Facilitators and barriers to the effective management of major trauma by prehospital medical services following road traffic accidents in Saudi Arabi

Abstract

<p>Emergency medical services (EMS) provide assistance to patients through pre-hospital management and support, including on-site treatment of traumatic injuries arising from road traffic accidents. Saudi Arabia currently has one of the highest road traffic accident-related mortality rates in the world; however, there is a dearth of published research in the Saudi Arabian context that examines pre-hospital emergency management practices in the context of blunt trauma patients' outcomes arising from road traffic accidents. The Saudi Red Crescent Authority, the main provider of community emergency medical services in Saudi Arabia, is the primary service that delivers pre-hospital trauma assistance to patients injured in a road traffic accident. The goal of this thesis is to establish information can be used to develop and recommend specialised and specific solutions for adoption by the Saudi Red Crescent Authority to reduce the currently high rate of mortality and morbidity following road traffic accidents.</p> <p>Specifically, the current mixed methodology research was designed to establish evidence that can be used in developing an updated protocol for the Saudi Red Crescent Authority to assist with pre-hospital management of major trauma arising from road traffic accidents. The following three objectives underpinned the achievement of this aim:</p> <p>1) Examine current practice in pre-hospital management of major trauma among adults in Saudi Arabia and associated patient outcomes;</p> <p>2) Explore the perceptions of both ambulance and trauma centre staff and managers personnel in Saudi Arabia in order to identify contributory factors, both positive and negative, associated with current management practices of major trauma; and</p> <p>3) Use the findings of this project to identify areas in which the Saudi Red Crescent Authority pre-hospital management of major trauma among adults can be improved and make suggestions for practice change.</p> <p>In addressing these three research objectives, the following thesis questions will be answered:</p> <p>• What is the current practice in the Saudi Red Crescent Authority with respect to the provision of care for major trauma arising from road traffic accidents in Saudi Arabia?</p> <p>• How can the Saudi Red Crescent Authority improve its response to trauma arising from road traffic accidents, and thus reducing morbidity and mortality?</p> <p>While initially conceptualised as a solely qualitative study, a sequential mixed-methods approach was ultimately chosen to investigate EMS practice in the delivery and management of pre-hospital management arising from road traffic accidents in Saudi Arabia. In the first stage, a systematic review of the known research quantum was undertaken, and this information was used to develop the second stage of the project. This next stage involved a purposively-developed survey of 125 Saudi Red Crescent Authority EMS employees using the online Qualtrics software, with the knowledge gained from the first stage guiding the development of this survey tool. Then, a retrospective collection of data from EMS patient' care records and hospital medical records was undertaken, with a focus on outcomes arising from blunt traumatic injury associated with road traffic accidents in the Western Region of Saudi Arabia. These data were examined descriptively and cross tabulations were used to compare proportions by group. Chi. square and Fisher's tests were used in SPSS (version 26) software to assess statistical significance at the 0.05 level. Finally, stage three of the project involved semi‐structured interviews conducted with ambulance station managers (n = 5) and trauma centre managers (n = 5). The data from the qualitative stage of this research was used to develop the interview guide, and the purpose was to establish the key barriers and impediments to the provision of pre-hospital care from the perspective of EMS management personnel. Thematic analysis was the chosen model for analysis of this qualitative data.</p> <p>In this thesis, the current practice of the Saudi Red Crescent Authority EMS in relation to road traffic accidents was investigated, with a focus on various aspects of pre-hospital treatments and support using an online survey, existing patient's trauma records, and in-depth semi-structured interviews. The data identified a number of performance gaps and deficiencies. Specifically, this research revealed six crucial aspects of performance that are currently affecting the Saudi Red Crescent Authority's emergency services:</p> <p>1) systemic issues with pre-hospital medical interventions;</p> <p>2) the need to update the current trauma protocol update;</p> <p>3) pre-hospital training improvements;</p> <p>4) response time management;</p> <p>5) clinical decision making; and,</p> <p>6) barriers to effective trauma patient transfer</p> <p>Critically, the participants in the thesis overwhelming highlighted the urgent need for The Saudi Red Crescent Authority to update its response protocol for major trauma arising from road traffic accidents, which was considered likely to assist in reducing future morbidity and mortality.</p> <p>The other key findings of this project that underpin the recommendations include:</p> <p>• Patients who were attended by EMS (paramedic) crew had statistically significantly lower hospital ICU (intensive care unit) stay days (16.23 ± 5.52 days) compared to those who were attended by EMT (Emergency Medicinal Technician) 22.53 ± 8.26 days), t (182) =-6.051, p=0.022.</p> <p>• Patients who were attended by EMS had a statistically significantly lower hospital total stay days and better outcomes (mortality, neurological or physical functional outcomes) in hospital (41.06 ± 6.15 days) compared to those who were attended by EMT (46.77 ± 8.13 days), t (182) =-5.352, p=0.001.</p> <p>• Patients who were administered pre-hospital fluids had statistically significantly lower hospital ICU stay days (19.13 ± 7.11 days) compared to those who were not administered pre-hospital fluids (33.75 ± 18.19 days) t (182) =-3.890, p=0.000. </p> <p>• Patients who were administered pre-hospital ETI (endotracheal intubation) had statistically significantly lower ICU stay days (16.15 ± 5.362 days) compared to those who were not administered pre-hospital ETI (23.21 ± 8.27 days), t (182) =-6.944, p=0.000.</p> <p>• Patients who were administered pre-hospital ETI had statistically significantly lower stay days at hospital (41.26 ± 6.43 days) compared to those who were not administered pre-hospital ETI (47.07 ± 8.01 days), t (182) = -5.453, p=0.000.</p> <p>• The majority of the EMS staff (58.33%) reported that Tranexamic Acid (TXA) was not administered to blunt trauma patient prior to or on arrival at a trauma centre.</p> <p>• Minimum on-scene treatment time taken was 8 minutes. The maximum reported onscene treatment time was 18 minutes, with an average time of 12.51 minutes ± 2.19 minutes. These times are greater than those previously reported in other countries.</p> <p>• Barriers that negatively affected on-scene treatment and transfer time included traffic congestion, crowding at the site, and inadequate communication with trauma centres.</p> <p>• Updated training courses are particularly crucial to assist pre-hospital staff enhance their abilities and keep their knowledge up to date in the trauma field. Further, these training courses must be repeated frequently to support staff in remaining up-to-date.</p> <p>It is recommended that there is a vital need to focus on the development of an up-to-date prehospital trauma protocol to assist in addressing the identified concerns. Training and development for emergency staff, and easy access to alternative options to trauma centres, were also seen as priority issues. It is hoped that the recommendations presented in this research will help in the development of a new and current pre-hospital trauma management protocol and subsequently assist in improving the overall quality of pre-hospital EMS interventions in Saudi Arabia.</p>