Trauma is a leading cause of death and injury worldwide, with especially high mortality rates in Africa. Emergency Medical Services (EMS) provides prehospital care and timely transport to a trauma center and are critical for reducing morbidity and mortality, as implementation in low- and middle-income countries (LMICs) results in a reduction of trauma related mortality by over 25%. Kenya has had significant development and focus on emergency medical care over the past decade. Despite many advances, the public infrastructure for prehospital care is lacking, making it difficult for vulnerable populations to access emergency services. Prehospital care is fragmented into different county-level approaches across its 47 counties making it so the government cannot estimate the number or location of ambulances countrywide. There is no equivalent 911 national emergency response phone call line to coordinate ambulance dispatch. EMS training and education requirements, scope of practice, and level of prehospital provider (i.e. emergency medical technician versus paramedic) are not well defined, without national or county-level standards. Rescue.co, an emergency response organization headquartered in Nairobi, aims to improve access to critical emergency services. Rescue.co serves as a central 24/7 dispatcher for over 1000 contracted ambulance partners in Kenya and provides real-time support for prehospital providers on scene. Recognizing the lack of standardized training amongst their contracted prehospital providers, Rescue.co partnered with Stanford Emergency Medicine International to develop an innovative trauma and injury training program. The aim of the course is to improve prehospital trauma and injury management, with a focus on traumatic shock, to reduce morbidity and mortality for vulnerable populations in Kenya.
Our initial trauma training pilot course took place in Nairobi, Kenya, in January 2024. The course consisted of two days of in-person lectures, interactive case discussions, hands-on skills stations, and trauma case simulations. We focused on management of traumatic shock with a standardized, algorithmic approach to all trauma cases. We conducted the course four times to train a total of 54 prehospital providers. We collected demographic data on participants and administered pre-course and post-course tests to assess immediate knowledge gained from the course. The next phase of our project will focus on expansion of the trauma course through a training of trainers model, creation of online content and development of a post-course digital framework to encourage continued learning and knowledge retention. We will train prehospital providers who completed the pilot course on how to teach the same course to their peers, with the goal of training all prehospital providers contracted with Rescue.co. We will assess knowledge retention at 12 week and 6-month intervals from the completion of the initial course through online testing. Students will be encouraged to continue asynchronous learning via nudging and incentives.
Our pilot program demonstrated statistically significant improvement in knowledge from pre-course to post-course testing, with a score increase of 15% on average (pre-test mean= 71.7%, SD=11.3%, post-test mean=86.7%, SD=7.7%, p<0.001). While assessment of knowledge improvement is useful in evaluating the effectiveness of the course, our primary aim is to assess the course’s impact on clinical management and outcomes in prehospital trauma care. One method previously studied to assess quality of prehospital care is in the identification and management of traumatic shock. Mould-Millman et al. validated a prehospital traumatic shock care chart abstraction tool amongst South African prehospital providers. We will utilize this validated instrument to study the quality of prehospital trauma care for providers who have undergone our trauma training programs. In addition to assessment of clinical practice change in management of traumatic shock, our we also aim to assess the utility of patient care record (PCR) data in analyzing guideline appropriate care. PCRs are used widely in LMICs to document patient encounters and serve as the prehospital paper medical record. PCRs are also depended upon for assessing quality of care and are therefore utilized for quality improvement initiatives. However, Musa et al. found that the available health data in Africa is limited and is often of poor quality, particularly data on acute and traumatic surgical conditions. They argue that the lack of quality health data limits informed clinical decision making and hinders advances in healthcare. The accuracy of PCR data and whether it is a valuable tool to assess quality of patient care has not been well established. There is real concern that information recorded on PCR forms does not accurately reflect patient care; although, to our knowledge, this has not been previously studied. The prehospital care environment is chaotic, and records are often completed after hospital transfer, making it challenging for providers to document the patient encounter thoroughly and accurately. We aim to evaluate the accuracy of PCR data and identify potential methods to streamline documentation and data collection.