SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
May, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
The majority of trauma deaths in low and middle income countries occur outside of hospitals. Improving pre hospital trauma care, such as emergency care through first responders and timely transport to an appropriate facility, has been suggested as a mechanism for reducing mortality and morbidity.
Key messages
People deciding whether to introduce pre hospital trauma systems.
Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta analysis. The journal of trauma and acute care surgery. 2012;73(1):261-268.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
The immediate period after injury is when resuscitation and stabilization is most beneficial to the patient. There is therefore a brief window of time in which to provide emergency care and rapid transport to hospital of people with injuries, in order to reduce mortality and morbidity.
The capacity to provide this immediate, basic level of care is lacking in many poor countries. Pre hospital trauma care involves a set of interacting elements that includes triage, airway management, oxygen administration, intravenous fluid administration, splinting, spinal immobilization, wound care and patient transport. Pre hospital trauma care can be categorised into two approaches: (1) first responders, and (2) ambulance services.
| Review objectives: To assess the effectiveness of pre hospital trauma systems in developing countries. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non randomised trials, controlled before after studies, uncontrolled before after studies and cohort studies assessing the effectiveness of pre hospital trauma systems. |
14 included studies of which 8 were included in a meta analysis (3 non randomised trials, 4 before after studies and 1 retrospective cohort study). |
| Participants | (1) Community members; and (2) professionals delivering pre hospital trauma care for communities. |
Communities of rural areas (4 studies) and urban areas (4 studies). |
| Settings | Developing countries (International Monetary Fund’s World Economic Outlook Report 2010). |
Mexico (2 studies), Iran (2) and one each from Afghanistan, Brazil, Cambodia, Iraq and Trinidad and Tobago. |
| Outcomes | Mortality (primary outcome), injury severity, physiologic severity, and pre hospital time. |
Mortality and pre hospital time analysed by injury severity. |
| Date of most recent search: December 2010 | ||
| Limitations: This is well conducted systematic review with only minor limitations. | ||
Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta analysis. The journal of trauma and acute care surgery. 2012;73(1):261-268.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
14 studies were included in the review of which eight were included in a meta analysis.
Four of the eight studies included in the meta analysis were conducted in rural areas without an ambulance system. In three of these studies, a two tiered response system with lay (non professional) first responders was established. The fourth study was conducted in a combat zone where paramedics were trained to provide advanced trauma life support.
The remaining four of the eight studies included in the meta analysis were conducted in urban areas. In three of these studies, an uncoordinated ambulance system was in place and these systems were re organized as part of the studies and training provided to ambulance personnel. In one study, firefighters were trained to provide trauma care and an ambulance system was established.
Pre hospital trauma systems compared to no pre hospital trauma system |
||||
| People: Patients from rural areas and urban areas. Settings: Community Intervention: Pre hospital trauma systems. Comparison: No pre hospital trauma system. |
||||
| Outcomes | Impact | Certainty of the evidence (GRADE) |
||
| Mortality |
Relative risk reduction of 25% (95% CI 15 to 34%) - Rural areas 29% (95% CI 14 to 41%) - Urban areas 21% (95% CI 6 to 35%) |
Low
|
||
| Response time from injury to first medical contact in the field |
May be reduced in both rural (without an ambulance system, reduction of 66 minutes (95% CI 24 to 108 minutes)) and urban (with an ambulance system, reduction of 6 minutes (95% CI 5.47 to 6.53 minutes)) settings |
Low
|
||
|
CI: Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page |
||||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| All studies included in the systematic review were conducted in low and middle income countries (most were in middle income countries) |
These findings are likely to be applicable in many low income country settings. However all of these interventions require the availability of lay or professional health workers who can be trained to provide first response care following trauma.
|
| EQUITY | |
|
There is limited evidence that pre hospital trauma systems may have larger impacts on mortality and response times in rural areas
|
The training of lay (non professional) people as first responders may help to reduce inequities if these lay people are drawn from and then work in resource poor areas.
|
| ECONOMIC CONSIDERATIONS | |
| The systematic review did not address economic considerations |
Scaling up of these interventions may require considerable resources.
|
| MONITORING & EVALUATION | |
| The available evidence on the impacts of pre hospital trauma systems is of low certainty |
Larger and more rigorous studies are required to determine the effects and the cost effectiveness of pre hospital trauma systems, particularly in low income countries.
|
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods |
|
These systematic reviews provide complementary information:
Beuran M, Paun S, Gaspar B, et al. Prehospital trauma care: a clinical review. Chirurgia. 2012;107(5):564-570.
Callese TE, Richards CT, Shaw P, Schuetz SJ, Issa N, Paladino L, Swaroop M. Layperson trauma training in low and middle income countries: a review. J Surg Res. 2014;190(1):104-10.
Callese TE, Richards CT, Shaw P, Schuetz SJ, Paladino L, Issa N, Swaroop M. Trauma system development in low and middle income countries: a review. J Surg Res. 2015;193(1):300-7.
Jayaraman S, Sethi D, Wong R. Advanced training in trauma life support for ambulance crews. Cochrane Database of Systematic Reviews 2014; 8: CD003109.
Obermeyer Z, Abujaber S, Makar M, Stoll S, Kayden SR, Wallis LA, Reynolds TA; Acute Care Development Consortium. Emergency care in 59 low and middle income countries: a systematic review. Bull World Health Organ. 2015;93(8): 577-586G.
Sun JH, Shing R, Twomey M, Wallis LA. A strategy to implement and support pre hospital emergency medical systems in developing, resource constrained areas of South Africa. Injury. 2014;45(1): 31-8.
Sasser S, Varghese M, Kellermann A, Lormand JD. Prehospital Trauma Care Systems. Geneva: World Health Organization; 2005.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Timothy Craig Hardcastle and Jaymie Henry.
Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta analysis. The journal of trauma and acute care surgery. 2012;73(1):261-268.
Ciapponi A. Do pre-hospital trauma systems reduce mortality? May 2017. www.supportsummaries.org
All Summaries:
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care.
Prehospital; rural trauma system; first responder; developing countries; advanced trauma life support.
