Pre-referral stabilization and compliance with WHO guidelines for trauma care among adult patients referred to an urban emergency department of a tertiary referral hospital in Tanzania

Trauma is a leading cause of death and disability globally, accounting for more deaths than human immunodeficiency virus (HIV), malaria and tuberculosis combined [1‐3]. Injury contributes about 5.8 million deaths worldwide, and it is estimated that 90% of trauma- associated mortality occurs in Low and Middle Income Countries (LMIC) [4, 5], increasing the overall burden of disease in these countries [3, 4, 6].

The incidence of trauma in LMIC has increased substantially [8‐10]. In Tanzania, deaths from road traffic accidents accounts for over 40 % of all injuries [11]. For every death occurring due to road traffic accident there are fifty more survivors with permanent disability and deformity [4]. Despite this burden of trauma in Tanzania, the trauma system and preparedness for caring for trauma cases is inadequate, further contributing to death and disability [12].

In Tanzania, there are different levels of hospitals ranging from the health centers with limited resources and staffed by non-physicians with a diploma in clinical medicine, to the regional hospitals with more resources and specialist care. There is no formal pre-hospital system, thus trauma patients are brought to a nearby hospital by bystanders, relatives, or police who don’t have the knowledge to handle these patients appropriately. Moreover, local hospitals are not necessarily capable of caring for these trauma patients. As in other LIMC, emergency medicine is a new field (and few hospitals have emergency departments (ED), and only “casualty” units, who largely triage patients. Across the country there is only one full capacity trauma care centre the Muhimbili Orthopaedic Institute that is located in Dar es salaam and cares for all trauma patients with orthopaedic, trauma and neurosurgical cases. The Muhimbili National Hospital Emergency Department (MNH ED) receives these trauma patients in transfer from the district and regional hospitals in the city and outside the city.

Initial stabilization in trauma patients is defined by the World Health Organisation (WHO) essential trauma care as services provided to any trauma patient to prevent death or disability [2]. This includes recognition and correction of airway obstruction, breathing compromise and circulatory compromise at all hospitals. Depending on the level of hospital, additional stabilization measures are recommended [13]. The WHO essential trauma care guideline categorizes human and physical resources (infrastructure, equipment and supplies) that are necessary for provision of care at different levels of health facilities. The lower level health facilities are expected have less health care providers, and hence perform fewer interventions as compared to the higher-level health facilities.

It is unclear how well referring hospitals in Tanzania are able to comply with the WHO recommendations for initial stabilization for trauma patients. In order to improve the care of these trauma patients we conducted a study to determine the types of initial stabilization/intervention done for these patients and evaluate it in terms of WHO recommendations.

Stabilization of trauma patients prior to transfer improves outcome [15‐17]. Our study provides a snapshot of initial stabilization of adult trauma patients provided by referring hospitals in Tanzania. We found that few patients had stabilization interventions before being referred to our ED. Moreover, most patients arrived more than 24-h after the injury. Lower facilities had a higher percentage of patients who received any form of initial stabilization compared to higher facilities, possibly as a result of patients passing from more than one facility prior to reaching MNH.

The majority of patients in our study were between 18 and 30 years old, with a predominance of males. These statistics are similar to other studies done previously in both HIC and LMIC illustrating the impact of trauma on a productive age group [7, 16‐19]. Moreover the most common mechanism of injury was road traffic injuries, similar to these prior studies [6‐8, 20, 21], However, motorcycle injuries were more common than MVA’s and falls in our study, which is similar to previous studies in LMIC, but less common in HICs [19, 22]; again these motorcycle accidents primarily affected an economically productive age group. With increasing urbanization in LIMC’s, motorcycles have become popular due to their lower cost and ability to maneuver through traffic. Poor roads and lack of adherence to traffic laws increases accidents [9, 23].

The primary purpose of this study was to investigate how well hospitals in Tanzania comply with initial stabilization of adult trauma patients according to the WHO essential trauma care guideline [24]. The majority of both head and extremity injury patients did not receive appropriate initial stabilization prior to referral to EMD MNH per WHO recommendations. We believe that this result is likely due to a knowledge gap among providers regarding initial stabilization and emergency care. Emergency medicine is a new field in Tanzania; there is only one full capacity emergency medicine department in the country, which opened in 2010. Lack of resources and equipment may also contribute to the low performance of stabilization measures [25]. Although not all patients were likely to require many of the specified interventions, there were clearly some areas where intervention was required but not done, patients with extremity injury needed splinting however it was not done properly or not done at all; patients with traumatic head injury should have cervical spine stabilization until they have been cleared; however none of them arrived to our hospital with a cervical spine protection and it was not recorded in the referral note. It is possible that additional procedures were done but not recorded. Even then, however, this can jeopardize patient care due to poor communication with the receiving facility.

Appropriate and timely initial stabilization in adult trauma patients is found to have reduced avoidable morbidity and mortality in developed countries with several studies providing evidence for recommendations regarding what should be performed, and how it should be done, in the initial stabilization of these patients [16, 18]. In order to translate this to LIMC’s, WHO created guidelines and a checklist. It is unclear if these facilities are aware of these guidelines and thus may benefit from the use of a checklist for referrals.

The delay in arrival to our ED after trauma is a result of the referral system currently established in the country and absence of formal pre hospital services [26]. It is important to note that the performance of stabilization measures was low across all levels of hospitals, including regional hospitals that are considered well resourced. The development of a prehospital system and designated trauma centers would avoid patients going to hospitals that do not contribute to care, and improve the timeliness of arrival at the appropriate facility. At the same time such a structure would reduce the burden of trauma on smaller hospitals which have more limited resources.

In this urban public emergency department in Tanzania, majority of trauma patients were referred from lower health facilities after 24-h of injury. Most did not receive initial trauma stabilization as recommended by the World Health Organisation guidelines. Future studies should identify barriers to pre-referral stabilization of adult trauma patients.