Demographic Characteristics of the Interviewees
Interviews were conducted with 18 key-informants from wide range of health services including ministry of health, public and private health facilities and pre-hospital providers. Characteristics of the interviewees are summarized in table 1. Of the 18 interviewees, most of them were male (n=15, 83.4%) and majority of the participants (n=8, 44.4%) had 8-10 year of experience dealing with trauma and emergency care in Kabul, Afghanistan.
Table 1. Characteristics of the interviewees (N=18)
Characteristics
|
n (%)
|
Age
|
|
30-35 years
|
3 (16.6)
|
36-40 years
|
10 (55.5)
|
41-45 years
|
2 (11.1)
|
46-50 years
|
3 (16.6)
|
Gender
|
|
Male
|
15 (83.4)
|
Female
|
3 (16.6)
|
|
|
Respondent’s Type of Institution
|
|
Public
|
11(61.2)
|
Private
|
7(38.8)
|
Years of Experience
|
|
2-4 years
|
2 (11.1)
|
5-7 years
|
5 (27.8)
|
8-10 years
|
8 (44.4)
|
11-13 years
|
3 (16.6)
|
Primary role of the Respondents
|
|
Managers in the Ministry of Public Health
|
2 (11.1)
|
Hospital Managers
|
4 (22.2)
|
Physicians
|
4 (22.2)
|
Nurses
|
4 (22.2)
|
Ambulance Staff
|
3 (16.6)
|
Ambulance Administrator
|
1 (5.5)
|
Demographic Characteristics of the ECSA respondents
A total of 35 respondents completed the structured questionnaire. Most of the respondents were male (n=26, 74.2%) and had been involved for in managing trauma and emergency care for 5-7 years. The characteristics of the respondents are given in Table 2. Majority of the respondents identified themselves as clinical provider (n=20, 57.1%).
Table 2. Characteristics of the ECSA respondents (N=35)
Characteristics
|
n (%)
|
Age
|
|
30-35 years
|
4(11.4)
|
36-40 years
|
7 (20)
|
41-45 years
|
19 (54.2)
|
46-50 years
|
5 (14.4)
|
Gender
|
|
Male
|
26 (74.2)
|
Female
|
9 (25.8)
|
Respondent’s Type of Institution
|
|
Public
|
21(60)
|
Private
|
14(40)
|
Years of Experience
|
|
2-4 years
|
13 (37.5)
|
5-7 years
|
16 (45.4)
|
8-10 years
|
4 (11.4)
|
11-13 years
|
2 (5.7)
|
Primary role of the Respondents
|
|
Policy maker
|
2 (5.7)
|
Pre-hospital Administrator
|
3 (8.6)
|
Head of surgery, trauma or emergency unit
|
9 (25.7)
|
Researcher or epidemiologist
|
1 (2.9)
|
Clinical provider
|
20 (57.1)
|
An analytical thematic framework was developed by identifying the emerging themes from the transcribed interviews. Four key themes were synthesized: 1) pre-hospital care, 2) cohesive trauma management system, 3) physical and human resources and 4) stewardship. These themes are further categorized into sub-themes which were ascertained by grouping the related phrases from the interview transcripts. Table 3 shows the themes and sub-themes in the form of thematic analytical framework.
Table 3. Analytical themes and sub-themes based on participant’s perceptions
Themes
|
Sub-themes
|
Pre-hospital care
|
Ambulances
Layman involvement
Transportation care
Road infrastructure
Universal access number
|
Cohesive trauma management system
|
Multidisciplinary approach
|
|
Implementing trauma care guidelines
|
|
|
Physical and human resources
|
Trauma care workforce
|
|
Physical equipment/supplies
|
|
Technical capacity
|
|
|
Stewardship
|
Accountability
|
|
Quality improvement approaches
|
Pre-hospital Care
The participants expressed concerns related to the provision of trauma care at the pre-hospital level. Among the many factors hindering the delivery of effective pre-hospital trauma care; inadequate ambulances, bystander involvement, poor road infrastructure and lack of universal access number were highly emphasized.
Many participants talked about the challenges related to the availability, functions and transportation mechanism of the ambulances. The number of ambulances to cater the needs of trauma victims in Kabul is inadequate and the ambulances lack adherence to appropriate medical direction protocols for transportation and transfer. Furthermore, perpetuating environmental factors, sub-standard road infrastructures and untrained bystander involvement in medical care complicates the management of trauma care at the pre-hospital level.
“These ambulances are meant to transport the patients from the scene to the hospital…there is no medical care available during transportation”. (Participant 9)
“Just because there are no protocols to manage the transportation care and transfer… there have been many instances in the past when critical patients have been taken to the low-resourced hospitals… and the management of the critically injured patients have been affected” (Participant 11)
Other challenge related to the optimal pre-hospital care was sub-standard road infrastructure. It causes delay in response time for ambulances.
“Nearly 30% of the roads in Kabul are not constructed for example interior Qargha (place in north of Kabul) …now if there is an emergency case in this area…it is very difficult for ambulance to reach there in less time” (Participant 4)
The participants also expressed that majority of the injured patients are transported either by family members, community residents or bystanders. These individuals are untrained and may increase the complications. However, in the absence of immediate pre-hospital care, these individuals can be a good source in transporting the patients to the healthcare facility.
“In most of the cases…such as road traffic injuries and mass casualties, the injured victims are transported by the taxi drivers, and bystanders…they are unskilled and try to help with inappropriate interventions.” (Participant 7)
“Most of the time, taxi drivers, community residents, and family members take most of the injured patients to the hospital in Kabul.” (Participant 9)
Cohesive trauma management system
The participants described that systems for trauma management in Kabul needs multidimensional functions. The current trauma care approach is uncoordinated and complicated in terms of navigating the appropriate trauma services. Few participants expressed that trauma care becomes challenging when there is a gap in implementing guidelines and protocols both at the pre-hospital and in-hospital level. In addition, the receiving hospitals needs to be well-resourced with the essential supplies and workforce to provide the optimal level of care to the trauma patients.
“There is no well-articulated communication system that should respond in the emergency conditions and notify all the hospitals to be prepared to deal with the mass casualties.” (Percipient 5)
“There are number of hospitals with well-established emergency rooms…however, they are not adhering to some standard protocols for the management of trauma.” (Participant 9)
Participants also talked about poor interagency coordination at the pre-hospital level, specifically during large-scale emergencies that hinders the rapid evacuation and optimal trauma care.
“Some of the major challenges that we face is coordinating with the police when they put the cordon at the site of blast and do not allow our ambulances to get into the site of explosion which obviously cause delay in the care of those who have got massive bleeding and need immediate care” (Participant 9)
Participants described some other challenges regarding the management of trauma patients in the emergency rooms of the hospitals including unclear roles of the healthcare professionals that often creates confusion and chaotic situation. There is a need of a trauma team in the hospitals with pre-defined roles and responsibilities.
“We need a team of trauma care…that should have competent doctors, nurses and paramedics to deal with the emergency situations” (Participant 2)
“We have people working in the emergency unit with undefined roles…the situation of managing critical trauma care often creates confusion and anxiety…with this kind of disorganized care…I believe we would rather endanger the patient’s life”. (Participant 17)
Physical and Human Resources
Participants mentioned inaccessibility to appropriate physical and human resources an important factor for ineffective trauma care. Most of the hospitals in Kabul designated for trauma care lack trauma workforce. Furthermore, participants expressed that these hospitals are also deficient in physical resources such as resuscitation equipment to manage critical emergencies.
“The administration in most of the hospitals is such…that patient’s families have to bring the supplementary supplies when there is some surgery planned” (Participant 17)
“Most of the emergency departments don’t even have the crash cart for emergency situations” (Participant 5)
Some participants mentioned the need for diagnostic equipment such as radiological investigating machines to initiate the appropriate treatment. Additionally, some participants reported that hospitals lack technical professionals to fix the diagnostic machines.
“We do not have Computed tomography Scan and Magnetic Resonance Imaging (MRI) machines in many hospitals…I believe they are very important in some cases” (Participant 13)
“We don’t have technical people who can fix the machines used in hospital like biomedical engineers” (Participant 11)
Some other challenges were inappropriate staffing in the hospitals and lack of trauma care training as described by the participants
“It is very surprising to tell you…that midwives are deployed in the burn ward” (Participant 3)
“The healthcare providers in the emergency room are not trained enough to deal with the critical trauma patients.” (Participant 1)
Stewardship
According to the participants, the health authorities lack a unified vision to deal with trauma emergencies. There is a gap in the current trauma care system of Afghanistan in terms of having interagency strategic plan, quality improvement approaches and appropriate assignment of trauma related tasks.
“The emergency department of the public hospitals are funded by an external agency that functions completely independent of the hospital structure.” (Participant 4)
“No one asks about the quality of care…ministry of health should have some mechanism to assess the quality of care.” (Participant 16)
Lack of accountability and unresponsive to the monetary motivation of the trauma care workforce were some other challenges mentioned by the participants that affect the quality of trauma care.
“Many nurses who are employed in these hospitals have dual job…because they are not paid enough to run their livelihoods.” (Participant 10)
WHO Trauma and Emergency Care System Assessment Outcomes
A total of 35 mixed healthcare professionals responded to the WHO ECSA survey instrument. The primary role of these respondents ranged from pre-hospital provider, head of surgery or emergency unit, clinical provider, epidemiologist to policy managers. The following sections summarizes the perspectives of these respondents in response to emergency and trauma care system functionality.
Scene Care and Transportation
Respondents reported that population of Kabul is partially covered through emergency care access number (Kabul ambulance services-102). Less than 25% of the population is covered through this ambulance system. In addition, the coverage in rural areas is extremely low. Table 2 shows the view of respondents regarding scene care and transportation. Currently, the pre-hospital care is not governed through any kind of system-wide protocols. Participants also deemed the need for communication system to provide on-scene clinical guidance.
Table 4. Respondents views regarding scene care, transport and transfer
Indicators N=35
|
|
n
|
%
|
There are one or more emergency care access number with partial Kabul coverage.
|
27
|
77.1
|
Pre-hospital care is not governed by any system-wide protocols. However, an advisory service (e.g. staffed telephone) may be available for advice regarding pre-hospital care on ad-hoc basis
|
28
|
80
|
There is no communication system that allows on-scene clinical advising from facilities or dispatch centers
|
26
|
74.3
|
There is no system for determining the most appropriate destination for a given patient
|
29
|
82.9
|
Less than 25% of the population is covered by the pre-hospital ambulance system
|
23
|
65.7
|
The number of ambulances is grossly inadequate for the needs of the population
|
26
|
74.3
|
There is no policy to ensure that pre-hospital providers have adequate equipment to care for patients at the scene and during transport
|
29
|
83
|
There is no communication process between health care facilities to facilitate transfer
|
28
|
80.0
|
Respondents felt that existing number of ambulances is inadequate to cater the needs of population. Furthermore, there is no policy to ensure that ambulance service providers have adequate equipment in ambulances to manage patients. Additionally, there is no systematic process of communication for healthcare facilities to assist them with transfer information.
In-hospital Trauma Care and Emergency Preparedness
Respondents reported that less than 25% of the population have access to a well-equipped 24 hours facility-based emergency care. Table 3 shows respondents view regarding facility-based trauma care. Condition-specific protocols for emergency conditions are not consistent and their use is also not assured. Moreover, less than 25% of the patients who require immediate surgical intervention have access to surgical care in a staffed operating theatre within two hours. Approximately 25-50% of the facilities dealing with trauma emergencies have triage protocol. The Emergency Severity Index (ESI) algorithm is widely by many hospitals for triaging.
Table 5. Respondents view regarding In-hospital trauma care and emergency preparedness
Indicators
|
N=35
|
|
n
|
%
|
Less than 25% of the population have access to 24-hour facility-based emergency care
|
28
|
80
|
Some emergency units have protocols to govern key emergency conditions, but these are not consistently used
|
25
|
71.4
|
Less than 25% of patients with an injury requiring emergent surgery have access to surgical care in a staffed operating theatre within two hours of injury
|
19
|
54.2
|
25-50% of the trauma facilities have triage protocol with designated triage personnel
|
30
|
85.7
|
There is no regular assessment of the ability of the emergency care system to mobilize resources (human and physical) to respond to disasters, and other large-scale emergencies
|
28
|
80
|
There is emergency response plan, but it was created only by one agency, and not in conjunction with other necessary agencies.
|
26
|
74.3
|
There is no system-level plan in place for extraordinary events that specifically identifies a source for additional human resource and alternate transportation mechanism
|
29
|
83
|
Emergency preparedness across Afghanistan is coordinated by National Command Control Center for Emergency. There is an emergency response plan, but it lacks interagency coordination. Table 4 shows respondents view regarding emergency preparedness. The capacity of emergency care system to respond to large scale emergencies is seldom assessed and disaster drills are reasonably infrequent.