International Trauma Teleconference: Evaluating Trauma Care and Facilitating Quality Improvement

Abstract

Background: Evaluation, development, and implementation of trauma systems in Latin America are challenging undertakings as no model is currently in place that can be easily replicated throughout the region. The use of teleconferencing has been essential in overcoming other challenges in the medical field and improving medical care. This article describes the use of international videoconferencing in the field of trauma and critical care as a tool to evaluate differences in care based on local resources, as well as facilitating quality improvement and system development in Latin America. Materials and Methods: In February 2009, the International Trauma and Critical Care Improvement Project was created and held monthly teleconferences between U.S. trauma surgeons and Latin American general surgeons, emergency physicians, and intensivists. In-depth discussions and prospective evaluations of each case presented were conducted by all participants based on resources available. Care rendered was divided in four stages: (1) pre-hospital setting, (2) emergency room or trauma room, (3) operating room, and (4) subsequent postoperative care. Furthermore, the participating institutions completed an electronic survey of trauma resources based on World Health Organization/International Association for Trauma and Surgical Intensive Care guidelines. Results: During a 17-month period, 15 cases in total were presented from a Level I and a Level II U.S. hospital (n=3) and five Latin American hospitals (n=12). Presentations followed the Advanced Trauma Life Support sequence in all U.S. cases but in only 3 of the 12 Latin American cases. The following deficiencies were observed in cases presented from Latin America: pre-hospital communication was nonexistent in all cases; pre-hospital services were absent in 60% of cases presented; lack of trauma team structure was evident in the emergency departments; during the initial evaluation and resuscitation, the Advanced Trauma Life Support protocol was followed one time and the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage protocol on two occasions; it was determined that imaging resources were adequately used in half of the cases; the initial care was mostly provided by emergency room physicians; and a surgeon, operating room, and intensive care unit were not readily available 83% of the time. The ease of patient flow was cumbersome because of a lack of a structured system for trauma care except for one academic urban center. Adequate trauma resources are present in less than 50% of the time. Multidisciplinary resources, quality improvement programs, protocols, and guidelines were deficient. Conclusions: A well-structured international teleconference can be used as a dynamic window of observation to evaluate and identify deficiencies in trauma care in the Latin American region. These findings can be used to formulate specific recommendations based on local resources. Furthermore, by raising local awareness, leaders could be identified to become the executors of more efficient healthcare policies that can potentially affect trauma care.

Introduction

Trauma is a global epidemic that affects all nations, resulting in 5.8 million deaths per year globally. Furthermore, trauma accounts for 16% of the global burden of disease, with many cases resulting in permanent disability. Over 90% of trauma morbidities and mortalities occur in low- and middle-income countries.¹ The Americas account for 11% of the overall global rate of mortality related to trauma. In addition, trauma and noncommunicable diseases account for 76% of disability-adjusted life years in Latin America and the Caribbean.^2,3

The burden of disease associated with trauma is more severe in rural areas because of a lack of resources and appropriate infrastructure. In general, these trauma systems are either rudimentary or nonexistent. Therefore, the need to develop and implement trauma systems in these areas is of vital importance. This shortcoming is evident in the disparities in trauma outcomes between low- and lower middle-income countries and upper middle-income countries. Higher mortality rates related to trauma are associated with low- and lower middle-income countries, where rapid urbanization and expansion are occurring without adequate infrastructure and healthcare system growth and development to support it.¹ Unfortunately, public policy to distribute funds and resources toward the care of the injured is often neglected or not considered a priority. Frequently initiatives regarding trauma care rely on individuals who have an interest in this specialty.

In an effort to establish achievable and affordable standards of care for the injured patient worldwide, the World Health Organization (WHO) and the International Association for Trauma and Surgical Intensive Care (IATSIC) have designed specific guidelines and injury prevention strategies.⁴ The WHO/IATSIC Essential Guidelines for Trauma Care (EsTC guidelines) are aimed at promoting inexpensive improvements in facility-based trauma systems ranging from physical and human resources in order to provide basic and essential trauma services for the injured patient worldwide. The EsTC guidelines identify three broad categories to identify the “needs of the injured patient,” which are further separated into 11 core trauma services deemed essential in meeting those needs.⁴

As a globally accepted set of guidelines, the EsTC guidelines are used in on-site field surveys as a means to assess the status and determine the need of trauma systems throughout the world. They have been successfully used in various countries representing different regions and income classes such as Mexico, Vietnam, India, and Ghana.⁵ However, these on-site field studies often provide only a static view into the complexity of local trauma systems and are often difficult to obtain in hard-to-reach rural environments. Therefore, other avenues of analysis may also be used in order to supplement and maximize the assessment of trauma systems throughout the world.

The use of teleconferencing for the purpose of exchanging knowledge and experiences has been demonstrated in various medical specialties on an international level.^6,7 The use of telemedicine has also been documented in Latin America, but these reports are limited.^7,8 Specifically in the area of trauma, few if any reports exist documenting the use of teleconferencing at an international level. In this study we describe the use of an international teleconference as a first step to evaluate and promote quality improvement and aid in the development of trauma care in the Latin American region.

Materials and Methods

International Trauma and Critical Care Videoconference

The International Trauma and Critical Care Improvement Project was formed in February 2009 with the purpose of improving the diagnostic process and management of polytraumatized patients via multidisciplinary discussion of clinical cases. These discussions are attended by experts from various nations and are facilitated by teleconferencing. The overall mission of the International Trauma and Critical Care Improvement Project is the use of multidisciplinary, coordinated, and interactive international videoconferences as a tool for the evaluation of trauma and critical care systems between various regions with constant consideration of the resources and infrastructure in each region.

The monthly international videoconference was made possible via the utilization of the Polycom™ (San Jose, CA) system and software. The Polycom PictureTel™ unit ensuring connectivity via an Integrated Services Digital Network was used from Broward Regional Medical Center, a Level I trauma center in Fort Lauderdale, FL. The remaining participating institutions ensured connectivity with Internet protocol addresses via Polycom PVX™ computer-based software. All participants were then connected via the Polycom MGC Accord 100™ bridging device located at Nova Southeastern University (Fort Lauderdale). This allowed all participants to communicate with speeds up to 384 kilobits per second and up to 2 megabits per second of high-definition video.

Participating institutions from the period of February 2009 to July 2010 included a Level I and a Level II trauma center from the United States, three hospitals from Colombia, and two hospitals in Ecuador. Regions represented from each participating institution ranged from rural clinics to urban tertiary centers with the quantity of beds ranging from 16 to 726 beds. The population from each region ranged from 70,000 to 7 million people.

Academic Discussion Model and Study Design

The academic discussion model during the teleconferences was divided into four phases, which are representative of standard care rendered to trauma patients. The four phases are divided into care rendered in the pre-hospital setting, the emergency room or trauma room, the operating room, and the subsequent critical care or postoperative care.

A prospective analysis of clinical cases presented at each monthly international teleconference conducted from February 2009 to July 2010 was performed, considering the treatment provided in the pre-hospital setting, the emergency room or trauma room, the operating room, and the subsequent postoperative care. The local resources and existing infrastructure of each region were always taken into consideration when analyzing each clinical case presented.

Survey

An electronic survey based on the WHO/IATSIC EsTC guidelines was sent to each participating institution. Data on demographics, health professionals, resources, protocols and guidelines, and continuing medical education were collected from each participating hospital. The elements were categorized as “not applicable” or NA whenever an element was not relevant for that level, “absent” or 0 whenever an element was not available, “inadequate” or 1 when an element was not available or operational less than 50% of the time, “partly adequate” or 2 when an element was available and operational greater than 50% of the time, and “adequate” or 3 when an element was present and available at all times. The data collected were correlated with the prospective analysis of the clinical cases discussed via teleconferencing in order to identify deficiencies in trauma care in the Latin American region.

A secondary electronic survey was sent to all participating institutions in order to gather data on the impact of participating in the monthly international teleconferences: whether there was a perceived impact on trauma education, trauma system structure, distribution of resources, communication, and pre-hospital trauma care. Furthermore, data on whether there was an impact on trauma care awareness in the in-hospital or surrounding community were collected.

Results

In total, 15 clinical cases were presented between February 2009 and July 2010. Two institutions in the United States presented a total of 3 cases (n=3). Five institutions in Latin America presented a total of 12 cases (n=12). There were two cancellations due to staff vacations at separate institutions. In general, prospective analysis of the clinical cases presented from Latin America revealed a comparative absence of an overall structured trauma system, human resources and materials, protocols and guidelines, designated trauma registry, quality control programs, and regulatory bodies.

Pre-Hospital Phase

In regard to pre-hospital care, all clinical cases presented were analyzed for the presence of pre-hospital communication, formal/trained emergency medical services team, immobilization of the patient with a cervical collar and/or backboard, and appropriate pre-hospital management of the patient's airway, breathing, and circulation. Pre-hospital communication was lacking in all 12 cases presented from Latin American institutions. Pre-hospital services were absent in 60% of Latin American cases. In Latin American cases in which pre-hospital care was provided, this care was often rudimentary, providing only immobilization and transport. In contrast, pre-hospital communication, pre-hospital care, and a formal trauma team were present in all cases presented by U.S. institutions (n=3).

These pre-hospital results were then compared with the subsequent survey responses regarding pre-hospital care. Six points of pre-hospital care were surveyed in regard to the availability and presence of pre-hospital communication, trained paramedics, and trained pre-hospital transportation whether by Red Cross, civil defense, fire department, or private ambulance. The results from the survey correlated with those drawn from clinical cases presented in the monthly videoconferences. Of the Latin American institutions surveyed (n=5), aspects of pre-hospital care were either absent or inadequate in 5 (17%) and 15 (50%) points of care, respectively. Aspects of pre-hospital care in Latin American institutions were also found to be partially adequate in four (13%) and adequate in six (20%) points of care.

Emergency Department or Trauma Room Phase

In terms of care in the emergency department or trauma room, a formal trauma team was present in only 1 of the 12 (8%) Latin American cases presented. The Advanced Trauma Life Support protocol was used for the evaluation and resuscitation of the patient in only 1 of 12 (8%) Latin American cases presented. However, the European Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage protocol was used in 2 (17%) of the Latin American cases for the evaluation and resuscitation of patients. All cases presented by United States institutions (n=3) used the Advanced Trauma Life Support protocol for the evaluation and resuscitation of trauma patients. X-ray, computed tomography scan, and ultrasound for focused assessment with sonography for trauma in the emergency department and/or trauma room were used appropriately in 50% of the cases from Latin America.

The presence of 28 trauma resources deemed essential by the WHO/IATSIC EsTC guidelines was surveyed within both Latin American (n=5) and U.S. (n=2) institutions. Survey results showed that certain essential resources were available 59% of the time in Latin America. Other essential trauma resources were shown to be partially adequate 13% of the time, inadequate 7% of the time, and absent 21% of the time in surveyed Latin American institutions.

Operating Room Phase

Analysis of care given in the operating room showed that appropriate intra-hospital communication between the emergency room or trauma room and the operating room was only present in 6 (50%) cases assessed from Latin America. Furthermore, because of the lack of a formal trauma team, there is a delay in alerting operating room personnel to incoming or current trauma patients. Further analysis showed that 83% (10 of 12) of the Latin American cases did not have an operating room, surgeon, or surgical personnel readily available.

Postoperative/Intensive Care Unit Phase

As mentioned before, patient flow was shown to be cumbersome between the operating room and recovery room or intensive care unit because of a lack of intra-hospital communication. Cases presented from 80% (four of five) of the participating Latin American institutions displayed a lack of intra-hospital communication with the exception of one academic urban center.

Furthermore, no protocol to bypass the recovery room to the intensive care unit in the event that damage control surgery is needed in the presence of hypothermia, acidosis, and coagulopathy (the triad of death) was present in 80% (four of five) of the participating Latin American institutions. In addition, 83% (10 of 12) of the Latin American cases did not have either an intensive care unit bed readily available or an in-house intensive care unit.

However, despite the limited availability of advanced equipment, monitors, and intensive care, postoperative care for patients with multiple injuries in small and rural hospitals is still accomplished with limited resources. Analysis of clinical cases has shown that this lack of resources often produces innovative methods of treatment and care.

Trauma Program

Data regarding individual trauma programs at participating institutions were obtained via electronic survey. Results of the survey show that 80% (four of five) of the participating Latin American institutions have a formal quality control program specific for trauma care. A formal trauma registry or database on trauma patient information exists in 40% (two of five) of the Latin American institutions.

Trauma programs within institutions in the United States proved to have quality control programs dedicated to trauma at various levels. On the national level, the American College of Surgeons Committee on Trauma meets biannually, state-level committees meet on average four times per year, and county-level committees meet monthly. Both institutions in the United States also have intra-hospital quality control programs that meet on a multidisciplinary level monthly.

Secondary Survey

Results of the secondary electronic survey aimed at assessing the organizational changes in trauma care due to participation in the International Trauma and Critical Care Improvement Project showed the most impact by increasing education in regard to trauma care. Four of the five (80%) Latin American institutions surveyed reported trauma education within their respective hospitals being significantly improved.

Other areas of noticed improvement involved increased awareness of intra-hospital communication, distribution of resources, trauma system structure, and formation and use of protocols and guidelines. However, the area of awareness and impact on pre-hospital care was the least impacted after this period.

Discussion

The overall purpose of this project is to utilize international videoconferencing in conjunction with electronic surveys as a tool to evaluate various trauma systems within different regions of Latin America and identify areas for quality improvement. The findings taken from both clinical case presentations and surveys from urban and rural clinics in Latin America and the United States were similar to other findings in low- and middle-income countries such as Mexico, Vietnam, Ghana and India.^5,9

–12

The differences in trauma care between low middle-income nations and high middle-income nations are a tangible reality that has been well documented by the WHO and the Pan American Health Organization. Traditionally, surveys and on-site evaluations have been the mainstay to assess the care provided.^5,13 However, surveys are limited in their scope of assessment as they do not evaluate the integration of the various components essential to trauma care.

Teleconferencing is an additional tool that allows for an assessment of dynamic intricacies that healthcare providers in the field of trauma are able to offer to such patients in different environments according to the resources available. Teleconferencing provides a unique view into problems encountered during the course of patient care as evidenced in deficiencies of a cohesive trauma system. These experiences and difficulties encountered in the variety of regions represented, both urban and rural, can be shared with other institutions in order to facilitate collaborative efforts to overcome similar limitations.

The use of low-cost, “off-the-shelf” software has increased the ease with which institutions can connect and participate. There are many documented uses for videoconferencing, including clinical applications, educational applications, and administrative applications.^6
–8 A well-structured videoconference has the ability to make use of all these applications simultaneously. Academically, the multidisciplinary exchange of ideas has benefited all participants. Furthermore, using videoconferencing can bring the highest level of expertise in a given field to the enrichment of academic discourse. The clinical and administrative applications are derived from the discussion of case presentations, in which the analysis of various treatment modalities may eventually lead to the creation of protocols and guidelines that will ultimately improve the quality of care provided to the polytraumatized patient.

Dissecting the analysis of the videoconference into pre-hospital care, emergency room/trauma room, operating room, and postoperative care allows for an improved understanding of the care provided at each level with appreciation for how the use of resources available affects patient care throughout the chain of survival. Additionally, the creation of a teleconferencing program assists in the identification of local leaders, who in turn contribute in raising local awareness of trauma care and prevention. Furthermore, the process of case presentations and subsequent academic discussion empowers local individuals to take a continuous interest in the development and improvement of local trauma systems. Meanwhile, representatives from mature trauma systems are available to serve as consultants for trauma system development.

Conclusions

A well-structured international teleconference can be used as a dynamic window of observation to evaluate and identify deficiencies in trauma care in the Latin American region. These findings can be used to formulate specific recommendations based on local resources. Furthermore, by raising local awareness, leaders could be identified to become the executors of more efficient healthcare policies that can potentially affect trauma care. Teleconferencing has the potential to become an essential quality assessment tool to enhance the public health of regions around the world.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Hofman

, Primack

, Keusch

et al. Addressing the growing burden of trauma and injury in low- and middle-income countries. Am J Public Health, 2005; 95:13–17.

Pan American Health Organization. Regional core health data and country profile initiative. 2000–2007. www.paho.org. 2011 January 10.

Pan American Health Organization. Distribution of broad causes of death by groups of countries according to income. 1995–2009. www.paho.org. 2011 January 10.

Mock

, Lormand

, Goosen

et al. Guidelines for essential trauma care. Geneva: World Health Organization, 2004.

Mock

, Nguyen

, Quansah

, Arreola-Risa

, Viradia

, Joshipura

. Evaluation of trauma care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care. World J Surg, 2006; 30:946–956.

Augestad

, Lindsetmo

. Overcoming distance: Video-conferencing as a clinical and educational tool among surgeons. World J Surg, 2009; 33:1356–1365.

Jarvis-Selinger

, Chan

, Payne

, Plohman

, Ho

. Clinical telehealth across the disciplines: Lessons learned. Telemed J E Health, 2008; 14:720–725.

Beltran

, Newball

. A Latin American telemedicine social perspective from a Colombian telemedicine center initiative. Telemed J E Health, 2005; 11:616–619.

Quansah

. Essential trauma care in Ghana: Adaptation and implementation on the political tough road. World J Surg, 2006; 30:934–939.

10.

Joshipura

. Guidelines for essential trauma care: Progress in India. World J Surg, 2006; 30:930–933.

11.

Son

, Mock

. Improvements in trauma care capabilities in Vietnam through use of the WHO-IATSIC Guidelines for Essential Trauma Care. Int J Injury Contr Saf Promot, 2006; 13:125–127.

12.

Arreola-Risa

, Mock

, Vega

et al. Evaluating trauma care capabilities in Mexico with the World Health Organization's Guidelines for Essential Trauma Care publication. Rev Panam Salud Publica, 2006; 19:94–103.

13.

Aboutanos

, Mora

, Rodas

et al. Ratification of IATSIC/WHO's Guidelines for Essential Trauma Care assessment in the South American region. World J Surg, 2010; 34:2735–2744.