Ratification of IATSIC/WHO’s Guidelines for Essential TraumaCare Assessment in the South American Region

Michel B. Aboutanos • Francisco Mora •

Edgar Rodas • Juan Salamea • Marcelo Ochoa Parra •

Estuardo Salgado • Charlie Mock • Rao Ivatury

� Societe Internationale de Chirurgie 2010

Abstract

Background The purpose of the present study was to

evaluate the usefulness of the International Association for

Trauma Surgery and Intensive Care (IATSIC)/World

Health Organization (WHO)’s Guidelines for Essential

Trauma Care (EsTC Guidelines) in providing an interna-

tionally applicable and standardized template to assess

trauma care capabilities in the South American Region.

Methods Field assessment was conducted in seven

provinces (urban and rural, pop. 2,239,509) and 24 facili-

ties (5 large hospitals (LH); 15 small hospitals (SH); 4

basic hospitals (BH)) in Ecuador using EsTC criteria. A

total of 260 individual items in Human Resources

(HR– availability, clinical knowledge, skills) and physical

resources (PR) were evaluated via inspection, review of

local statistics, and administrative and staff interviews.

EsTC was evaluated on a scale as follows: 0 (absent);

1(inadequate; \ 50%); 2 (partly adequate [ 50%); 3 (ade-

quate–100%).

Results 210,045 Emergency Department (ED) visits and

61,365 (29%) ED trauma visits were recorded (incidence

rate 2,740/100,000 population). Deficits were noted in

prehospital trauma care (inadequate coordination, com-

munication), education and training (ATLS \ 30%, TNCC

0%), facility based trauma care (poor physical resources

[PR] and human resources [HR]), and quality assurance

(1/27 hospitals).

Conclusions The IATSIC/WHO EsTC Guidelines pro-

vide a simple and useful template to assess trauma care

capability in variable facilities and international settings,

and they could serve as a valuable tool for trauma sys-

tem development. Endorsement of EsTC Guidelines by the

Panamerican Health Organization and lead trauma

societies (the Panamerican Trauma Society) should be

considered.

Introduction

Trauma is a global epidemic, with 90% of the fatalities and

morbidities occurring in low and middle income countries

[1–3]. The region of the Americas accounts for 11% of the

global injury related mortality rate and 10% of the global

injury burden [4, 5].Injuries and non-communicable dis-

eases account for greater than 73% of deaths and 76% of

disability adjusted life years (DALYS) in the Latin

American region [2, 6]. This epidemiological transition has

been attributed to rapid urbanization and globalization of

the developing countries [6–8].

M. B. Aboutanos (&) � F. Mora � R. Ivatury

Department of Surgery, International Trauma System

Development Program, Virginia Commonwealth Medical

Center, 1200 East Broad Street, Richmond, VA 23298, USA

e-mail: mbaboutanos@vcu.edu

E. Rodas

Department of Surgery, Broward General Medical Center,

303 SE 17th Street, Fort Lauderdale, FL 33316, USA

E. Rodas

Cinterandes Foundation, Av. Unidad Nacional and Gran

Colombia (Horizontes Building) 4th Floor # 404,

Cuenca, Ecuador

J. Salamea � M. O. Parra � E. Salgado

Ecuadorian Trauma Society, Cinterandes Foundation,

Av. Unidad Nacional and Gran Colombia (Horizontes Building)

4th Floor # 404, Cuenca, Ecuador

C. Mock

Department of Surgery, Harborview Injury Prevention and

Research Center, University of Washington, 325 Ninth Avenue,

Box 359960, Seattle, WA 98104, USA

123

World J Surg

DOI 10.1007/s00268-010-0716-9

However, because of the lack of appropriate injury

assessment tools in their respective countries, public health

officials and policy makers have failed to recognize trauma

as a serious public health issue [1, 7]. This is of signifi-

cance in the Latin region, especially in rural areas that

shoulder much of the burden of injury and where rapid

urbanization and development is ongoing without the cor-

responding improvement in infrastructure and health care

systems [9, 10]. Trauma care in rural areas of Latin

America remains rudimentary without appropriate injury

prevention and control efforts [11, 12]. Without appropri-

ate planning and organization no effective primary and

secondary prevention efforts can be carried out. The lack of

such planning and organization is highlighted by the World

Health Organization (WHO) as one of the primary reasons

for the health and injury outcome disparities between low-,

middle-, and high-income countries [13–15].

In response to the global burden of traumatic injuries,

significant efforts have been undertaken by WHO and the

International Association for Trauma and Surgical Inten-

sive Care (IATSIC) to delineate specific guidelines

regarding various injury prevention strategies that could be

implemented in developing nations [1, 16, 17]. The WHO/

IATSIC Guidelines for Essential Trauma Care (EsTC

Guidelines) are advocated to establish achievable and

affordable standards for the care of the injured patient

worldwide [18].

The EsTC Guidelines delineates eleven core essential

trauma care services that could, and should, be made

available to every injured person in the world. The EsTC

Guidelines additionally identified 260 individual items of

human resources (HR: knowledge, skills, training, staffing)

and physical resources (PR: equipment and supplies) that

would be needed to ensure these services are in place in

health facilities in countries at all economic levels.

The items are comprehensive, addressing both essential

and desirable elements at all levels of health care facilities

from rural health care clinics and hospitals, to larger spe-

cialty staffed hospitals and tertiary care facilities [18].

The EsTC Guidelines have been implemented in various

countries including Ghana, India, Vietnam, and Mexico

[19–23]. In the Latin American Region, the EsTC Guide-

lines were also adapted nationally and endorsed by the

Mexican Association for the Medicine and Surgery of

Trauma (AMMCT) [22, 23]. Additionally, in both Mexico

and Colombia recommendations contained in the WHO

Prehospital Trauma Care Systems were incorporated into

national legislation establishing standards for prehospital

care providers [22–24].

So far, the WHO/IATSIC EsTC Guidelines have not

been implemented regionally in South America. The pur-

pose of the present study was to carry out a comprehensive

regional assessment in a representative South American

region undergoing rapid urbanization and rural develop-

ment. This study was carried out jointly by the Ecuadorian

Trauma Society (ETS) and the International Trauma

System Development Program (ITSDP) of the Virginia

Commonwealth University (VCU), endorsed by the Pan-

american Trauma Society (PTS), the American Association

for the Surgery of Trauma (AAST), and approved by the

Ecuadorian Ministry of Health (EMH).

Methods

Site selection

According to the Pan American Health Organization,

Ecuador is experiencing one of the fastest urbanization

processes in the Andean region of South America [25]. We

selected the southeastern region of Ecuador, where large

urban and rural provinces are undergoing steady increase in

regional population and development with a 1.5% to 2.8%

estimated annual growth rate compared to the national

estimate of 1.1% [26–29]. Southeast Ecuador is made of

seven provinces including Azuay, Canar, El Oro, Loja,

Morona Santiago, Pastaza, and Zamora Chinchipe, which

cover an area equivalent to one-third of Ecuador

(91,527 km2) with a total population of 2,239,509 inhab-

itants (2007 Estimates) (Fig. 1) [27].

Facility selection

Field assessment using The WHO/IATSIC EsTC Guide-

lines was conducted in 27 facilities. Five large public

hospitals were selected from the four provinces with urban

Fig. 1 Map of Ecuador. Dotted line represents the assessment

area covered. Shaded areas represent the areas between the Andean

and the Amazonian region undergoing rapid development and

urbanization

World J Surg

123

centers (Azuay, Canar, El Oro, and Loja). These hospitals

are the tertiary care hospitals in the provincial capitals

responsible for the majority of trauma care in their

respective provinces. Other large hospitals that may occa-

sionally receive some trauma patients were not evaluated in

the study. Fifteen small general hospitals responsible for

significant trauma care were also selected from the Andean

province of Azuay and the Amazonian provinces of

Morona Santiago, Pastaza, and Zamora Chinchipe. The

small general hospitals were selected from representative

small towns and rural areas undergoing population growth,

rapid urbanization, and new road construction. Also

selected were seven representative rural clinics with high

trauma volumes from Azuay and Morona Santiago.

The EsTC Guidelinesemploys four categories for eval-

uation of trauma facilities: clinics, small hospitals staffed

with generalists, hospitals staffed with specialists, and

large hospitals serving as tertiary care facilities [18]. In

Ecuador, the small generalist-staffed hospitals are rare and

the majority of small hospitals involved with trauma care

have some degree of specialist staffing. Therefore, for this

study, only three facility levels were used: clinics, small

general hospitals, and large hospitals.

Assessment tools and process

The assessment tools used included two hospital assessment

forms provided by WHO, which were slightly modified and

adapted to the Ecuadorian circumstances (http://www.who.

int/violence_injury_prevention/services/traumacare/estc_

checklist.pdf). The first hospital form addressed the fol-

lowing criteria: (1) hospital type, (2) hospital size, (3)

trauma-related emergency visits and admissions, (4) staff

level of responders and their trauma care related training

and education (ATLS�, TNCC� or equivalents, in-service

training), and (5) staff availability [30, 31]. The assess-

ment form also evaluated the presence of trauma-related

quality improvement programs, trauma registry, contin-

uing medical education (CME) programs, and presence

and organization of ‘‘Trauma Teams’’ for acute resusci-

tation and management.

The second, more extensive assessment form employed

a 14-page checklist containing the 260 individual elements

suggested in the EsTC Guidelines, which address HR in

terms of availability, clinical knowledge, skills and train-

ing, and PR in terms of availability, operability, and

functionality. The elements were categorized as ‘‘not

applicable—NA’’ whenever an element was not relevant

for that level, ‘‘Absent—0’’ whenever an element was not

available, ‘‘Inadequate—1’’ when an element was not

available or when it was operational less than 50% of the

time, ‘‘Partly adequate—2’’ when an element was available

and operational greater than 50%, but not all, of the time,

and ‘‘Adequate—3’’ when an element was present and

available at all times.

To conduct the evaluation, permission was obtained from

all the provincial ministers of health. The facilities were

notified about the upcoming evaluation. All the evaluations

were performed in September 2007 by a team composed of

members from the VCU International Trauma System

Development Program (ITSDP) and the Ecuadorian

Trauma Society. The evaluation was carried out via

administrative and staff interviews of all individuals

involved in the care of the injured patient (nurses, residents,

physicians, supportive clerks, and technicians) from the

various services (general surgery, orthopedics, neurosur-

gery, emergency medicine, intensive and critical care,

radiology, pharmacy, and laboratory). To ensure the accu-

racy and completeness of the information, thorough walk-

throughs, inspections, and demonstrations of all supplies

and equipment were carried out, along with extensive

review of the ministry of health and hospital statistics. After

each facility evaluation, all information was reviewed by at

least two members of the team, and a second evaluation was

carried out to resolve any discrepancies if necessary.

Additionally all large hospitals and three small general

hospitals with large trauma services were re-visited at night

to verify the reported availability of staff, supportive ser-

vices, and machine operability.

Results

Facilities

Twenty-seven facilities were visited and evaluated. Despite

prior notification, only three hospitals made arrangements

for the visit. Therefore, the evaluation presented a more

accurate assessment of the daily operational capability of

each facility. Three of the clinics did not have enough staff

available to obtain a valid assessment and were excluded

from the study. This study was limited to the 24 facilities

where an adequate assessment could be obtained. Table 1

shows the type and size of the hospitals that were evaluated.

Overall, 210,045 emergency (ED) visits and 61,365

(29%) ED trauma visits per year (2006–2007) were

recorded. with an incidence rate of 2,740/100,000 inhab-

itants. The large urban hospitals had an average of 38,000

ED visits per year, which is equivalent to many U.S. urban

hospitals. One-third of these visits were trauma-related and

resulted in a 20% trauma admission rate. The small general

hospitals within areas undergoing rapid urbanization

showed a similar profile to urban hospitals, with a slightly

higher trauma admission rate (30%). The rural clinics had

fewer but still-significant numbers of trauma-related visits

(20%) (Table 1).

World J Surg

123

Prehospital and interhospital transport

Prehospital communication in the urban areas was noted to

be adequate. Major deficits were noted in interhospital

transfers at all levels. There was no effective coordination

or communication (no common communication channel, or

pre-existing agreements) between the facilities and no prior

notification of the patient’s transfer. Most of the ambulance

services for rural to urban areas were transport vehicles

devoid of any interhospital monitoring or paramedical care

services. All well-equipped ambulances were limited to the

provision of local services only. Fifteen of the twenty-five

ambulances inspected in the large and small facilities were

either nonfunctional or in repair.

Training and staffing

The large and small general hospitals were staffed by

physicians, nurses, and various specialists. The clinics were

staffed by health care promoters or general doctors with

very limited trauma training or resources (Table 2). None

of the physicians staffed the facilities full time. Most

physicians worked an average of 4 h per day at the public

hospitals. Nursing coverage, on the other hand, was more

comprehensive in all facilities, but incredibly limited in

trauma management. Specialty trained doctors were pres-

ent in the large and small general hospitals. However,

100% coverage of specialists in any setting was not pres-

ent. In one small general hospital representing the only

facility for trauma care in the province of Zamora-

Chinchipe, there was one general surgeon available for the

first two weeks of every month. Equally sparse in the small

general hospitals was the radiology staff (physicians and

technicians). In the province of Morona Santiago, trauma

care in six of the small hospitals was carried out without

diagnostic radiology support.

The level of preparation for essential trauma care was

alarmingly low in all settings (Table 2). The first responders

in the emergency rooms of the large hospitals and small

general hospitals were the interns, residents, and nurses.

The majority did not have trauma care training or education.

Less than 15% of physicians were trained in ATLS� or an

equivalent trauma course. No nurse had ever participated in

TNCC� or equivalent trauma care course for nurses. In the

large urban hospitals, few of the attending physicians and

administrators were ATLS� certified. However, they were

not involved in the initial management and resuscitation of

the injured patients. Most noted that ATLS� is expensive

and not feasible for most settings of the southeastern region

of Ecuador. In the small general hospitals, in-service trauma

education and training was minimal for both physicians and

nurses. The lack of adequate preparation and response and

the need for basic trauma care training was witnessed by the

authors (M.A., F.M.) during the inspection of a small pro-

vincial general hospital. Without any prehospital warning,

the emergency room was inundated by multiple casualties

from a motor vehicle crash. The response was marked by

Table 1 Hospital facilities and trauma care

Facilities Large hospitals (n = 5) Small hospitals (n = 15) Clinics (n = 7)

Range Average Range Average Range Average

No. functional beds 145–280 221 15–57 27 0–10 7

No. emergency ED visits 9 1,000/year 13.5–55 38 2–9 5 0.01–1.15 0.3

No. ED trauma visit 9 1,000/year 5–24 12 0.3–3.5 1.5 0.001–0.2 0.05

% ED trauma visit 20–40 33 5–30 30 16–30 21

No. trauma admissions 9 1,000/year 1–4.6 2.4 0.2–0.7 0.45 NA NA

Table 2 Staffing and training level for initial responders and trauma

care providers

LH SH Cl

Staffinga

Nurse in Emergency Department (ED) 3 2 3

Intern/resident in ED 3 2 2

General surgeon 2 1 NA

Orthopedic surgeon 2 1 NA

Neurosurgeon 2 NA NA

Anesthesia 2 1 NA

Intensivist 2 0 NA

Radiologist 2 1 NA

Emergency attending physician 1 0 NA

Training

Nurses: % with TNCC�b 0 0 0

Intern/resident/health promoter % ATLS� trainingb 1 1 0

Attending/physician: % ATLS� trainingb 1 1 0

LH large hospitals; SH small hospitals; Cl clinicsa 24 h/day, 7 day/week availability, in hospital or on call from homebor equivalent continuing medical education course (CME)

Rating: NA not applicable, 0 (absent); 1(inadequate), 2 (partially

adequate), 3 (adequate)

World J Surg

123

disorganization, inappropriate resource utilization, and a

lack of systematic approach to the management of one and/

or multiple trauma patients.

In the clinics, the generalists and local health care

workers had significant knowledge and training in basic

primary care, but a disproportionately low level of knowl-

edge in basic injury mechanisms, trauma stabilization, and

referral.

Resources for essential trauma care

Human and physical resources for essential trauma care in

terms of airway, respiratory, and shock management are

summarized in Tables 3 and 4. Basic airway management

was adequate at the large urban hospitals. In the small

general hospitals, basic airway management was also

adequate in terms of skill and equipment. Advanced airway

management, however, in terms of endotracheal or surgical

airways were alarmingly deficient even in hospitals where

surgical specialties were present. This was not only due to

lack of equipment but also to lack of training. In some

small general hospitals, obtaining a definitive airway was

not a priority because there was lack of ventilators, critical

care capability, and timely transport.

In terms of respiratory support, 4 of the 5 large hospitals

had the training and equipment for sufficient management.

This was not the case in 13 of the small general hospitals

evaluated. For the treatment of a pneumothorax, the gen-

eralists and residents needed to wait for a surgical attending

to help in the placement of a chest tube. If the surgeon was

unavailable (nights and weekends), the patient was usually

transferred irrespective of the patient’s stability. Other

treatment measures, such as needle decompression or

placement of a Heimlich valve were not used in any hos-

pital evaluated. The majority of physicians and residents

attributed this to the lack of supplies for use in training and

acute events. However, during direct inspection all small

hospitals had chest tubes locked in inaccessible cabinets or

storage rooms. During the motor vehicle collision (MVC)

incident mentioned above, endotracheal tubes and Foley

catheters were modified and used as makeshift chest tubes),

with noted breakdown in sterility and loss of time.

Both large and small general hospitals had staff with

adequate knowledge and skills to control hemorrhage and

perform shock management. One common deficiency seen

throughout the southeastern region of Ecuador was the lack

of blood transfusion capabilities, especially during emer-

gencies and operative resuscitations. This was mainly

attributed to financial and logistical constraints. In the

urban areas, there was no formal process or agreement

between the hospitals and the local blood banks for a quick

supply of blood products. Additionally, blood needed to be

purchased by the patient prior to its administration. In the

urbanizing rural regions, no blood banks were available.

Finally, end-points of resuscitation in the small general

hospitals and one of the large hospitals were based on

blood pressure and urine output. Central venous pressure

measurement, lactate, and blood gases could not be per-

formed. Human and physical resources for essential trauma

Table 3 Human resources for essential trauma care

Resuscitative management: knowledge and skills LH SH Cl

Airway

Basic: manual maneuvers/assistance/suction 3 2 1

Advanced: ET intubation/cricthyroidotomy 2 1 NA

Respiratory

Assessment and oxygen administration 3 2 1

Treatment of pneumothorax 2 1 0

Circulation

Shock assessment 2 2 1

Control: external compression/splinting/binding 2 2 1

Shock resuscitation: fluid/blood/access 2 1 1

Rating: NA not applicable, 0 (absent); 1(inadequate), 2 (partially

adequate), 3 (adequate)

Table 4 Physical resources for essential trauma care

Physical resources: equipment and supplies LH SH Cl

Airway

Oral or nasal airway 3 2 1

Suction devices/tubing 2 1 0

Laryngoscope/endotracheal tubes 2 2 0

Breathing

Stethoscope 3 3 1

Oxygen supply 3 3 1

Chest tubes 2 1 NA

Pulse oximetry 2 1 NA

Arterial blood gas measurement 2 0 NA

Bag-valve-mask 3 3 0

Mechanical ventilator 2 0 NA

Circulation

Blood pressure cuffs 3 3 1

Crystalloids 3 3 1

Blood transfusion capability 1 1 NA

Urinary catheter 3 3 NA

Determination of hemoglobin 3 2 NA

Electronic cardiac monitoring 2 1 NA

Electrolyte determination 3 1 NA

Blood gas and lactate determination 2 0 NA

Rating: NA not applicable, 0 (absent); 1 (inadequate), 2 (partially

adequate), 3 (adequate)

World J Surg

123

care in terms of airway management, respiratory support,

hemorrhage control, immobilization, and transfer were not

adequate at the clinic levels.

Resources for management of specific injuries

In the large hospitals, knowledge, skills, supplies, and

equipment were mostly adequate for the management of

specific injuries (Table 5). One common deficiency noted

was the unavailability (\50%) of radiologic equipment

(portable X-rays, compute tomography [CT] scans, angi-

ography).

In the small general hospitals, knowledge and skill were

mostly adequate for head and neck injuries, but not for

torso injuries. Of concern is the lack of skills and knowl-

edge for abdominal trauma management (Table 5). On

direct inspection, all small hospitals had portable sono-

graphic machines. However, few of the generalists and

local surgeons could perform a Focused Abdominal

Sonographic Exam for Trauma (FAST). Furthermore, such

a skill was not recognized as part of the diagnostic arma-

mentarium of emergency responding physicians. Resources

for management of specific injuries largely did not apply to

clinics.

Trauma program

Administrative functions specific to trauma care were weak

(Table 6). No trauma-related quality improvement pro-

grams were present. One large hospital had a general

quality improvement program where trauma cases were

occasionally presented. All facilities had medical records

systems established, with mandatory reporting to the pro-

visional minister of health on a monthly basis. None were

appropriate for trauma patients as they were mostly

incomplete and lacked information about the mechanism of

injury, injury severity, morbidity and outcomes. No trauma

registry was present in any facility except in the rural areas

(6 small hospitals in Morona Santiago and Pastaza) where

ITSDP has been working in the last 5 years. There were no

CME programs. Except in one large hospital, no facility

had any form of a trauma team with preassigned roles for

acute resuscitation and management.

Universal precautions

Universal precautions were hardly applied throughout all

the facilities. This was attributed to a lack of enforcement.

Gloves, goggles, and gowns were available more than 50%

of the time. Adaptations of and home-made sharps disposal

units were used in all facilities. However, not all were

adequate. For example, a large plastic soda bottle with a

narrow opening was hazardous for sharps insertion and for

disposal with a risk of injury. The use of hard plastic

bottles seemed the most useful, safe, and cost-effective.

Biological disposal was adequate in all institutions with

few exceptions.

Discussion

The purpose of the present study was to evaluate the use-

fulness of the WHO/IATSIC EsTC Guidelines in a region

in South America to assess trauma care capability. To that

Table 5 Resources for management of specific injuries

Specific injuries LH SH Cl

Head

Prevention of second head injuries (fluid; oxygen) 2 2 0

Intracranial pressure monitoring 1 0 0

Computed tomography (CT) scan 1 NA NA

Operative neurosurgical capabilities 2 NA NA

Neck

Operative capability for neck injuries 3 2 NA

Contrast radiography for esophageal injury,

endoscopy

1 NA NA

Angiography 1 NA NA

Chest

Autotransfusion from chest tubes 1 0 NA

Operative capability for intermediate thoracotomy 2 NA NA

Operative capability for advanced thoracotomy 2 NA NA

Abdomen

Diagnostic peritoneal lavage 3 1 NA

Ultrasonography (FAST) 2 1 NA

Operative capability for laparotomy 3 1 NA

Extremity

Operative management/compartment syndrome 3 0 NA

Basic immobilization equipment 3 2 0

Skeletal traction 3 1 NA

External fixation 3 1 NA

Internal fixation 3 NA NA

X-ray films 2 1 NA

Portable X-ray 1 1 NA

Image intensification 1 NA NA

Spine

Immobilization: cervical collar, back board 2 2 1

Operative capabilities for spine/vertebral injuries 2 NA NA

Burns and wounds

Dressings with topical antibiotics 1 0 0

Skin grafting 3 0 NA

Tetanus prophylaxis (toxoid, antiserum) 3 2 1

FAST Focused Abdominal Sonographic Exam for Trauma

Rating: NA not applicable, 0 (absent); 1(inadequate), 2 (partially

adequate), 3 (adequate)

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123

end, the EsTC Guidelines provided a simple, comprehen-

sive, and detailed assessment of trauma care capability in

the southeastern region of Ecuador in terms of human and

physical resources in variable settings. The findings

encountered in the large urban hospitals and rural clinics

were similar to other findings in low and middle income

countries such as Mexico, Vietnam, Ghana, and India

[19–23].

With proper organization and planning, most of the

large hospitals appeared to have adequate resources to

deliver essential trauma care. Their ability to quickly

modify their situation to meet the expected care was evi-

dent after the survey was conducted and preliminary results

were conveyed to the chiefs of surgery and hospital

administrators. There was a dramatic increase in ATLS

administration and a surge of interest in the development of

a trauma registry and a quality assessment program in

the urban areas. It is important to note that even though the

evaluation process represented only the first step in

the public health model, it promoted a wide awareness of

the needs of each facility and at all levels.

The rural hospital findings highlighted the basic need to

develop targeted educational strategies that are simple and

basic, reflecting the resource limitations of such areas.

Trauma care education, leadership, and infrastructure and

system development are currently limited to urban areas.

The three essential principles of rural trauma care in terms

of assessment, stabilization, and transfer were not capable

of being met in the rural clinics of southeastern Ecuador.

Although Ecuador contains an active ACS chapter, ATLS�

was not available or affordable in the rural areas of

Ecuador. Large efforts to improve rural trauma care were

undertaken jointly by the Ecuadorian Trauma Society, the

Provincial Ministry of Health and the College of Physi-

cians of the Amazonian Province of Morona Santiago, the

Cinterandes Foundation of Ecuador, and ITSDP (http://

www.cinterandes.org/trauma.html; www.itsdp.vcu.edu).

A Basic Trauma Care (BTC) course was developed for the

Amazonian Province of Morona Santiago, resulting in

improved retention of basic knowledge and application

[12]. The BTC is now pending promulgation to the other

rural provinces in Ecuador. Its major impediment is

dependence on ITSDP administration and the lack of

trauma leadership in the rural region for local course

ownership. These basic organizational and administrative

deficiencies were clearly highlighted in the present study

and would need serious consideration by the Ecuadorian

Ministry of Health and the Ecuadorian Trauma Society.

The present study also emphasizes the need for trauma

care development in the small towns and rural regions

undergoing population growth, rapid development, road

construction, and urbanization. These regions are supported

by small general hospitals with variable degrees of trauma

care resources and capability. Secondary to their designa-

tion as rural areas and the lack of any trauma statistics, the

need for trauma care is not properly recognized by gov-

ernment officials. Significant efforts are underway for the

development of a regional trauma registry in the south-

eastern region of Ecuador to demonstrate the burden of

trauma care in these developing rural regions [32].

Apart from injury surveillance and injury control efforts,

the most important and cost-effective means for regional

trauma care improvement is the development of a prehos-

pital care system, providing the clinics and small general

hospitals the capability to effectively communicate and

appropriately link with urban trauma facilities. Low cost

and feasibility of such systems in the Latin and Caribbean

regions have been demonstrated by studies in Trinidad,

Mexico, and Brazil [33–36]. At present, in the southeastern

region of Ecuador, a prehospital care system is established

in the urban areas, but it remains rudimentary in neigh-

boring rural areas.

This study has concentrated mainly on the capabilities of

facilities for trauma care. A more thorough assessment

using the WHO Prehospital Trauma Care System guide-

lines will be needed [24]. Such evaluations have been

carried out in Colombia, Mexico, and Vietnam and resulted

in national legislation establishing standards for prehospital

care providers [37].

A common complaint by all providers throughout the

region of focus of the present study was the lack of supplies

and equipment. However, the lack of staff and specialist

availability was mostly accepted at all levels. The expec-

tation for suboptimum delivery of care, especially in the

small towns and rural areas undergoing rapid development

and experiencing an increasing burden of trauma, presented

a ‘‘double-edged sword,’’ affording patience for system

development yet allowing complacency regarding the use

Table 6 Administrative and organizational functions for essential

trauma care capabilities

Hospital: trauma program LH SH Cl

Trauma-related quality improvement programs 0 0 0

General quality improvement program 1 0 0

Trauma registry with severity adjustment 0 1 0

ATLS� or equivalent 1 1 1

TNCC� or equivalent 0 0 0

CME programsa 1 0 0

Trauma team for acute resuscitation

and management

1 0 0

Rating: NA not applicable, 0 (absent); 1(inadequate), 2 (partially

adequate), 3 (adequate)a Continuing medical education (CME) programs other than ATLS�

and TNCC� or equivalent courses include live activities (e.g.,

in-service training and education), online learning on injury man-

agement, injury-related guides, workbooks and journals and the like

World J Surg

123

of basic, innovative, and cost effective measures. These

attitudes and perceptions can only be overcome with the

active involvement of trauma societies in educating trauma

care providers, average citizens, and policy makers regard-

ing the ‘‘essential rights of all trauma patients’’ as clearly

delineated in the EsTC Guidelines.

Additionally, the EsTC Guidelines provided specific

measures for the leaders in trauma care and for hospital

administrators as to how these guidelines can be achieved

and implemented in terms of improving trauma education,

in-service training, trauma team organization, development

of a trauma registry, and development of quality improve-

ment programs. All national trauma societies should take an

active advisory role to their provisional ministries of health

to help decide which elements delineated in the EsTC

Guidelines are essential and cost-effective, and can be

realistically assured to any injured patient at each facility

(Table 7).

The results of the present study were presented to the

Ecuadorian Trauma Society, the Ecuadorian National

Association of Rural Physicians, the Ecuadorian Chapter of

the American College of Surgeons, and the Ecuadorian

Ministry of Health. The EsTC Guidelines were endorsed by

members of the ETS, with plans to extend the assessment

to the remaining region of Ecuador. Additionally, a pro-

posal for trauma system development in Ecuador was

Table 7 Summary of

recommendationsPrehospital and inter-hospital transport

Improve prehospital and interfacility communication and transfer

Establish formal agreement and protocols for interfacility transfer

Define a core set of prehospital equipment and supplies for essential trauma care

Initiate cross training of prehospital personnel in urban and rural prehospital care

Rural clinics

Provide basic education in trauma definition, mechanism, and physiology

Provide targeted educational strategies and training initiatives to develop competency in basic trauma

care: assessment, stabilization, and transfer

Develop leadership training in organization and system development

Enhance coordination with urban facilities to improve transport and patient care

General and tertiary hospitals

Improve coordination and communication with prehospital and rural facilities

Improve capability for ED resuscitation and management

Redirect training resources toward first responders in ED

Develop targeted trauma education for nurses (TNCC or equivalent) and for residents and physicians

(ATLS or equivalent)

Enhance ‘‘Trauma Team’’ approach toward acute trauma resuscitation

Improve immediate accessibility to basic adjuncts for trauma care (airway adjuncts, chest tubes, X-rays,

ultrasound) and enhance capability for their use

Improve capability for surgical management of certain injuries: neck and abdomen

Administrative function per facility

Reorganization and planning for provision of essential trauma care within facility based

identified and documented local needs and resources

Develop a trauma registry with severity adjustment

Initiate trauma quality improvement programs focusing on preventable morbidity and mortality and

addressing correctable system and individual risk factors

Use of EsTC Guidelines to monitor improvement in trauma care capabilities

Require and subsidize CME programs for emergency and trauma care responders

Enforce universal precautions in all trauma care settings

Develop agreements with local blood banks for blood availability during emergencies and operative

resuscitations

Ecuadorian Trauma Society

Initiate targeted education for emergency care providers, hospital administrators, and policy makers on

‘‘essential rights of all injured patients’’ as delineated in the EsTC Guidelines

Define leadership positions and political advocacy plan for national, regional, and local promulgation of

the EsTC Guidelines

Advocate for health care policy development and national legislation to ensure universal provision of

essential trauma care as delineated in the EsTC Guidelines

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jointly developed by the Ecuadorian Committee for the

Prevention, Management & Control of Injuries (CEP-

MCR), a joint committee composed of members of ETS

and the Ecuadorian ACS chapter, and VCU’s ITSDP and

submitted to the Ecuadorian Ministry of Health for con-

sideration. The objective is to incorporate the EsTC

Guidelines into national legislation and establish standards

for essential trauma care in all regions in Ecuador.

The methods and results of this study, along with similar

findings in Mexico and Colombia, regarding the effective

use of the EsTC Guidelines for trauma care prompted the

development of the Trauma System Committee (TSC) by

the Panamerican Trauma Society (PTS) [22, 37]. The PTS

serves as the ‘‘parent’’ organization for the various national

specialty societies dedicated to the care and management of

trauma patients in several countries, including Argentina,

Bolivia, Brazil, Canada, Chile, Colombia, Cuba, Ecuador,

Guatemala, Mexico, Panama, Paraguay, Peru, Uruguay,

and Venezuela. The objectives of the TSC include the

adaptation of the EsTC Guidelines to the Latin American

countries and their regional promulgation and implemen-

tation. This study does not reflect an assessment of other

areas or facilities throughout the entire South American

region. This endeavor is to be undertaken jointly with the

national trauma societies in collaboration with the Pan

American Health Organization (PAHO)/WHO.

Limitations to the present study include the fact that

skills assessments are mainly subjective. Thus documen-

tation of in-service training and presence of specialty care

was important. Also, improvement in physical resources

does not always equate with improvement in outcome.

However the availability of resources is integral to system

development and has been shown to improve trauma pro-

cesses and outcomes [38, 39].

Conclusions

The IATSIC/WHO EsTC Guidelines provide a simple and

useful template to assess trauma care capability in variable

facilities and international settings. The present study has

shown the usefulness of the EsTC Guidelines in various

economic settings and in various stages of development

and urbanization. This is important and increases the

ability of the EsTC Guidelines to provide an internationally

applicable and standardized template with which to assess

trauma care capabilities in the Latin American region. The

adaptation of the EsTC Guidelines for the Latin American

region and its joint endorsement by PAHO, the Panamer-

ican Trauma Society, and their respective national chapters

is the next important step for the promulgation of the EsTC

Guidelines throughout the Latin Region.

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