A trauma system for KwaZulu-Natal : local development for local need.
Hardcastle, Timothy Craig.
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Introduction: The need for Trauma Care in South Africa is without question one of the four major health issues facing the country and indeed the African continent today. First-world developed systems focus on the care of trauma from prevention to rehabilitation, yet in Africa the issue of access to even resuscitation is often the challenge faced by communities in poverty. The philosophical concepts which underpin the main thrust of the thesis are summarised as the introductory chapter. “The 11 P’s of an Afrocentric trauma system for South Africa” and “Guideline for the assessment of trauma centres for South Africa” were the result of this literature review. “Trauma care in South Africa: From humble beginnings to an afrocentric outreach” examines the history of trauma care in South Africa and the current desire to be relevant to the greater African Continent, highlighting the realities of practicing trauma care in this country. Local development is essential with regionally specific injury profiles, especially in a country like South Africa with very high trauma rates when compared to the rest of the world. Aim: This PhD submission aims to review the practical problems and the ethical issues facing trauma in South Africa. This submission examines the current burden of disease of live-injured patients entering the existing informal system in KwaZulu-Natal, both at a prehospital and in-hospital level of care. This submission also examines the current facilities and transfer processes within the government hospital sector, including specifically the utilization of the Level 1 Trauma Centre at Albert Luthuli Central Hospital. The submission aims to provide a solid provincial dataset on which to design a proposal for a practical system of trauma care across the province, and that may be potentially exportable to the rest of the country, and to Africa. Methods: This PhD proposal provides the evidence for the achievement of the stated aims through the submission of linked papers published in peer-reviewed medical journals relevant to the field of study covering an overview of the literature, examination of the ethical challenges in trauma facing South Africa, and the need for trauma systems. The current prehospital and hospital disease burden is examined and facility structure and staff skill-sets reviewed. A review of utilisation of and need for a major trauma centre is undertaken. Finally the thesis proposes an appropriate regionalised trauma system, emphasising the need for more such facilities across the province. The methods were described in the approved protocol and these are presented in the overview chapters. Results: The three papers that form the thrust of the scientific contribution of this work were all published in July 2013 in World Journal of Surgery and are as follows: 1. The Prehospital Burden of Disease due to Trauma in KwaZulu-Natal: The Need for Afrocentric Trauma Systems. 2. An Assessment of the Hospital Disease Burden and the Facilities for the In-hospital Care of Trauma in KwaZulu-Natal,South Africa. 3. Utilisation of a Level 1 Trauma Centre in KwaZulu-Natal: Appropriateness of Referral Determines Trauma Patient Access All three studies received BREC approval (BE011/010). The essential methodology, findings and conclusions derived from these three papers are outlined here: Paper 1: Methods: Using a convenience data set all Emergency Medical Service (EMS) call data for the months of March and September 2010 were reviewed for the three main EMS providers in KZN. Data were extrapolated to annual data and placed in the context of population, ambulance service, and facility. The data were then mapped for area distribution and prehospital workload relative to the entire province. Questionnaire-based assessments of knowledge and deficiencies of the current system were completed by senior officers of the provincial system as part of the analysis of the current system. Results: The total annual call burden for trauma ranges between 94,840 and 101,420, or around 11.6 trauma calls per thousand of the population per year. Almost 70 % of calls were either for interpersonal intentional violence or vehicular collisions. Only 0.25 % of calls involved aeromedical resources. Some 80 % of patients were considered to be moderately to seriously injured, yet only 41 % of the patients were transported to a suitable level of care immediately, with many going to inappropriate lower level care facilities. Many rural calls are not attended within the time norms accepted nationally. Deficiencies noted by the questionnaire survey are the general lack of a bypass mechanism and the feeling among staff that most EMS bases do not have a bypass option or feel part of a system of care, despite large numbers of staff having been recently trained in triage and Conclusions: The prehospital trauma burden in KZN is significant and consumes vital resources and gridlocks facilities. A prehospital trauma system that is financially sustainable and meets the needs of the trauma burden is proposed to enable Afrocentric emergency care planning for low and middle income regions. Paper 2: Methods: Hospital administrators in KZN were requested to submit trauma caseloads for the months of March and September 2010. Caseloads were reviewed to determine the trauma load for the province per category using two extrapolation methods to determine the predicted range of annual incidence of trauma, intentional versus non-intentional trauma ratios and population-related incidence of trauma. The results were GIS mapped to demonstrate variations across districts. Hospital data were obtained from assessments of structure, process, and personnel undertaken prior to a major sporting event. These were compared to the ideal facilities required for accreditation of trauma care facilities of the Trauma Society of South Africa and other established documents. Results: Data were obtained from 36 of the 47 public hospitals in KZN that manage acute emergency cases. The predicted annual trauma incidence in KZN ranges from 124,000 to 125,000, or 12.9 per 1,000 population. This would imply a national public hospital trauma load on the order of at least 750,000 cases per year. Most hospitals are required to treat trauma; however, within KZN many hospitals do not have adequate personnel, medical equipment, or structural integrity to be formally accredited as trauma care facilities in terms of existing criteria. Conclusions: There is a significant trauma load that consumes vital emergency center resources. Most hospitals will need extensive upgrading to provide appropriate care for trauma. An inclusive trauma system needs to be formalized and funded, especially in light of the planned National Health Insurance for South Africa. Paper 3: Methods: An audit was performed of the referral proformas used in the unit to record admission decisions and of the computerised trauma database. The audit examined referral source (scene vs. interhospital), regional distribution, and final decision regarding admission of the injured patients. The study was approved by the UKZN Ethics Committee (BE207/09 and 011/010). Results: Of the 1,212 external consults, 540 were accepted for admission while the rest were not accepted for various reasons. These included 206 cases where no bed was available, 233 did not meet admission criteria (minor injury or futile situation), and 115 were for subspecialty management of a single-system injury. Finally, 115 were initially refused pending stabilisation for transfer at a regional facility. Twenty-six percent of the cases were referrals from the scene, with an acceptance rate of 96 %. Most patients (59 %) were from the local eThekwini region. Conclusion: Major multiorgan system trauma remains a significant public health burden in KwaZulu-Natal. A Level 1 Trauma Service is used appropriately in most circumstances. However, the additional need for more hospital facilities that provide such services across the whole province to enable effective geographical coverage for those trauma patients requiring such specialised trauma care is essential. After evaluation of the submitted papers a summative chapter is provided as to how they provide a framework to design a Trauma System relevant to KZN, South Africa and potentially Africa. Overall Conclusions: In the developed world trauma systems have been shown to substantially reduce mortality and morbidity after major and moderate trauma. Few such systems and centres of excellence exist within the developing world scenario. The solutions offered by such systems may not be entirely relevant to the African scenario. A trauma system relevant to KwaZulu-Natal, South Africa and the African continent is essential to reduce the huge mortality burden in low to middle income regions, where trauma is a major source of reduced life-years. The results of the studies presented here are valuable in providing insight to the needs and potential solutions to the challenges faced in our environment. A plea is therefore made for pilot implementation at provincial level. This will involve further research into the feasibility of introduction and how such an introduction could be audited and refined for broader adoption in South Africa and the African continent.