The April 2017 issue of the Bulletin featured an article titled “Using global surgical indicators to improve trauma care in Latin America,”1 which introduced the relationship between The Lancet Commission on Global Surgery (LCoGS) core surgical indicators 1–6 and specific components of trauma program and systems development in Latin America (see Table 1).1 In this article, the authors elaborate on the specific link between LCoGS indicator 1 (LCoGS I-1) and prehospital care in Colombia by members of the newly established Latin America Indicator Research Coalition. This body comprises an indicator working group, research partnerships in the Americas, and the individuals participating in and leading this endeavor, all stemming from a 2016 Panamerican Trauma Society’s (PTS) Trauma Systems Committee initiative.
Table 1. LCoGS core indicators and associated trauma program/system element
|Category||LCoGS indicator||Description||Proposed trauma program/
system element focus
|Preparedness||1||The geographic accessibility of surgical facilities||Prehospital system
and integration with hospital registry
|2*||The density of specialist surgical providers||Acute care surgeon/fellowships; trauma program manager|
|Delivery||3*||The number of surgical procedures provided per 100,000 population||Trauma and emergent/essential hospital/societal registries|
|4||30-day perioperative mortality rates||Trauma and emergent/essential hospital/societal registries, formal trauma performance improvement and patient safety, and trauma morbidity/mortality review process|
|Impact||5*||The risk of impoverishing expenditure when surgery is required||Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration|
|6*||The risk of catastrophic expenditure when surgery is required||Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration|
*World development indicators
The burden of surgical disease worldwide is a public health crisis. Recent literature has consistently demonstrated the devastating results of a lack of capacity to provide surgical care—particularly in low- and middle-income countries (LMICs). In recognition of this problem, the LCoGS in 2015 proposed six indicators for use in shaping policy and strategies to address the access and preparedness (indicators 1 and 2), delivery (indicators 3 and 4), and impact (indicators 5 and 6) of surgical care (see Table 2).2 That same year, the World Health Assembly (WHA) passed resolution WHA 68.15, Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage.
Table 2. Core indicators for monitoring of universal access to safe, affordable surgical and anesthesia care when needed
|Access to timely essential surgery||Proportion of the population that can access, within 2 hours, a facility that can do cesarean delivery, laparotomy, and treatment of open fracture (the bellwether procedures)||A minimum of 80% coverage of essential surgical and anesthesia services per country by 2030|
|Specialist surgical workforce density||Number of specialist surgical, anesthetic, and obstetric physicians who are working, per 100,000 population||100% of countries with at least 20 surgical, anesthetic, and obstetric physicians per 100,000 population by 2030|
|Surgical volume||Procedures done in an operating theater, per 100,000 population per year||80% of countries by 2020 and 100% of countries by 2030 tracking surgical volume; a minimum of 5,000 procedures per 100,000 population by 2030|
|Perioperative mortality||All-cause death rate before discharge in patients who have undergone a procedure in an operating theatre, divided by the total number of procedures, presented as a percentage||80% of countries by 2020 and 100% of countries by 2030 tracking perioperative mortality; in 2020, assess global data and set national targets for 2030|
|Protection against impoverishing expenditure||Proportion of households protected against impoverishment from direct out-of-pocket payments for surgical and anesthesia care||100% protection against impoverishment from out-of-pocket payments for surgical and anesthesia care by 2030|
|Protection against catastrophic expenditure||Proportion of households protected against catastrophic expenditure from direct out-of-pocket payments for surgical and anesthesia care||100% protection against catastrophic expenditure from out-of-pocket payments for surgical and anesthesia care by 2030|
These indicators provide the most information when used and interpreted together; no single indicator provides an adequate representation of surgical and anesthesia care when analysed independently.
The LCoGS I-1 measures the proportion of the population that can access, within two hours, a facility that is capable of providing the bellwether procedures: cesarean delivery, laparotomy, and treatment of open fracture.2 Ideally, this indicator should be tied to a regional surgery and trauma system infrastructure. The optimal management of trauma is defined as “care rendered within an inclusive trauma system unaffected by geographical location of injury or geographical location of care.”3 Consequently, prehospital care, transportation, and communication among regional entities are fundamental to effectively address emergent and essential surgical conditions. The target of LCoGS I-1 is to provide at least 80 percent of the world’s population with timely access to surgical services by 2030 (see Table 2).2 Achieving this objective will require solutions that, at the very least, include means of measuring the relevant aspects of regional access to emergent and essential surgical care and strategies for effective delivery when hemorrhage from trauma requires timely access, such as the “golden hour.”
Prehospital care and LCoGS I-1
Measuring regional access to timely surgical care is challenging. As yet, there is no consensus on a gold standard for measuring The Lancet surgical indicators. One way to address this void is by considering the component parts that contribute to each of the indicators. LCoGS I-1 is a measure of surgical system preparedness and, by extension, access to temporizing and resuscitative treatment before the patient arrives at the hospital (prehospital care).4 Prehospital care is integral to any trauma system, and in many cases dictates the patient’s chances for survival. In fact, as many as 50 to 70 percent of trauma deaths occur before the patient reaches the hospital due to a patient’s inability to seek (delay 1), reach (delay 2), or receive (delay 3) timely surgical care within a surgical system (see Figure 1).5,6 Delay 2, the delay in reaching care, is closely associated with prehospital care—and often the most significant contributor to LCoGS I-1. Accordingly, prehospital data may be used to assess a region’s baseline needs for emergency care and surgical system preparedness. This framework allows LCoGS I-1 to be systematically and consistently measured, and suggests that the trauma community is uniquely positioned to lead efforts to collect the relevant data and generate prehospital quality improvement measures for all emergencies.
Prehospital care in Latin America
High-quality prehospital care can be particularly challenging in resource-poor areas such as LMICs, where fragmented emergency medical services (EMS) and lack of multisectoral coordination limit access to care. In Latin America, 11 percent of overall mortality is due to trauma and ranks first among all global regions for the highest number of deaths from road traffic accidents, with 19.2 road fatalities per 100,000 inhabitants.7,8 Modern prehospital systems in many high-income countries (HICs) were born of the need to address high-speed motor-vehicle collisions;4 however, organizational, political, clinical, financial, and workforce limitations often preclude implementation of this inclusive prehospital system in Latin America.9 Furthermore, national oversight and prospective research in prehospital practice is scarce among all Latin American countries.
Prehospital care in Colombia
Like other Latin American and resource-constrained countries, Colombia’s prehospital system design varies, ranging from nationally planned, to locally funded, to hospital-based.10-12 In 2011, the Colombian national government passed Act 1438, which reformed the General System of Social Security in Health (Sistema General de Segundad Social en Salud) and established the legal framework for Article 67 to organize the nation’s emergency medical system. However, the statute omitted any provisions pertaining to the distribution and coordination of ambulance services. Although some Colombian cities have developed urban prehospital care, people in remote areas of the country lack access to timely care.13 Historically, and specific to Colombia, 50 years of guerrilla warfare and the geographical context of the country split by the Andes Mountains has made some rural areas totally inaccessible, and created tremendous transportation and road access challenges that still exist today.
At present, the prehospital system comprises two informal divisions: the private sector, which is composed of privately run hospitals, ambulance companies, and insurance companies (Empresas Promotoras de Salud) subject to government regulation; and the public sector, which is decentralized and government-run. In several cities, including Cali, Colombia, local governments or private companies administer the prehospital system and ambulances. Some affluent patients can purchase private emergency services that may have contracts with private hospitals, indiscriminate of level of care capability. There is no clear regulation on who coordinates the prehospital system.
These and other barriers to accessing ambulance services and centralizing prehospital care lead to disparities in access to surgical and trauma care. In 2011, two co-authors of this article, Carlos Ordoñez, MD, FACS, and Luis Fernando Pino, MD, as well as Marisol Badiel, MD, and Monica Morales, submitted a proposal to the Colombian government requesting support for creation of a center of excellence for adequate trauma preparedness for the southwest region of Colombia, an area burdened by its geographic location and narco-trafficking. Although initially the proposal was rejected, Andres Rubiano, MD, representing the Prehospital Care Association of Colombia as the former president of this professional society, was instrumental in advocating for national support at the Colombian Ministry of Health. The PTS and other stakeholders continue to advocate for Latin American prehospital care expansion at the grassroots level in this region.
Collecting LCoGS I-1 in Latin America
Providers in many Latin American countries find themselves in a predicament similar to the one in Colombia. Hospitals and trauma programs that are best equipped to deliver care are working in an exclusive system. Significant reductions in current prehospital mortality will not be achieved unless issues such as the absence of an effective EMS workforce, resources, and national standards in prehospital care and data collection are systemically addressed. Stakeholders at the hospital, EMS, and national levels are collaborating to improve and take responsibility for performance improvement and/or quality assurance in the prehospital care of the trauma victim. A needs assessment conducted by Rutgers University and Universidad Del Valle (HUV) led to an early focus on the prehospital system in Cali and was based on a Research and Innovation Fellowship Program funded by the U.S. Agency for International Development. A team composed of medical students, EMS professionals and agencies, hospitals, and acute care surgery stakeholders from the U.S. and Colombia identified specific challenges at the grassroots level (see Table 3). Each organization’s institutional review board (known as ethics committees in Cali and Medellin) has participated in this approval process in order to strengthen local buy-in and expand multidisciplinary trauma teams to include epidemiologic and public health professionals, including Robinson Pacheco, PhD, from Fundación Valle del Lilli (FUV) Research Center, and Andrés Fandiño Losada, MD, PhD, MSc, from the HUV School of Public Health. Moreover, Drs. Rodrigo Guerrero and Maria Isabel Gutierrez at the Center for Investigation on Violence at HUV (also known as CISALVA), created injury surveillance schemes and a culture of data collection in Colombia during the last 20 years, establishing a foundation for multidisciplinary collaboration that is key to the multisectoral participation in Colombia today.
Table 3. Prehospital care grassroots challenges and targets
|1||Professional, public, and private EMS agencies collect their own data variables with differing data management software||Establish standard clinical data collection for multisectoral agencies at the hospital level for any trauma patient (prehospital data forms completed in ER by medical students who are participating in quality improvement projects); ultimately this form will reflect standard data sets such as the PTS prehospital data tier and have a mechanism for all EMS agencies to enter into the EHR before arriving at the hospital.|
|2||Data, if collected by prehospital agencies, do not penetrate hospital registries||Design process to integrate prehospital and hospital data. (A specific process for the predetermined prehospital data contained in the forms needs to be included into inpatient EHR.)|
|3||The full continuum of care and, therefore, outcomes of trauma care are not assessed without proper prehospital data penetration of registry consistently (that is, through a PTS registry)||Create process for prehospital data to penetrate the PTS prehospital data tier (established in 2017). (First step is a multi-institutional Redcap database for simple data registry [see data collection form figure], then after process learned, scale up to collect all the PTS trauma prehospital tier data.)|
|4||Nonexistent prospective prehospital research and/or performance improvement for prehospital care and national outcomes||Leverage current LCoGS preparedness to deconstruct current EMS agency and hospital exclusivity for prospective research and performance improvement (use as national motivator).|
|5||No workforce for hospital or registry data entry||Funding for the education and training of trauma registrars by way of collaboration with the ACS Committee on Trauma, LCoGS, and Trauma Center Association of America.|
These and other local champions in trauma care have initiated process improvement targets (see Table 3) to advance prehospital care practices and LCoGS I-1 data collection. Prehospital data collection, an underfilled fourth data tier in the PTS registry, was reinvigorated in 2016 in Colombia after it became apparent there was a diminishing data acquisition effort from its inauguration time in 2011 (see Table 4). No process or workforce (outside of medical students in research rotations) existed for prehospital data collection or entry into the hospital electronic health record (EHR) and/or the PTS registry. A short standardized prehospital data collection tool (see Figure 2) was implemented in the emergency departments (EDs) at FUV and HUV in 2016, serving as a handover document to promote ED triage and prehospital-to-hospital data integration. This simplified prehospital data collection tool is designed as a preliminary step in developing processes for prehospital data to integrate with PTS registry, and to teach ancillary staff at the grassroots level data acquisition, entry, and management.
Figure 2. Prehospital data collection form
Table 4. PTS prehospital tier data points
|PTS prehospital tier data points
The prehospital tier is one of four total tiers in a 250 data element PTS registry—an evolution of a 2005 Virginia Commonwealth University International Trauma System Development Program test set in Ecuador
The feasibility of this data collection process was demonstrated in 2016 at the HUV ED. Intentions to expand these activities and to include other facilities including the Universidad de Antioquia, San Vicente Hospital (UOA) will take place this year. This is an important step in the transition to durable PTS registry prehospital tier data collection (see Table 4).14 This simplified process of data collection, prehospital to hospital integration, and PTS registry data management allows investigators to evaluate the full continuum of care, and consider time from injury to definitive surgical intervention as a complete measure of timely, emergent, and essential care. It is the first tool that will prospectively broaden measurement applications of two-hour access in definitive emergent/essential care facilities in Colombia. As a result, Colombian trauma stakeholders can leverage these data and data collection processes for LCoGS I-1 2030 targets and national inclusive trauma and surgical system planning. Additionally, a goal for implementation this year is to quantify the workforce required to perform quality improvement and data collection tasks in order to assess and support sustainability of this initiative, because no trauma and surgery program registrars exist in Colombia. Promoting the value of these positions as opportunities to increase health care employment and infrastructure further adds value to prehospital data utilization and maintenance of data collection registries such as the PTS registry in Latin America. We have achieved a fourth-year no-cost extension to the 2014 United States Agency for International Development–Research and Innovation Fellowship program (also known as USAID-RIF) grant that supports travel of the participating team members, but in-country progress durability will be dependent on multi-institutional collaboration to scale pursuit and securing of necessary funding for study protocol advancement and broadening of the Americas’ participation in this type of collaborative work.
A call to action
LCoGS I-1, at its core, reflects the confluence of multiple factors involved in the development of trauma systems in Latin America. It is a measurement of the first step in caring for the surgical patient—emergency access to health care providers equipped to resuscitate and prevent further injury; and transportation to the appropriate facilities. Achieving adequate surgical capacity by 2030 will require simultaneous action across all six Lancet indicators in order to promote a functioning surgical system as a whole. The role that trauma and the prehospital community can play in strengthening the interdependent surgical system is particularly acute when addressing timely access to surgery, LCOGS I-1. In other words, while the sum is greater than its parts, we are working to scale up the latter.
This article highlights early approaches to prehospital quality improvement and indicator research, focusing on LCoGS I-1. The efficacy of using prehospital measurements is particularly informative regarding regional access to care, or preparedness within a surgical system. Additionally, this method—assessing prehospital capacity to evaluate LCoGS I-1—is generalizable to multiple regions in Latin America.
In December 2016, the PTS executive committee approved the formation of an indicator working group to assess LCoGS indicators in Latin America. Shortly thereafter, workgroup chairs sought to organize and direct an inter-institutional conglomerate formed by emergent and essential surgery (acute care surgery) research partnerships between North, Central, and South America. Boston Children’s Hospital, MA; Columbia University, New York, NY; George Washington University, Washington, DC; Harvard Medical School, Boston; University of Maryland Shock Trauma, Baltimore; Massachusetts General Hospital, Boston; University of Miami, FL; Northwestern University, Chicago, IL; Rutgers University, New Brunswick, New Jersey; Virginia Commonwealth University, Richmond, and others, along with their respective partnerships in Bolivia, Brazil, Colombia, Cuba, Ecuador, Guatemala, Mexico, and Peru have demonstrated early commitment to the conglomerate. Within these academic partnerships, along with developments occurring in all of the Latin American countries, surgery research fellows are poised to conduct indicator research that links to trauma systems development in several countries simultaneously to stimulate sustainable, standardized data acquisition by Latin American providers in Latin America. These activities, and earnest pursuit for funding, will be carried out under the aegis of the Latin America Indicator Research Coalition.
The Coalition urges members of the American College of Surgeons to engage in similar efforts to link prehospital capacity with LCoGS I-1 and to do so by learning more about the Latin America Indicator Research Coalition at the XXX Panamerican Congress of Trauma, Critical Care, and Emergency Surgery, November 29–December 1, in Mexico City, Mexico. While also promoting the relationships necessary for surgeons in the Americas to reach LCoGS 2030 targets, the data gathered within this domain are intended to provide a foundation for comprehensive work in all six indicators, insight to guide national surgical planning efforts, and universal, emergent, and essential health care to fulfill the recommendation in WHA resolution 68.15 in Latin America.
- Peck G, Saluja S, Blitzer D, et al. Using global surgical indicators to improve trauma care in Latin America. Bull Am Coll Surg. 2017;102(4):11-16. Available at: nowherefacs.wpengine.com/2017/04/using-global-surgical-indicators-improve-trauma-care-latin-america/. Accessed on May 16, 2017.
- Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
- American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons, Committee on Trauma; 2014.
- The Lancet Commission on Global Surgery. Data for the sustainable development of surgical systems: A global collaboration. June–September 2015. Available at: media.wix.com/ugd/346076_26d4a927dc074b128be2e61f34e14018.pdf. Accessed May 22, 2017.
- Pearce AP. Emergency Medical Services at the Crossroads. Washington, DC: The National Academies Press. 2009:32-43.
- Barnes JD, Myntti C, Augustin A. The three delays as a framework for examining maternal mortality in Haiti. Soc Sci Med. 1998;46(8):981-993.
- Aboutanos MB, Mora F, Rodas E, et al. Ratification of IATSIC/WHO’s guidelines for essential trauma care assessment in the South American region. World J Surg. 2010;34(11):2735-2744.
- World Health Organization. Global status report on road safety 2013. Available at: www.who.int/violence_injury_prevention/road_safety_status/2013/en/. Accessed May 2, 2017.
- World Health Organization. Strengthening care for the injured: Success stories and lessons learned from around the world. 2010. Available at: apps.who.int/iris/bitstream/10665/44361/1/9789241563963_eng.pdf. Accessed May 22, 2017.
- Tarighi P, Tabibi SJ, Motevalian SA, et al. Designing a model for trauma system management using public health approach: The case of Iran. Acta medica Iranica. 2012;50(1):9-17.
- Waseem H, Naseer R, Razzak JA. Establishing a successful pre-hospital emergency service in a developing country: Experience from Rescue 1122 service in Pakistan. Emerg Med J. 2011;28(6):513-515.
- Thomson N. Emergency medical services in Zimbabwe. Resuscitation. 2005;65(1):15-19.
- Arbelaez C, Patiño A. State of emergency medicine in Colombia. Inter J Emerg Med. 2015;8(1):9.
- Ivatury RR, Aboutanos M. Panamerican Trauma Society: The first three decades. J Trauma Acute Care Surg. 2017;82(5):966-973.