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Background and Aims Improving the quality of pre‐hospital traumatic shock care, especially in low‐ and middle‐income countries, is particularly relevant to reducing the large global burden of disease from injury. What clinical interventions represent high‐quality care is an actively evolving field and often dependent on the specific injury pattern. A key component of improving the quality of care is having a consistent way to assess and measure the quality of shock care in the pre‐hospital setting. The objective of this study was to develop and validate a chart abstraction instrument to measure the quality of trauma care in a resource‐limited, pre‐hospital emergency care setting. Methods Traumatic shock was selected as the tracer condition. The pre‐hospital quality of traumatic shock care (QTSC) instrument was developed and validated in three phases. A content development phase utilized a rapid literature review and expert consensus to yield the contents of the draft instrument. In the instrument validation phase, the QTSC instrument was created and underwent end user and content validation. A pilot‐testing phase collected user feedback and performance characteristics to iteratively refine draft versions into a final instrument. Accuracy and inter‐ and intra‐rater agreement were calculated. Results The final QTSC instrument contains 10 domains of quality, each with specific criteria that determine how the domain is measured and the level of quality of care rendered. The instrument is over 90% accurate and has good inter‐ and intra‐rater reliability when used by trained pre‐hospital provider users in South Africa. Pre‐hospital provider user feedback indicates the tool is easy to learn and quick to use. Conclusion We created and validated a novel chart abstraction instrument that can reliably and accurately measure the quality of pre‐hospital traumatic shock care. We provide a systematic methodology for developing and validating a quality of care tool for resource‐limited care settings.

ObjectivesThis project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.DesignWe conduct a two-arm, controlled, mixed-methods, hybrid type II study.SettingThis study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.InterventionsWe pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measuresWe assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).ConclusionsIn this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.