title: Can focused trauma education initiatives reduce mortality or improve resource utilization in a low-resource setting?
abstract: BACKGROUND
  Over 90% of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization.
  
  
  METHODS
  Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ(2) and Fisher's exact test.
  
  
  RESULTS
  A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3%, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3-8 had the highest injury-related mortality, which significantly decreased from 58.5% (n = 55) to 37.1% (n = 23), (p = 0.009, OR 0.42, 95% CI 0.22-0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3-5 in the post-intervention period had higher utilization of head CT scans and chest X-rays.
  
  
  CONCLUSIONS
  The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.
authors.affiliation: Department of Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA, rtp3z@virginia.edu.
authors.forename: Robin T
authors.initials: RT
authors.lastname: Petroze
authors.forename: Jean Claude
authors.initials: JC
authors.lastname: Byiringiro
authors.forename: Georges
authors.initials: G
authors.lastname: Ntakiyiruta
authors.forename: Susan M
authors.initials: SM
authors.lastname: Briggs
authors.forename: Dan L
authors.initials: DL
authors.lastname: Deckelbaum
authors.forename: Tarek
authors.initials: T
authors.lastname: Razek
authors.forename: Robert
authors.initials: R
authors.lastname: Riviello
authors.forename: Patrick
authors.initials: P
authors.lastname: Kyamanywa
authors.forename: Jennifer
authors.initials: J
authors.lastname: Reid
authors.forename: Robert G
authors.initials: RG
authors.lastname: Sawyer
authors.forename: J Forrest
authors.initials: JF
authors.lastname: Calland
mesh_terms: D000293:Adolescent; D000328:Adult; D061906:Advanced Trauma Life Support Care; D002648:Child; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy*; D003906:Developing Countries; D004502:Education, Medical, Continuing; D004509:Education, Nursing, Continuing; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D015600:Glasgow Coma Scale; D006295:Health Resources / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013902:Radiography, Thoracic / Q000706:statistics & numerical data; D012042:Registries; D012151:Resuscitation / Q000193:education; D012432:Rwanda; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D055815:Young Adult