Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting
Objectives This project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.Design We conduct a two-arm, controlled, mixed-methods,...
| Հիմնական հեղինակներ: | , , , , , , , , , , , , , , , |
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| Ձևաչափ: | Հոդված |
| Լեզու: | English |
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BMJ Publishing Group
2023-04-01
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| Շարք: | BMJ Open |
| Առցանց հասանելիություն: | https://bmjopen.bmj.com/content/13/4/e060338.full |
| _version_ | 1826987014520569856 |
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| author | Corey B Bills Shaheem de Vries Charmaine Cunningham Julia Dixon Nee-kofi Mould-Millman Vikhyat S Bebarta Adit A Ginde Edward P Havranek Brenda L Beaty Krithika Suresh Beatrix Bester Fabio Moreira Kubendhren Moodley Radomir Cermak Steven G Schauer Joseph K Maddry |
| author_facet | Corey B Bills Shaheem de Vries Charmaine Cunningham Julia Dixon Nee-kofi Mould-Millman Vikhyat S Bebarta Adit A Ginde Edward P Havranek Brenda L Beaty Krithika Suresh Beatrix Bester Fabio Moreira Kubendhren Moodley Radomir Cermak Steven G Schauer Joseph K Maddry |
| author_sort | Corey B Bills |
| collection | DOAJ |
| description | Objectives This project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.Design We conduct a two-arm, controlled, mixed-methods, hybrid type II study.Setting This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.Interventions We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measures We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results 198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).Conclusions In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness. |
| first_indexed | 2024-04-09T15:53:14Z |
| format | Article |
| id | doaj.art-9b56a2cd0fdc45e6846aa681cc35451b |
| institution | Directory Open Access Journal |
| issn | 2044-6055 |
| language | English |
| last_indexed | 2025-02-18T07:31:42Z |
| publishDate | 2023-04-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | BMJ Open |
| spelling | doaj.art-9b56a2cd0fdc45e6846aa681cc35451b2024-11-06T07:20:09ZengBMJ Publishing GroupBMJ Open2044-60552023-04-0113410.1136/bmjopen-2021-060338Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African settingCorey B Bills0Shaheem de Vries1Charmaine Cunningham2Julia Dixon3Nee-kofi Mould-Millman4Vikhyat S Bebarta5Adit A Ginde6Edward P Havranek7Brenda L Beaty8Krithika Suresh9Beatrix Bester10Fabio Moreira11Kubendhren Moodley12Radomir Cermak13Steven G Schauer14Joseph K Maddry15Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USAEmergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South AfricaFamily, Community and Emergency Care, University of Cape Town Faculty of Health Sciences, Cape Town, South AfricaDepartment of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USADepartment of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USADepartment of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USADepartment of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USADepartment of Medicine, Denver Health Medical Center, Denver, Colorado, USAAdult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USADepartment of Biostatistics & Informatics, University of Colorado School of Public Health, Aurora, Colorado, USAEmergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South AfricaEmergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South AfricaEmergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South AfricaEmergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South AfricaUS Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USAUS Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USAObjectives This project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.Design We conduct a two-arm, controlled, mixed-methods, hybrid type II study.Setting This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.Interventions We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measures We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results 198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).Conclusions In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.https://bmjopen.bmj.com/content/13/4/e060338.full |
| spellingShingle | Corey B Bills Shaheem de Vries Charmaine Cunningham Julia Dixon Nee-kofi Mould-Millman Vikhyat S Bebarta Adit A Ginde Edward P Havranek Brenda L Beaty Krithika Suresh Beatrix Bester Fabio Moreira Kubendhren Moodley Radomir Cermak Steven G Schauer Joseph K Maddry Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting BMJ Open |
| title | Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting |
| title_full | Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting |
| title_fullStr | Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting |
| title_full_unstemmed | Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting |
| title_short | Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting |
| title_sort | improving prehospital traumatic shock care implementation and clinical effectiveness of a pragmatic quasi experimental trial in a resource constrained south african setting |
| url | https://bmjopen.bmj.com/content/13/4/e060338.full |
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