RESUMO
Identification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post-ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago.
Assuntos
Serviços Médicos de Emergência , Ferimentos e Lesões/terapia , Serviço Hospitalar de Emergência , Estudos de Avaliação como Assunto , Hospitais Gerais , Trinidad e TobagoRESUMO
Indentification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago.
Assuntos
Humanos , Ferimentos e Lesões , Traumatologia/educação , Serviços Médicos de Emergência , Médicos , Trinidad e Tobago , Acidentes de Trânsito/mortalidade , Escala de Gravidade do Ferimento , Pessoal Técnico de Saúde/educaçãoRESUMO
Improvement in trauma patient outcome has been reported after Advanced Training Life Support training (ATLS) in the developing country of Trinidad and Tobago (T & T). The cognitive impact of ATLS training was assessed from pre-ATLS and post-ATLS performance of T & T physicians in multiple choice question tests and comparison with post-ATLS test performance among Nebraska physicians. Overall, improvement between the pre-test and post-test among the T & T physicians was 22.0% +/- 2.0%. All physicians including failures (199 out of 212 passed) improved in their post-test scores. Individual item analysis of the post-test, including the KR-20 determination, varied but the overall performance was similar for both physician groups with the T & T physicians performing slightly better in test 2 (6 of 16 vs. 25 of 100 failures, p < 0.05). Attitudinal impact was assessed through 87 questionnaires from 50 physicians (92% response) and 37 nurses (89% response). Physicians (97.8% compared with 69.7%) were more aware of the ATLS training, and both groups (physicians, 77.3%; nurses, 69.6%) differentiated ATLS-trained physicians based on better resuscitation, more timely and appropriate consultation, greater confidence in trauma management, and improvement in trauma mortality and morbidity; all respondents recommended ATLS training for all emergency room physicians. The demonstrated positive cognitive and attitudinal effects very likely contributed to the improved post-ATLS trauma patient outcome.
Assuntos
Países em Desenvolvimento , Educação Médica Continuada , Cuidados para Prolongar a Vida , Traumatologia/educação , Atitude do Pessoal de Saúde , Estudos de Avaliação como Assunto , Humanos , Cuidados para Prolongar a Vida/psicologia , Médicos , Inquéritos e Questionários , Trinidad e TobagoRESUMO
Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990--post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The frequency of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access (i.v.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies (%) were 83.5 vs. 65.3 for ET, 97.3 vs. 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies (%) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley, 3.2 vs. 95.9 for NG, and 3.9 vs. 95.2 for CT. The differences in the application of these life saving procedures between the pre-ATLS and post-ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patients with severe chest injuries (AIS > or = 3) 87.7% had chest tubes post ATLS (94.4% in ER) compared with 48.1% pre ATLS (3.2% in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Cuidados para Prolongar a Vida , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Cateterismo Periférico/estatística & dados numéricos , Tubos Torácicos/estatística & dados numéricos , Serviço Hospitalar de Emergência , Humanos , Intubação Gastrointestinal/estatística & dados numéricos , Intubação Intratraqueal/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Trinidad e Tobago/epidemiologia , Cateterismo Urinário/estatística & dados numéricosRESUMO
Trauma outcome variables before and after the institution of the Advanced Trauma Life Support (ATLS) program were compared for the largest hospital in Trinidad and Tobago from July 1981 through December 1985 (pre-ATLS) and from January 1986 to June 1990 (post-ATLS). A total of 199 physicians were ATLS trained by June 1990. Outcome data were analyzed for all dead or severely injured patients (ISS > or = 16; n = 413 pre-ATLS and n = 400 post-ATLS). Trauma mortality decreased post-ATLS (134 of 400 vs. 279 of 413) throughout the hospital, including the ICU (13.6% post-ATLS ICU mortality vs. 55.2% pre-ATLS). The odds of dying from trauma increased with age (1.02 for each year), ISS score (1.24 for each ISS increment), and blunt injury, both pre-ATLS and post-ATLS. Post-ATLS mortality was associated with a higher ISS (31.6 vs. 28.8). Although there was a higher percentage of blunt injury pre-ATLS (84.0%) versus post-ATLS (68.3%), the mortality rates for both blunt and penetrating injuries were higher in the pre-ATLS group (19.7% pre-ATLS vs. 6.3% post-ATLS for penetrating and 76.6% pre-ATLS versus 46.2% post-ATLS for blunt). For each ISS category, mortality was greater in the pre-ATLS group (ISS > or = 24 pre-ATLS mortality 47.9% vs. 16.7% post-ATLS; ISS 25-40 pre-ATLS mortality 91.0% vs. 71.0% post-ATLS). The overall ratio of observed to expected mortality based on the MTOS data base was lower for the post-ATLS period (pre-ATLS ratio 3.16; post-ATLS ratio 1.94).(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Países em Desenvolvimento , Cuidados para Prolongar a Vida , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Fatores Etários , Feminino , Humanos , Escala de Gravidade do Ferimento , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Trinidad e Tobago/epidemiologia , Ferimentos e Lesões/terapia , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/terapiaRESUMO
Trauma outcome variables before and after the institution of the Advanced Trauma Life Support (ATLS) program were compared for the largest hospital in Trinidad and Tobago from July 1981 through December 1985 (pre-ATLS) and from January 1986 to June 1990 (post-ATLS). A total of 199 physicians were ATLS trained by June 19990. Outcome data were analysed for all dead or severely injured patients (ISS greater than and equal to 16; n=413 pre-ATLAS and n=400 post ATLS). Trauma mortality decreased post ATLS (134 ICU mortality vs. 279 of 413) throughout the hospital, including the ICU (13.6 percent post-ATLS ICU mortality vs. 55.2 percent pre-ATLS). The odds of dying from trauma increased with age (1.02 for each year), ISS score (1.24 for each ISS increment), and blunt injury, both pre-ATLS and post-ATLS. Post-ATLS mortality was associated with a higher ISS (31.6 vs 28.8). Although there was a higher percentage of blunt injury pre-ATLS (84.0 percent) versus post-ATLS (68.3 percent), the mortality rates for both blunt and penetrating injuries were higher in the pre-ATLS group (19.7 percent pre-ATLS vs 6.3 percent post ATLS for penetrating and 76.6 percent pre-ATLS versus 46.2 percent post-ATLS for blunt). For each ISS category, mortalilty was greater in the pre-ATLS group (ISS greater than and equal to 24 pre-ATLS mortality 47;9 percent vs. 16.7 percent post-Atls; ISS 25-40 pre-ATLS mortality 91.0 percent vs. 71.0 percent post-ATLS). The overall ration of observed to expected mortality based on the MTOS data base was lower for the post-ATLS period (pre-ATLS ratio 3.16; post-ATLS ratio 1.94). Multiple logistic regression analysis indicated that although post-ATLS mortality was affected by the lower incidence of blunt injury and a lower overall ISS score, the ATLS program was a significant factor in determing the observed decrease in mortality. Postinjury functional status among survivors was improved post-ATLS (minor disabiltiy 88.3 percent post-ATLS vs. 22.4 percent pre-ATLS and major disability 1.9 percent post-ATLS vs. 6.7 percent pre-ATLS). Our data demonstrate that the ATLS program significantly improved trauma patient outcome in a developing country, thus supporting the concept of international promulgation of this program for physicians(AU)