle of care in South Africa

Cited by 3 publications

References 33 publications

Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting

Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting

Prolonged casualty care: Extrapolating civilian data to the military context

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