World J Surg (2009) 33:874885 DOI 10.

1007/s00268-008-9900-6

Evaluation of Trauma Care Resources in Health Centers and Referral Hospitals in Cambodia
Shinji Nakahara Saly Saint Sary Sann Radian Phy Masao Ichikawa Akio Kimura Lycheng Eng Katsumi Yoshida

Published online: 22 January 2009 Societe Internationale de Chirurgie 2009

Abstract Background The aim of this study was to evaluate the available resources for trauma care at health centers (HCs) and referral hospitals (RHs) in rural Cambodia and to examine whether the resources at HCs are allocated on the basis of actual need based on the referral distance and number of severely injured patients referred to RHs. Methods We conducted a cross-sectional facility survey by phone interview or mail using structured questionnaires at nationally representative samples of 85 HCs and 17 RHs from December 2006 to April 2007. The questionnaire included a modied checklist of the guidelines for essential trauma care as well as questions on distance for referral and the number of injured patients received and referred during the last 3 months. We analyzed the association between

resource availability at HCs and their need using multivariate linear regression. Results Median (interquartile range) numbers of available resources at HCs and RHs were 25.5 (22.027.5) and 35 (2841) among 37 and 62 essential items, respectively. Basic equipment, including both consumable supplies and durable devices and life-saving knowledge/skills, were not satisfactory at either HCs or RHs. A longer distance to the RH was associated with more knowledge/skills but not with equipment supplies; the number of referred patients was not associated with equipment or knowledge/skills. Conclusions Staff training emphasizing life-saving knowledge/skills and better organization and planning to supply physical resources are needed. There is a gap between resource allocation and need, which should be addressed through clear policies to prioritize remote areas and to allocate resources based on reliable injury data.

Part of this study was presented at an annual conference of the Japan Association for the Surgery of Trauma, Okinawa, May 2008. S. Nakahara (&) K. Yoshida Department of Preventive Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki 216-8511, Japan e-mail: snakahara@marianna-u.ac.jp K. Yoshida e-mail: k2yosida@marianna-u.ac.jp S. Saint National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia e-mail: salysaint@yahoo.com S. Sann R. Phy Hospital Services Department, Ministry of Health, Phnom Penh, Cambodia S. Sann e-mail: sarydhsd@yahoo.com R. Phy e-mail: radianmd@yahoo.com M. Ichikawa Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan e-mail: masao@md.tsukuba.ac.jp A. Kimura Department of Emergency Medicine, Traumatology, and Toxicology, International Medical Center of Japan, Tokyo, Japan e-mail: akimura@imcj.hosp.go.jp L. Eng University Research Co., Phnom Penh, Cambodia e-mail: lycheng_eng2000@yahoo.com

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Introduction In low- and middle-income countries, injuries are a growing public health concern, especially road trafc injuries, which are increasing because of rapid motorization and insufcient safety measures [13]. Globally, 5.2 million people die of injuries every year, accounting for 9% of all deaths; more than 90% of these occur in lowand middle-income countries [4]. A survey in Cambodia in 2005 reported 1.9% of those surveyed experienced injuries and 0.1% died of injuries during the past 12 months; road trafc injuries were the leading cause of injury, followed by falls [5]. Foreign aid to Cambodia invested in road rebuilding has contributed to increasing deaths due to road trafc injuries [3, 6]. To tackle these increasing injury deaths, strengthening of trauma care systems as well as injury prevention measures are crucial in low- and middle-income countries. Injury fatalities vary by country or by region because of the disparity in access to quality trauma care between rich and poor countries or between urban and rural areas [79]. In remote areas of Cambodia, although quantied data are lacking, anecdotal information suggests that trauma patients have to travel long distances to the capital city usually by taxi without any prehospital care because of poor trauma systems, resulting in high case-fatalities [10]. To address these inequalities, the World Health Organization (WHO) devised Guidelines for Essential Trauma Care (EsTC), which set minimum standards of physical (equipment) and human (knowledge/skills) resources for trauma care at reasonable cost in low- and middle-income countries depending on the level of care from primary to tertiary, and started the EsTC Project to improve trauma care [11]. Several studies have assessed trauma care resources in low- and middle-income countries based on the Guidelines [1216]. A study in Vietnam compared resources before and after starting the EsTC Project and showed notable improvements in district and city hospitals but small improvements in rural clinics [13]. These studies, however, used convenient samples that were not representative of the nation or area. The studies from Vietnam investigated all levels of facilities ranging from primary to tertiary care. However, special attention was not paid to health centers (HCs), where people make the rst contact with health care in many lowand middle-income countries. At HCs, where physicians are not usually available, nonphysician practitioners such as midwives and nurses provide curative and preventive care, including basic trauma care; their ability in rst aid and even more advanced care dictates the subsequent chain of survival especially in remote areas [17, 18].

When evaluating necessary resources for trauma care, in addition to the level of care, we also should consider whether supply meets the need, such that facilities far from higher levels of care or receiving more patients have more resources. A study in Vietnam showed that hospitals with longer distances from referral hospitals (RHs) had more available resources, probably reecting a policy of allocating more resources to geographically isolated areas [16]. This study, however, did not consider the number of severe cases received. Also, it did not distinguish between equipment and knowledge/skills, which are related to different administrative mechanisms: equipment supply and staff training. Therefore, we evaluated the available resources for trauma care at a provincial level, selecting nationally representative samples of HCs and RHs in rural areas of Cambodia, with emphasis on HCs. We also examined a research question whether, in rural areas of Cambodia, more trauma care resources are allocated at HCs with the higher actual neednamely, a longer distance from RHs and a larger number of severely injured patients who need referral to RHs.

Methods Study settings Cambodia consists of 24 provinces, which are divided into operational districts based on the population so each operational district covers between 100,000 and 200,000 people. In total, there are 76 operational districts in the country. Operational districts are units of the health care system that are different from administrative districts; some operational districts consist of two or more administrative districts. Each operational district has a network of HCs, each of which covers approximately 10,000 people; it usually has an RH that receives patients referred from HCs. At the time of the study, there were 975 HCs and 68 RHs in total. Study design We conducted a cross-sectional facility survey at nationally representative samples of HCs and RHs from December 2006 to April 2007. We excluded from our survey two urban neighboring provinces, Phnom Penh and Kandal, where people have easy access to national hospitals, because our focus was the capacity of rural trauma care where HCs and RHs play a major role. We also excluded Kampong Speu and Donkeo operational districts where we conducted a pilot survey in February 2006.

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Sampling Stratied two-stage cluster systematic random sampling with probability proportional to size was used. The sampling units of the rst and second stages were operational districts and HCs, respectively. We used stratied sampling in both stages, with an equal sampling fraction in each stratum. During the rst stage, we stratied provinces by population density (1998 census) into low (119/km2), lowermiddle (2049/km2), upper-middle (5099/km2), and high (100 ?/km2) population density strata and selected operational districts from each stratum using a systematic random sampling technique with probability proportional to the number of HCs in each operational district. These procedures were based on a standard community survey sampling technique, with village and population size being replaced by the number of operational districts and HCs, respectively [19]. Of the 76 operational districts in total, 62 were included in the sampling procedures, and 17 operational districts were selected. Each of the selected operational districts had one RH; we recruited all these RHs. During the second stage, three HCs in the same compound of RHs and one HC acting as an RH in its operational district with no RH were excluded from the sampling because this survey had another purpose in analyzing referral between HCs and RH. Then ve HCs were selected using stratied random sampling in each operational district. HCs were stratied into one of three categories based on access to main roads and vehicle availability: the number of categories depended on the heterogeneity of the HCs. HCs were then randomly selected from each stratum. In total, 85 HCs were selected. The sample size was determined to test two correlation coefcients of 0.45 to be signicantly larger than zero, with an a of 0.05 and a power of 0.8. The required sample size for one coefcient was 36. We also assumed a 15% dropout due to nonresponse or missing data. Data collection We collected information by interviewing the staff or sending a questionnaire to them. Structured questionnaires, in which the questions asked were precisely written, were used in both methods so that asking questions would take place exactly the same way. Our research assistants, trained for interviewing, contacted directors of the HCs, explained the objectives and procedures of the survey, and interviewed them after obtaining their consent: oral consent for phone surveys and written consent for face-to-face interviews. Of the 85 HCs, the assistants did face-to-face interviews at 5 centers and phone interviews at 70 centers. We collected information by mail from directors of 10

centers in the low population density areas where visiting and phoning were difcult owing to poor accessibility. We collected information on RHs from their directors with a questionnaire sent by mail asking them to let a person in charge of trauma care answer it. The collected information included availability of trauma care resources (equipment and knowledge/skills), number of injured patients received and referred to higher level facilities during the past 3 months as recorded in the logbook, distance to a higher level facility, and number of staff members. We also asked what they perceived were the main economic activities in their regions and the main causes of injuries among their patients, and we asked them to indicate up to three. To assess trauma care resources, we modied and used the resource checklist of the Guidelines, in which health facilities are categorized into four levels with increasing requirements at higher levels: basic, general practitioner, specialist, and tertiary levels [20]. Of the 260 items in the list, we selected items relevant to the Cambodian situation; we focused on life-saving and limb-saving trauma care procedures and excluded items related to drugs and rehabilitation. Although the omitted information is also important for improving comprehensive trauma care, we did this to shorten the questionnaire because we collected data by phone or mail, and a long questionnaire would be likely to be inconvenient for the respondents and tire them, thus lowering the quality of the data. We prepared two questionnaires for HCs and for RHs, including 44 and 82 of the 260 items, respectively (see Appendix). Some items in the list assessing knowledge/skills were based on subjective opinions [15]; we omitted them if inappropriate for structured questionnaires, or we developed specic questions about knowledge/skills for structured questionnaires if possible. For example, to assess skills in shock assessment we developed seven questions about physiological changes. There were 29 and 41 HC questions regarding equipment and knowledge/skills, respectively, and 98 RH questions. There were 37 HC questions and 62 RH questions related to essential resources at basic and specialist levels, respectively, as designated in the Guidelines [11]. Although the status of each item in the checklist was to be rated using a four-point scale (0, absent; 1, inadequate; 2, partly adequate; 3, adequate) [20], we dichotomized them (0, absent; 1, present) to collect data by phone or mail. In the pilot survey in February 2006, we eld-tested the questionnaire by visiting nine HCs and two RHs and interviewing the staff. We observed the listed resources in these HCs to validate the response from the staff, although this could not be done in RHs. This study was approved by the Cambodia National Ethical Committee for Health Research and the Cambodia Ministry of Health.

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Data analyses Of the 85 sampled HCs, 3 were found to be in the same compound of RHs after data collection, although three such HCs had already been excluded before the sampling. However, we included them in the analyses, assuming that their inclusion does not distort the results because this study did not deal with the referral system. The presence or absence of examined resources at HCs and RHs is described. We then examined associations between HC resources and hypothesized predictors using multivariate linear regression. The dependent variables were the number of available equipment devices among those examined (0.5 was assigned to ready to make a splint, sling, sandbag, or backboard) and the number of available knowledge/ skills (number of correct answers to the questions). We selected the following independent variables based on our aim of evaluating whether resource allocation met the need (facilities far from a higher level of care or receiving a high number of severely injured patients should have more resources): distance from the RH and number of referred patients due to severe injuries during the past 3 months. The multivariate model also included the following variables as confounders: population density categories and number of medical and co-medical staff. To ensure the linear regression assumptions of a normal distribution, we log-transformed the distance from the HC to the RH and the number of staff members after excluding HCs with a distance of zero to RH (zero cannot be log-transformed). The number of referred patients was categorized into three groups and entered as dummy variables into the regression models because variable transformation could not meet the requirement. We also excluded HCs with a score of zero for knowledge/skills as outliers. Two HCs missing the number of referred patients and one HC missing the number of staff were excluded from the regression analyses. To assess the inuence of omitting HCs with zero distance, we performed regression analyses that included them without log-transforming the distance. For each independent variable, we indicate the regression coefcient (B) with a 95% condence interval (CI) and standardized coefcient (b). B values are dependent on the measurement units of variables, but b values indicate changes in dependent variables in standard deviation units for a change of one standard deviation (1 SD) in independent variables; b values are comparable among variables with various measurement units [21] SPSS version 12.0 was used for the statistical analyses.

Results All of the contacted facilities responded. Table 1 shows the characteristics of the surveyed facilities and their regions.

Road trafc injuries are the leading cause of injuries followed by violence, contact with agricultural equipment/ machinery, and animal bites. Table 2 shows the number of available resources by category at each level (basic and specialist). HCs were fairly well equipped with resources for circulation (shock) management but were poorly equipped with resources for airway and breathing management. For specic injuries, they had resources for wound management for extremity injuries but not for fracture management or the other types of injury. RHs were poorly equipped with resources for head, neck, chest, and spinal injuries. Table 3 shows the availability of important resources for resuscitation at HCs and RHs. Some HCs were not well equipped with basic life-saving knowledge/skills. For example, most HCs did not have knowledge/skills on chin lifting or jaw thrust, neck protection to prevent hyperextension or hyperexion, three-way dressing, or pelvic wrapping. Not all HCs were well equipped with essential physical resources, such as needles and syringes, gauze and bandages, pressure cuffs, and stethoscopes. Some important life-saving resources were lacking even at RHs. Chest tube insertion, central venous line insertion, or even needle thoracentesis could not be done in most of the RHs. Table 4 shows the availability of resources for specic injuries. Readily available equipment was lacking at HCs. Most did not have a pocket torch (ashlight) and were not currently equipped with splints, backboards, or sandbags, which they said they could make from local resources if necessary. Not all HCs had basic physical resources such as normal saline solution or tetanus toxoid. Basic skills to prevent spinal injury such as immobilization and log-rolling were lacking in both HCs and RHs. Diagnostic skills were lacking at HCs. Computed tomography (CT) scans, advanced surgical skills, and skills for making burr holes were unavailable in most of the RHs surveyed. At HCs, the mean SD number of available equipment devices was 14.0 3.2 of 29 surveyed, and the mean number of positive answers about knowledge/skills was 20.0 4.6 of 41 questioned. Table 5 shows the results of multiple linear regression analyses. For equipment availability, a 2.7 times greater number of staff (an increment of one in its log-transformed values) was associated with availability of two additional items of equipment with the biggest b value (0.40) in the model; the distance was not signicantly associated. For knowledge/skills, staff members of HCs in low population density areas correctly answered ve or six fewer questions than those in the other areas. A 2.7 times longer distance was associated with 0.8 more correct answers (3.6 times longer distance was associated with one more correct answer). Neither equipment nor knowledge/skill showed an association with the number of referred patients.

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878 Table 1 Characteristics of the examined facilities Characteristic Health centers (n = 85)a No. or median (IQR) Population densityb 119/km2 2049/km2 5099/km2 100?/km2 No. of staff members, median (IQR), (minmax) Doctors (in total) General surgeons Medical assistants Midwives Nurses Pharmacists Economic activities (%)c Agriculture Trading Fishing Livestock Public administration Distance traveled for referral (km)d No. of injured patients during the last 3 months No. of patients referred to higher level hospital during the last 3 months Main causes of injuries (%)c Road trafc injuries Violence Agricultural machine-related Fall Animal bite Landmine Burn Factory machine related IQR interquartile range
a

World J Surg (2009) 33:874885

Referral hospitals (n = 17) No. or median (IQR) Percent or minmax

Percent or min max

10 10 25 40 0 0 1 (12) 3 (35) 0 85 41 35 30 29 20 (1145) 6 (114.5) 0 (03) 02 02 011 018 01 100 48 41 35 34 0135 059 035

2 2 5 8 6 (47) 1 (12) 2 (14) 5 (318) 12 (1137) 01 17 11 7 5 5 115 (50150) 63 (2589) 7.5 (312) 028 05 113 270 7131 07 100 65 41 29 29 40665 10139 016

74 51 47 33 10 8 8 4

88 61 56 39 12 10 10 5

16 13 4 4 5 4 4 1

94 76 24 24 29 24 24 6

One health center (HC) did not give the number of staff and main causes of injuries; both HCs gave no information on both number of patients and number of referred patients 1998 census data The respondents were requested to indicate up to three major economic activities and causes of injuries in their communities For HCs, the distance to the nearest referral hospital (RH); for RHs, the maximum distance to a higher level hospital

b c d

Analyses including HCs with a distance of 0 km from RHs without log-transforming the distance showed the same signicant associations: equipment availability was associated with the number of staff (B = 2.1, CI = 1.0 3.3, b = 0.40); knowledge/skills was associated with the log-transformed distance (B = 0.04, CI = 0.0020.07, b = 0.27) and population density. The association between the distance and equipment availability was weak (B = 0.01, CI = -0.013 to 0.040, b = 0.13, p = 0.33).

Discussion The present study evaluated the availability of resources for trauma care at HCs and RHs based on the criteria designated for the respective levels by the Guidelines and revealed that many of the facilities surveyed did not satisfy the criteria. Important life-saving knowledge/skills that should be available even at basic levels were lacking in most of the facilities, and not all facilities had even the

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World J Surg (2009) 33:874885 Table 2 Number of examined and available essential resources at health centers and referral hospitals Injury Health centers No. of questions on essential resources Airway and breathing Circulation Specic injuries Head, neck, chesta Abdominal injury Extremity injury Spinal injury Total
a b b

879

Referral hospitals Available resources, median (IQR) 2 (22) 12 (1113) 5 (46) 2 (23) 4 (3.04.5) 25.5 (22.027.5) No. of questions on essential resources 19 16 6 7 10 4 62 Available resources, median (IQR) 12 (814) 11 (1011) 1 (14) 4 (15) 6 (49) 1 (01) 35 (2841)

5 15 7 5 5 0 37

No essential resources for neck and chest injuries were included at the health center level Equipment that they could readily make from local materials was rated as 0.5

most basic equipment that is necessary for any health facility. The present study also showed, in multivariate regression analyses, an association between knowledge/ skills at HCs and the distance to an RH, whereas equipment availability was not associated with the distance but was strongly associated with the number of staff; the number of patients was not associated with the availability of any resources. The distribution of resources among HCs did not reect actual needs. Basic knowledge/skills lacking in some HCs and even in RHs, such as a chin lift or jaw thrust, three-way dressing, and pelvic wrapping, are easily learned and effective in saving lives when performed before referring severely injured patients, particularly from areas far from facilities where patients can receive denitive care. Improvement of basic knowledge/skills in many facilities should be given higher priority and integrated into staff training at all levels. For example, introducing an Advanced Trauma Life Support (ATLS) course in RHs would improve their performance [22, 23]; having HC staff work shifts in RHs for a couple of weeks as training could improve their knowledge/skills and might improve communication with RH staff. The supply of essential equipment without which no health facility can function, such as stethoscopes, pressure cuffs, gauze, and bandages, was also far from satisfactory. In some HCs, although not many, stocks were depleted and equipment was lacking. To keep resources functioning, maintenance of durable equipment as well as restocking of consumable supplies should be ensured. Furthermore, equipment that can be easily made with local resources, such as splints and backboards, should be prepared in advance. The absence of these basic items of equipment is attributable to inappropriate planning rather than a lack of funding [11]. Better maintenance and restocking of

physical resources can be achieved through improved organization rather than increased investments. The gap between the need for trauma care resources and their actual distribution, which the present study identied, probably reects predetermined policies that were not exible or responsive. In particular, the decision-making regarding equipment supply was mainly based on the size of the facility, which reected regional population size (a predetermining factor), giving minor or no consideration to geographic characteristics of the areas, injury characteristics and severity, and number of injured patients received and referred. In contrast, the association between the knowledge/skills of HC staff and the distance was signicant; at HCs located farther away from RHs, the staff, who care for severely injured patients until they reach a distant hospital, may have a higher motivation to learn knowledge/ skills. However, this association was not strong; as the regression analysis showed, the increment in knowledge/ skills in relation to the increasing distance was quite small. Furthermore, the staff in remote areas with the lowest population density had by far the least knowledge/skills, probably because the HCs in such areas are usually poorly staffed. Policies for resource allocation should be more responsive to the local need (the distance and the number of patients) to improve the situation. To this end, we may need to adjust the criteria designated by the Guidelines, which are not the absolute standard, to accommodate the local need. Resource allocation based on geographic characteristics would reduce inequalities in access to care. Greater distances to higher-level of care deter referral, increase delays in denitive care, and increase transportation costs, all of which reduce accessibility to quality trauma care [24], resulting in poorer outcomes of injuries because the timely provision of appropriate care can

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880 Table 3 Availability of resources for resuscitation at health centers and referral hospitals

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Injury

Health centers Available No. of valid responses

Referral hospitals Available No. of valid responses

Airway Oral/nasal airway Suction device Bag-valve mask Laryngoscope Chin lift/jaw thrust Neck protectionb Endotracheal intubation Cricothyroidotomy Breathing Stethoscope Oxygen Needle syringe Chest tube Mechanical ventilator Three-way dressing Needle thoracentesis Circulation Blood pressure cuff Gauze and bandage Arterial tourniquet Intravenous uid (crystalloid) Blood transfusion capability Italic values are essential resources at respective levels Hb/Ht hemoglobin/hematocrit
a

14 60 26 17 2 84 4 79 3 0 1 82 81 64 76 1 53 4 68 37

85 85 85 84 84 85 84 85 85 83 83 85 85 85 85 85 85 85 83 81

12a 17 12a 13 6 6 9 6 17 15 16 6a 1 2 3 17 17 15 16 10 17 14 0 14 1

16 17 15 16 14 17 15 17 17 17 17 16 16 16 16 17 17 16 17 17 17 17 16 17 16

Urinary catheter Laboratory tests for Hb/Ht Direct pressure for hemostasis Pelvic wrapping for pelvic fracture Peripheral cutdown access Central venous lines

Asked about skill and knowledge

Prevention of hyperextension/ hyperexion/rotation

prevent death or disability [2426]. We can minimize the response delay by providing more advanced care at the HC and RH levels in more remote areas, where the transfer time to denitive care is quite long and rapid transportation means are not readily available; unlike in high-income countries, helicopter ambulance services are not affordable, and even the ordinary ambulance system is almost nonexistent in remote areas due to resource limitations. Husum et al. showed a successful example of advanced care in remote areas, where the introduction of ATLS skills at the HC level and the organization of rst responder groups in the community could successfully reduce response time and injury mortality in remote areas in Cambodia and northern Iraq [17]. Although an ATLS course at the HC level is far beyond the minimum requirements in the Guidelines, such an adjustment can be

justied in areas with poor access to denitive care. Advanced skills desirable in remote settings may include pleural decompression at HCs and burr holes for head injuries at RHs. The safety of prehospital chest tube placement is controversial, but clinically evident tension pneumothorax should be immediately decompressed using needle thoracocentesis or surgical incision before transfer [27]. In cases when the transfer time to a hospital with a neurosurgical unit is long, intracranial hematoma with evident clinical signs of brain stem dysfunction should be decompressed using a burr hole before transfer. General surgeons can safely perform this technique with appropriate training, protocols, and instruction by a neurosurgeon [2830]. To better understand local needs, such as the number and characteristics of injured patients treated in health

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World J Surg (2009) 33:874885 Table 4 Resources for treatment of specic injuries at health centers and referral hospitals Health centers Available Head injuries Pocket torch Glasgow Coma Scale sheet Reex hammer Intracranial pressure monitoring CT scan Burr holes (skill and equipment) Surgical skill for open depressed skull fracture Neck Contrast radiography (barium meal) Angiography Surgical skill to explore neck Chest Rib block/intrapleural block Pericardiocentesis Repair of lacerated esophagus Abdominal injury Clinical assessment of abdominal injuries Visual examination Percussion Palpation Auscultation Digital rectal examination Diagnostic peritoneal lavage Ultrasonography Bowel resection Extremities injuries Slinga Splinta Radiography Normal saline solution Stock of tetanus toxoid Knowledge of tetanus prophylaxis for wounds Delayed closure Closed reduction Skeletal traction External xation Tendon repair Amputation Spinal injuries Backboarda Sandbaga Immobilization using two sandbags Immobilization using a backboard Log-roll/log-lift How to use two sandbags Cervical traction for spinal injury Surgical treatment of spinal injury No. of valid responses Referral hospitals Available

881

No. of valid responses

31 5 2

84 85 85

2 0 1 0 9 0 0 4 2 2 15 10 12 11 16 15 11 7 6 7 11 2 10 1 0 0

16 15 17 10 16 16 16 17 17 16 17 17 17 17 16 17 15 15 17 17 17 17 17 16 16 16

71 5 67 43 5 57 (7) 53 (42) 1 68 73 74 16 24 6 2 1 44 (36) 19 (14) 16 57 18 15

82 81 82 81 80 84 84 82 84 82 84 84 84 84 84 84 84 84 84 84 84 79

Italic values are essential resources at the respective levels a Numbers in the parentheses indicate health centers that were not equipped but were ready to make the equipment

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Table 5 Correlates of equipment and knowledge at the health center level: multivariate linear regression model Variable Equipment (n = 79)a B Population densityc Low, 09/km2 Lower middle, 2049/km2 Upper middle, 5099/km High, 100?/km2 Distance from RH (log) No. of staff members (log) No. of referred patientsc 0 13 C4 Adjusted R2 Model F P
a 2

Knowledge and skills (n = 78)a,b b B 95% CI b

95% CI

Reference 0.48 0.40 -0.31 0.44 2.1 Reference 0.77 -0.19 0.16 3.1 0.006 -0.77 -1.9 2.3 1.5 0.11 -0.03 -2.3 -1.9 -2.7 -0.13 0.98 3.2 2.7 2.1 1.0 3.3 0.05 0.06 -0.05 0.18 0.40

Reference 5.6 5.7 5.6 0.78 -0.17 Reference 0.61 0.66 0.12 2.5 0.02 -1.4 -1.6 2.6 2.9 0.07 0.07 2.0 2.7 2.5 0.02 -1.7 9.2 8.8 8.8 1.5 1.4 0.48 0.68 0.72 0.24 -0.02

Excluded from the analyses were three health centers (HCs) with a distance of 0 km from the referral hospital, two HCs with missing values in the number of patients, and one HC with a missing value in the number of staff members A HC with a knowledge score of 0 was excluded Categorical variables were entered into the model as dummy variables

b c

facilities, the collection and utilization of reliable facilitybased injury data are necessary [31]. Fortunately, Cambodia already has an injury surveillance system called the Road Trafc Accident and Victim Information System, which currently collects information on road trafc injuries only, but there are plans for it to collect information on all types of injury [3]. Policies on resource allocation, however, have not yet sufciently incorporated the data. The Cambodian government and foreign donors should give higher priority to injury prevention and trauma care when they invest in infrastructure for the purpose of economic development. Injuries occur disproportionately among young people who are economically productive; their deaths and disabilities due to injuries can undermine the effects of such investments. Donors and the government should play a more visible role in establishing an efcient trauma system, not only by increasing the resource allocation to HCs and RHs but by improving the prehospital care system including provision of ambulances. Foreign donors investing in road construction, which results in an increase in road trafc injuries, should consider road safety and improving the trauma system; they could correspondingly allocate even a small portion of their huge investments in these areas. These are important aspects to consider if the goal of economic growth is to be achieved through efcient investment.

Study strengths and limitations To our knowledge, the present study is the rst investigation of trauma care resources in nationally representative samples of HCs and RHs, which also ensures the generalizability of the results to the whole country except for urban areas around Phnom Penh. However, there are some limitations in our study that should be noted. First, the present study did not evaluate trauma patients outcomes (death, disability, hospital stay), which are important indicators of care quality. The association between improved trauma care organization (structure and process) and improved outcomes are well established in high-income countries [32]; therefore, the EsTC project has begun to focus on resource improvements [11]. In addition, the resource allocation structures in low-income countries are often so poor that the patient outcomes may be obvious (e.g., without basic resources such as equipment for chest tube insertions or needle thoracentesis, the outcome of patients with tension pneumothorax will not improve); as such, the lack of the most basic resources is a problem that must be solved. However, we do not deny the necessity of outcome studies to evaluate the effects of the EsTC Project in the future. Such evaluations require quality patient data, which will be obtainable from the nationwide trauma database that is under development in Cambodia.

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Second, we did not use the resource checklist as instructed; we collapsed the four-point scale into a dichotomous one, we omitted some questions based on subjective judgments, and we relied on self-reporting by the staff instead of direct observation. These might have resulted in overestimated resource availability with less precisionalthough in the pilot survey we validated the responses by comparing them with direct observations of the resources. However, despite the possibility of overestimation, the results indicated poor resource availability; meanwhile, overestimation would mean that the reality might be much worse. The four-point scale in the checklist also depends on the raters subjective judgments. Omitting subjective elements would be justiable to reduce biases; we added some questions on specic knowledge/skills to compensate for such omissions. Third, we could not interview the staff of 10 HCs located in the low population density areas, which might have resulted in different results for knowledge/skills between these areas and the other areas. However, because this difference is considered in the multivariate analysis as area differences, this would not distort the association between distance and knowledge/skills.
Table 6 Examined resources at health centers Injury No. of questions Knowledge Airway and breathing Circulation Shock assessment Shock management Head injury Abdominal injury Extremity injury Wound management Fracture management Spinal injury Total 7 (7)a 4 (3) 6 (6)a 5 (5)
a

Conclusions The resources available at HCs and RHs were insufcient. It is necessary to ensure staff training that emphasizes lifesaving knowledge/skills, a sufcient supply of consumable resources, and maintenance of durable equipment. To minimize the gap between resource allocation and need and subsequently to correct inequality in access to trauma care, Cambodia should have clear policies to prioritize remote areas and to allocate resources based on reliable injury data. This way, the Guidelines can clearly show what is lacking at each level of health care and enable us to formulate policies to improve the trauma care system.
Acknowledgments This work was supported by Grants for International Health Cooperation Research (16C-4 and 19C-5) from the Ministry of Health, Labour and Welfare. We thank Ms. Sang Remy, Ms. Keo Socheata, and Ms. In Sok Hoeun for their assistance and support throughout the study.

Appendix See Tables 6 and 7

No. of EsTC items Equipment 8 (1) 11 (5) 3 (1) 5 (2) 2 (0) 29 (9) Knowledge 3 (2) 1 (1) 3 (3) 1 (1) 1 (1) 3 (1) 5 (1) 1 (0) 18 (10) 1 (0) 26 (9) 5 (2) 1 (1) Equipment 8 (1) 11 (5)

No. of non-EsTC items Knowledge 1b 1 2

d

Equipment 2c 1e 3

5 (4)a

5 (2)a 5 (1) 4 (0)

a

41 (28)

Numbers in parentheses indicate essential items at the basic level EsTC essential trauma care
a b c d e

One item in EsTC was subdivided into several questions to obtain detailed information Utilization of forceps for hemostasis (incorrect) Glasgow Coma Scale sheet and reex hammer Log-roll Sandbag

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884 Table 7 Examined resources at referral hospitals (knowledge and equipment combined) Injury Airway and breathing Circulation Head injury Neck injury Chest Abdominal injury Extremity injury Spinal injury Total No. of questions 23 (19) 22 (16) 11 (1)a 6 (2)b 10 (3)c 9 (7)
d

World J Surg (2009) 33:874885 10. Nakahara S, Yi S, Phy R, Sann S (2007) Inequalities in access to trauma care in Cambodia. J Trauma 63(1):247 11. Mock C, Lormand JD, Goosen J, Joshipura M, Peden M (2004) Guidelines for essential trauma care. World Health Organization, Geneva 12. Arreola-Risa C, Mock C, Vega Rivera F, Romero Hicks E, Guzman Solana F, Porras Ramrez G, Montiel Amoroso G, de Boer M (2006) Evaluating trauma care capabilities in Mexico with the World Health Organizations guidelines for essential trauma care publication. Rev Panam Salud Publica 19:94103 13. Son NT, Mock C (2006) Improvements in trauma care capabilities in Vietnam through use of the WHO-IATSIC guidelines for essential trauma care. Int J Inj Contr Saf Promot 13:125127 14. Son NT, Thu NH, Tu NT, Mock C (2007) Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam. Injury 38:10141022 15. Mock C, Nguyen S, Quansah R, Arreola-Risa C, Viradia R, Joshipura M (2006) Evaluation of trauma care capabilities in four countries using the WHO-IATSIC guidelines for essential trauma care. World J Surg 30:946956 16. Okada K et al (2007) Emergency care and EsTC in Viet Nam and utility of the guidelines for essential trauma care. J Jpn Assoc Surg Trauma 21(2):213 (in Japanese) 17. Husum H, Gilbert M, Wisborg T (2003) Training pre-hospital trauma care in low-income countries: the Village University experience. Med Teach 25:142148 18. Nakahara S, Ichikawa M, Kimura A, Yoshida K (2008) The potential for essential trauma care to empower communities and tackle inequities. World J Surg 32:12031207 19. Sethi D, Habibula S, McGee K et al (eds) (2004) Guidelines for conducting community surveys on injury and violence. World Health Organization, Geneva 20. World Health Organization and International Association for Trauma and Surgical Intensive Care (2004) Essential trauma care project: checklists for surveys of trauma care capabilities. World Health Organization and International Association for Trauma and Surgical Intensive Care, Geneva:. Available at: www.who. int/entity/violence_injury_prevention/services/traumacare/estc_ checklist.pdf/. Accessed on 8 Oct 2008 21. Knoke D, Bohrnstedt GW, Mee AP (2002) Multiple regression analysis. In: Statistics for social data analysis, 4th edn. Wadsworth, Belmont, CA, pp 235285 22. Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D, Pitt-Miller P, Stedman M, Winn J, Williams JI (1993) Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma 34:890898 23. Ali J, Adam R, Stedman M, Howard M, Williams JI (1994) Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country. J Trauma 36:391394 24. Watt IS, Sheldon TA (1993) Rurality and resource allocation in the UK. Health Policy 26:1927 25. Sassers S, Varghese M, Kellermann A, Lormand JD (2005) Prehospital trauma care systems. World Health Organization, Geneva 26. Gonzalez RP, Cummings G, Mulekar M, Rodning CB (2006) Increased mortality in rural vehicular trauma: identifying contributing factors through data linkage. J Trauma 61:404409 27. Waydhas C, Sauerland S (2007) Pre-hospital pleural decompression and chest tube placement after blunt trauma: a systematic review. Resuscitation 72:1125 28. Schecter WP, Peper E, Tuatoo V (1985) Can general surgery improve the outcome of the head-injury victim in rural America? A review of the experience in American Samoa. Arch Surg 120:11631166

No. of EsTC items 23 (19) 22 (16) 6 (1) 5 (2) 5 (3) 6 (4) 12 (10) 3 (2) 82 (57)

No. of non-EsTC items 4e 2f 2g 8

12 (10) 5 (4)g 98 (62)

Numbers in parentheses indicate essential items at the health care level a Monitoring of intracranial pressure (ICP) and treatment of elevated ICP were separately asked
b

Availability of contrast radiography and endoscopy were separately asked

Skills of intermediate surgery was investigated with three questions and advanced surgery with two questions d Skills of intermediate surgery was investigated with two questions and advanced surgery with three questions
e

Air ventriculography, neurosurgeon, advice from specialists, and lumber puncture Bronchoscopy and pericardiocentesis

f g

Utilization of sandbag and log-roll were categorized as essential techniques for immobilization

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