Nominated From: University of the Witwatersrand
Research Site: Ghana
Research Area: Trauma
Primary Mentor: Peter Donkor
Advancing Prehospital EMS Trauma Care, Access, and Patient Outcomes
Comparative global trauma system development studies have shown that poor prehospital care –independent of in-hospital care – in Kumasi, Ghana, Mexico City, and Seattle, Washington, contributed to excess mortality rates (Mock et al, 1998). Therefore I propose a quantitative and qualitative analysis of Ghana’s current prehospital dispatch/response times, transportation network access, resources, Mass Casualty Incident (MCI) planning, patient treatment and outcomes, which could initially identify preventable deaths and disabilities due to transport delays, insufficient resources, access, and/or deficient training or care. Prehospital care constitutes a critical link in the continuum of trauma care, thus this research will compare formal and informal Emergency Medical Services (EMS) treatments, identify heavy-demand areas, evaluate public health literacy of EMS, and align prehospital capacity-building measures, MCI plans, and structural models to global healthcare agendas.
Effective prehospital care systems must comprise certain core administrative and programmatic elements, and the structural models chosen for prehospital care should take into account local factors and resources (WHO, 2005). Studies have also noted that the heavily capitalized and resourced ‘Western-style EMS system’ should not necessarily be automatically advocated for nascent Sub-Saharan prehospital systems, as geographical expansion and capacity-building measures are contingent upon local/regional requirements, resources, innovation and appropriateness (Mock et al, 1998). Therefore efficient local and national networking and sustainable, low-cost resource utilization will play critical roles in developing Ghana’s prehospital care infrastructure in order to increase its current coverage/access capacities, dispatch and communications mechanisms, public service support networks, and trauma education.
Currently the Ghana National Ambulance service covers only a small percent of the need in Ghana, with many rural and outlying areas without any access to systematic/formal prehospital care. According to a 2004 study, most roadway casualties in Ghana receive care and transport to the hospital from taxi, bus, or truck drivers (Tiska et al). Therefore an innovative methodology implemented in Ghana was the creation of a model for prehospital trauma training for commercial drivers, with over 300 commercial drivers attending a basic first-aid and rescue course designed specifically for roadway trauma and geared to a low education level. The training course was educationally appropriate and flexible, with hands-on skills training proving the most successful educational method. The study reported that the two primary areas in which it seemed that the drivers could make the greatest difference in prehospital mortality were protecting airway from obstruction (or aspiration) and control of external hemorrhage (Tiska et al, 2004). Other abridged arenas of prehospital instruction included scene management, universal precautions, extrication, splinting, transport, triage, and moving of casualties. Additionally, the need for the distribution of free/low-cost Personal Protective Equipment (PPE) and limited, rudimentary first-aid supplies to lay persons (who may not fully comprehend inherent transmission risks and routes of blood-borne diseases, and so on) for this program should perhaps also be considered. Ostensibly, reusable/re-sterilizable and cost- effective First Responder ‘Trauma Kit’ supplies could include: moldable, reusable splinting material (like SAMTM splint), self-adherent wrap (like Coban), fast-wicking rolled gauze bandage (like Kerlix), a soft or rigid cervical collar, nitrile gloves, and safety glasses. These low-cost kits could (hypothetically) be sponsored by airlines, pharmacies, or transport companies and given as useful yet inexpensive tokens of appreciation at the completion of the current First Responder (commercial driver) course or at the periodic refresher training sessions.
Research supports that the introduction of low-cost prehospital trauma training has had a significant effect on trauma mortality in low-income countries. As one example, a five-year study in Iraq and Cambodia comprising 1,061 trauma victims, 5,200 lay First Responders and 135 local paramedics, showed a pre-intervention trauma mortality rate reduction from 40% to 14.9% due to the introduction of a streamlined prehospital training approach (Husum et al, 2003). However, the observable non-availability of necessary prehospital medical supplies and equipment in Ghana represents yet another unique EMS challenge. Local Ghanaian studies have reported that the non-availability of supplies and equipment resulted from several contributing factors, namely equipment absence, lack of training, frequent stock-outs, and technology breakage, caused by ineffective healthcare financing (untimely national insurance reimbursements), procurement and stock-management practices, and critical gaps in local biomedical engineering and trauma care training (Mock et al, 2015).
Throughout the nine months, the overarching research focus will include the comparison of patient injury care, treatment costs, and outcomes in three primary Ghanaian patient care arenas: those with access to formally trained EMS/pre-hospital care; those utilizing only bystander (layperson; non-medical personnel) care and transport; and those utilizing traditional healers (like bonesetters and herbal healers). Other ongoing research components (in priority order) will include: the utilization of a methodical (qualitative) approach to identify specific regions of heavy trauma care need (via motor vehicle registration – Ghana Drivers and Vehicle License Authority, police accident reports, and trauma data); and the current state of Ghanaian out-of-hospital EMS assets/resources (training standards, equipment, accreditation, ambulances, funding and resources of NGOs, churches, fire and police department, private/military EMS services, etc.).
Secondary and tertiary components of this research, should time allow, would include the standardization of national EMS training and care protocols, policies, and procedures competencies. Some of these components comprise the planning and/or formation of an online EMT ‘National Registry’ and several set levels of EMS care, such as: First Responder, EMT-I (basic life support), EMT-II (Intermediate), EMT-III (Paramedic Specialist), Mobile Critical Care Paramedic (or Flight Paramedic or Pre-Hospital Registered Nurse). Readily available components of prehospital coursework can follow standards of the International Trauma Life Support (ITLS), or Prehospital Trauma Life Support (PHTLS), or some other accepted, culturally appropriate methodology. For instance, the ITLS method (endorsed by the American College of Emergency Physicians) stresses rapid assessment, appropriate intervention, and identification of immediate life threats, whereas the PHTLS method (endorsed by the American College of Surgeons) promotes critical thinking in addressing multi-system trauma, and provides the latest evidence-based treatment practices. Within this training mechanism would be a proposal for the standardization of national EMS terminology competencies, with culturally relevant definitions of EMS terms such as advanced/basic trauma life support, triage, emergency care, life-saving care, etc. As the 2013 “Prehospital Research in Sub-Saharan Africa: Establishing Research Tenets” study noted, there must be a consensus-building process to further clarify, define and standardize prehospital and acute care terminologies (such as “acute care referral system,” “out-of-hospital” and “emergency medical services”)(Millman, Sasser and Wallis, 2013). The Millman study also observed that any and all regional research priorities should be aligned and tied to the global healthcare agenda, such as the United Nation’s eight Millennium Development Goals or the World Health Organization’s agenda.
Additionally in the first six months, an ‘extension’ project I propose, time permitting, is the execution of qualitative interviews with general public residents and public service providers (police/fire/EMS/public health providers) to ascertain current perceptions and misperceptions of Ghanaian EMS usage, costs, and funding challenges. Interviews would use a snowball-sampling random methodology in order to discern the current state of EMS trauma perceptions and misperceptions in both urban (Kumasi) and rural (not located in or adjacent to a large urban city) areas and consist of 50-100 interviews utilizing open-ended queries. Queries would include: What is (constitutes) a medical emergency? When do you call an ambulance? If a public ambulance is offered here in your area, which entity should pay for the ambulance service/personnel/petrol costs? Have you ever used an ambulance? Do you know what an ambulance transport costs?
Lastly in the latter three months, pending the approval and support of both KATH and KNUST institutions, I propose to conduct a very brief preliminary needs/interest assessment for Mass Casualty Contingency Planning and Mass Incident Deployment by EMS service providers, beginning with a general hazard assessment and an EMS surge capacity evaluation, as a critical part of this future EMS trauma planning. During this time, I propose to offer disaster lectures on Mass Casualty Incident planning, Mass Casualty Contingency Planning, Mass Incident Deployment, and surge capacity valuations at various facilities conceivably including: district hospitals, officials from Ghana Armed Forces ambulance corps, the Ghana National Ambulance Service, or the Ministry of Health offices. Should time permit, I would finally propose to assist in planning for future annual national ‘EMS Expo’ in Kumasi and/or Accra for healthcare providers to demonstrate technological advances in care, capacity building, and development of urban/rural cooperatives of public service provisioning amongst EMS, fire and police agencies. Upon completion of the various research projects, further lectures and presentations would be pursued and welcomed via local universities (Cape Coast, KNUST, Ghana Medical School, etc.), as well as the publication of the research’s results in journal articles such as the Journal of Trauma, Journal of Emergency Medicine, International Journal of Mass Emergencies and Disasters, Journal of Emergency Medical Services, Injury Prevention, and others.