Non-Doctors as Trauma Surgeons? A Controlled Study of Trauma Training for Non-Graduate Surgeons in Rural Cambodia

Abstract

Introduction:Due to the accelerating global epidemic of trauma, efficient and sustainable models of trauma care that fit low-resource settings must be developed. In most low-income countries, the burden of surgical trauma is managed by non-doctors at local district hospitals.Objective:This study examined whether it is possible to establish primary trauma surgical services of acceptable quality at rural district hospitals by systematically training local, non-graduate, care providers.Methods:Seven district hospitals in the most landmine-infested provinces of Northwestern Cambodia were selected for the study. The hospitals were referral points in an established prehospital trauma system. During a four-year training period, 21 surgical care providers underwent five courses (150 hours total) focusing on surgical skills training. In-hospital trauma deaths and postoperative infections were used as quality-of care indicators. Outcome indicators during the training period were compared against pre-intervention data.Results:Both the control and treatment populations had long prehospital transport times (three hours) and were severely injured (median Injury Severity Scale Score = 9). The in-hospital trauma fatality rate was low in both populations and not significantly affected by the intervention. The level of post-operative infections was reduced from 22% to 10.3% during the intervention (95% confidence interval for difference 2.8–20.2%). The trainees' selfrating of skills (Visual Analogue Scale) before and after the training indicated a significantly better coping capacity.Conclusions:Where the rural hospital is an integral part of a prehospital trauma system, systematic training of non-doctors improves the quality of trauma surgery. Initial efforts to improve trauma management in low-income countries should focus on the district hospital.

The Impact of Trauma Care Systems in Low- and Middle-Income Countries

“…Other reports assessed the impact of training on mortality and morbidity: At a Médecins Sans Frontières-run first-level referral hospital in Masisi, Democratic Republic of the Congo, training nonspecialists to perform toileting of open fractures and external fixation decreased amputation rates among open fractures from 100% to 21% over 7 years (18). A surgical skills training program for nondoctors in Cambodia showed substantial reductions in postoperative infection rates and trauma mortality (93).…”

“…Of note, multiple initiatives specifically addressed training to extend the scope of practice for providers (task shifting or task sharing) as a means of expanding access to timely emergency care for injury. In Cambodia, for example, nondoctor health care providers were trained to provide essential trauma surgical care at rural first-level referral hospitals (93), and the Médecins Sans Frontières-run program in Democratic Republic of the Congo greatly improved outcomes by training nonspecialists to deliver specialized orthopedic services such as toileting of open fractures and external fixation (18). These reports suggest that task sharing may be an important mechanism for expanding the availability of services and improving quality and that training initiatives should be aligned with the frontline reality that emergency care for injury is delivered by a range of providers.…”

“…Reynolds et al Process (3,5,6,9,12,13,14,15,20,21,46,50,53,54,57,64,67,68,69,71,86,93,103) 23 (32) Clinical or population health outcome (3,4,12,14,15,16,17,18,19,22,23,24,28,29,35,36,41,42,43,45,48,49,53,54,57,59,60,61,64,…”

Effective Strategies for Global Health Training Programs A Systematic Review of Training Outcomes in Low and Middle Income Countries

“…Sample sizes ranged from 12 to 12795. Samples included physicians/healthcare workers being trained and clusters of regions where trainings were conducted (Ajuwon et al, 2008;Arreola-Risa et al, 2007;Autry et al, 2013;Baig et al, 2008;Bedada et al, 2015;Brown et al, 2000;Dizon et al, 2014;Dodani et al, 2008;Goodwin et al, 2011;Goudar et al, 2011;Hashmi et al, 2013;Hoban et al, 2013;Husum et al, 2003a;Husum et al, 2003b;Kauye et al, 2014;Kebede et al, 2012;Kulier et al, 2012;Levine et al, 2011;Lewin et al, 2005;Makanjuola et al, 2012;Tomatis et al, 2011;van Heng et al, 2008;Wang et al, 2014;Wee etal., 2011). Intervention duration ranged from one day to three years.…”

“…Out of the 24 articles, four measured knowledge (Ajuwon et al, 2008;Baig et al, 2008;Dodani et al, 2008;Goodwin et al, 2011), eight measured skill (Brown et al, 2000;Goudar et al, 2011;Hashmi et al, 2013;Husum et al, 2003a;Husum et al, 2003b;Kauye et al, 2014;Kebede et al, 2012;Lewin et al, 2005), seven measured knowledge and skill (Autry et al, 2013;Dizon et al, 2014;Hoban et al, 2013;Kulier et al, 2012;Levine et al, 2011;Wang et al, 2014;Wee et al, 2011), two measured mortality and skill (van Heng et al, 2008;Arreola-Risa et al, 2007), one measured knowledge and attitudes (Makanjuola et al, 2012), and two measured knowledge, skill, and attitudes (Kulier et al, 2012;Tomatis et al, 2011). Table 4 provides a comparison of the training methods used in eligible studies.…”