This was a prospective, observational cross-sectional study of all trauma patients (adult and paediatric) presenting to EU) at a sample of regional hospitals in Tanzania conducted for a period of six months, from 1st February 2018 and 31st July 2018.
The United Republic of Tanzania is a country with a population of 55 million people, located in the Eastern Africa, and designated as a Low Income Country with estimated per capita income of approximately US$ 920 (16). At the time of the study, Tanzania had 25 geopolitical regions, and a public health system provided in a pyramidal structure from dispensary, health centre, district hospital and regional hospital to consultant hospitals. There is no formal trauma care system, hence trauma patients are taken to the nearest available health facility that might provide definitive care or refer the patient to a higher level of care, depending on the capacity and resource availability (17). Most of the lower level facilities are not adequately prepared for stabilization of trauma patients needing emergency care (18,19). This study was conducted in the EU of five regional referral hospitals in Tanzania: Morogoro, Arusha, Mwananyamala, Coastal and Tanga hospitals (Figure 1). Together, these represent 20% of the regional hospitals in Tanzania: regional hospitals are expected to provide specialist level management (including trauma care), and receive referrals from all districts within the catchment area. The median bed capacity of these hospitals during the study time was 440 (range: 295-500), and Arusha (500 beds) had both the highest bed capacity and number of EU beds compared to other hospitals (Table 1). These hospitals were purposively selected, as they are representing the variety of emergency care settings for regional hospitals in Tanzanian, and see a high volume of emergency cases.
Coastal Regional Hospital is located in the Coastal region, in eastern Tanzania, positioned along the busiest road connecting the north and south of Tanzania. Hospital caters a catchment area of 1.2 million people.
Morogoro Regional Referral Hospital is the regional referral hospital for the Morogoro region, which is about 200 km from Dar es salaam city. Hospital serves a catchment area of 2.3 million people.
Arusha Regional Hospital, also known as Mt. Meru Regional Hospital is the regional hospital of Arusha region, located in the north of Tanzania. The hospital has a catchment area of approximately 1.7 million people.
Tanga Regional Hospital is the regional referral hospital for the Tanga Region, located in North-Eastern Tanzania along the Indian Ocean. The hospital has a catchment area of 2.0 million people.
Mwananyamala Regional Hospital is the designated regional hospital for the Kinondoni administrative region, within Dar es salaam city. The hospital serves a catchment area of 1.1 million people.
These five hospitals are in various stages of the development of emergency and trauma care in Tanzania. During the time of the study, Arusha and Tanga Regional hospital’s EU were undergoing structural renovation and equipment improvement to support enhanced care processes over the next three years. Morogoro and Coastal Regional hospitals are along a section of the Dar es Salaam to Morogoro corridor along which a pre-hospital emergency care pilot study/program will be implemented. Mwananyamala hospital does not have any planned emergency care system improvement.
All trauma patients (adult and paediatric) presenting to the study EUs for whom care was documented by a treating provider (medical doctor, Assistant Medical Officer or Clinical Officer).
This study was conducted from February to July 2018. Trained research assistants - clinical officers (middle level providers with clinical medicine) and diploma nurses - observed in real time the provision of clinical care in the EU for every consecutive patient, and documented all the performed assessment, clinical interventions, and final disposition. In each EU we recruited and trained a total of 3-research assistant to allow 24/7 coverage. After clinicians completed their documentation, research assistants used a purposefully designed case report form (CRF) incorporating the WHO DSI to perform data abstraction from the clinician clinical chart. The research assistants audited the clinical documentation to determine which fields in the WHO DSI were documented by the clinicians, as documented, not documented or incorrectly documented. Furthermore, the research assistants reviewed Ministry of Health issued Facility Register book that is specific for outpatients department (OPD) record (Health Management Information System (HMIS) book number 5-OPD Register) and recorded the documentation of variables for each patient in the book. The HMIS book number 5 is a designated book that the Ministry of Heath captures all the disease burden and demographics of patients who presents to the OPD (which includes the EU and designated acute intake areas). At each site, a second (separate) research assistant, independently reviewed a randomly selected subset of 15% of the charts and CRFs, to assess the degree of inter-observer agreement. Lastly, the research assistant used a structured survey tool to interview the administrative providers in each hospital on the human, equipment and structural infrastructure that are relevant for provision of emergency care.
Data from hand-written CRFs were transferred to an online data capture software (REDCap version 7.2.2, Vanderbilt, Nashville, TN, USA) and then exported to Statistical Package for Social Science (SPSS version 22.0, IBM, Ltd, Carolina, USA) for analysis. Procedure frequency and univariate functions was performed to check for any outliers and clean the dataset. The capture rate of each variable within the WHO DSI was calculated as the number of recommended WHO variables calculated for each patient divided by the total recommended number. A summary proportion of rate of capture for each of the variables with 95% CI’s was calculated for each hospital and measured collectively across all sites. The descriptive statistics of total patients and trauma cases seen in each EU was summarised by frequency distribution tables of proportions for each variable, and median and range were calculated for overall availability of infrastructure and EU coverage. In effort to gain an understanding of whether the registry should be limited to patients with potentially severe/major trauma, we performed a subgroup analysis of rate completeness of WHO recommended documentation for patients who were admitted for inpatient care, died at EU or were transfer to higher level of care. The Inter-observer agreement for the presence and accuracy of trauma injury variable documentation between treating providers was measured by the weighted Cohen’s kappa.