كوسشنير جاهزة

Traffic Accident Care at the HEODRA
hospital in the city of León, Nicaragua:

An explorative study on quality of care and its
association to organization, equipment and
resources
Johanna Puhakka
Degree project 30 c, Medicine Program Uppsala University
January 2018
International Maternal and Child Heath (IMCH), Department of Women´s

and Children´s Health, Uppsala University
Universidad Nacional Autónoma de Nicaragua, UNAN-León, Centro de Investigación en
Demografía y Salud, CIDS
Supervisors
Carina Källestål, PhD, Associate Professor, International Maternal and Child Health (IMCH), Women’s and
Children’s Health, Uppsala University, Sweden.
William J. Ugarte Guevara, MD PhD at Centro de Investigación en Demografía y Salud (CIDS), UNAN-León,
Nicaragua. International Maternal and Child Health (IMCH), Department of Women’s and Children’s Health,
Uppsala University, Sweden.
Table of contents
Abstract ....................................................................................................................................... 2
Populärvetenskaplig sammanfattning .......................................................................................... 3
Background ................................................................................................................................. 5
Aim ............................................................................................................................................ 11
Specific objectives ................................................................................................................. 11
Research questions ............................................................................................................... 12
Method ...................................................................................................................................... 12
Setting ................................................................................................................................... 12
Data collection ....................................................................................................................... 12
Study population .................................................................................................................... 14
Data analyses ........................................................................................................................ 14
Ethical consideration .............................................................................................................. 14
Results ...................................................................................................................................... 15
Availability of material for emergency care ............................................................................. 15
Organization of emergency care based on interviews and observation .................................. 15
Traffic accident care observed and assessment of quality of care.......................................... 17
Quality of emergency care and its association to self-assessed theoretical knowledge and
practical skills in trauma care at different professional levels ................................................. 21
Records ................................................................................................................................. 24
Discussion ................................................................................................................................. 26
Organization .......................................................................................................................... 26
Communication ...................................................................................................................... 28
Process.................................................................................................................................. 29
Medical knowledge ................................................................................................................ 30
Methological consideration..................................................................................................... 31
Conclusions and own experiences ......................................................................................... 32
Recommendations ................................................................................................................. 33
Acknowledgements ................................................................................................................... 34
References ................................................................................................................................ 35
Appendix 1: Interview Guide ...................................................................................................... 38
Appendix 2: Checklist ................................................................................................................ 39
Appendix 3: Questionnaire ........................................................................................................ 45
Appendix 4: Inventory List ......................................................................................................... 49
Appendix 5: Time Plan .............................................................................................................. 51
Appendix 6: Complete list of diagnoses ..................................................................................... 52
Appendix 7: Health care characteristics according to checklists ................................................ 55
Appendix 8: Self-assessed knowledge according to questionnaires .......................................... 63
1
Abstract
Background: Traffic accidents are one of the major causes of death worldwide, affecting especially
the younger ages and 90 % accidents happen in low- and middle-income countries. There are
disparities in mortality rates, showing higher death rates in low- and middle-income countries. This
study suggests a theoretical framework on assessment of quality of care for traffic accident victims.
Aim: To investigate and document the quality of emergency care on traffic accident victims and its
association to organization, equipment and resources. Methods: The explorative study at HEODRA
hospital in León, Nicaragua, used the instruments interview guide, checklist, questionnaire and
conducted a retrospective review of records. Records from August and September 2017 were
reviewed according to certain criteria. Results: In total 31 checklists were filled. Most patients
arrived at hospital by own transport. Shortcomings of initial care structure were recorded.
Assessment of airways, shock and spinal injuries were absent in 36 %, 19 % and 100 %
respectively. The overall medical knowledge was good in requested areas.
Conclusions: Overall the requested knowledge, skills and materials for trauma care are available.
Areas for improvement include implementing a structure for the initial care-taking process, easy
access to required equipment and improvement of communication systems.
2
Populärvetenskaplig sammanfattning
Trafikolyckor är en av de vanligaste orsakerna till död globalt och den vanligaste i åldrarna 15–29,
med över 1.2 miljoner människor dödsfall och upp till 50 miljoner skadade. Trafikolyckor beräknas
nu vara den nionde vanligaste dödsorsaken globalt och är ett snabbt växande problem. I låg- och
medelinkomstländer sker 90 % av alla trafikolycksrelaterade dödsfall i världen. Nicaragua är ett
lägre medelinkomstland i Latinamerika som är tungt drabbat av trafikolyckor, med 791 registrerade
trafikolycksorsakade dödsfall år 2016.
Det viktigaste efter en trafikolycka som i högsta grad påverkar patientutfallet är det initiala
omhändertagandet. Kvaliteten på vården är en viktig faktor för överlevnad och skillnader i vård är
en orsak till att fler dör efter trafikolyckor i låg- och medelinkomstländer. Vårdkvalitet kan
definieras på flera sätt och inom forskning diskuteras mycket kring hur det bör mätas.
Syftet med studien är att undersöka och dokumentera den vård som ges efter en trafikolycka och att
värdera vårdkvaliteten på det initiala omhändertagandet på akutmottagningen på sjukhuset
HEODRA i León, Nicaragua.
Datainsamling skedde med hjälp av fyra metoder; frågeguide, checklista, enkäter och journalstudier.
Frågeguiden användes för intervjuer med personal på sjukhuset. Checklistan användes för att mäta
kvaliteten på den initiala vården vid omhändertagandet av patienter efter en trafikolycka. Enkäterna
delades ut till läkare som jobbade på akutmottagningen, där de fick värdera sina färdigheter inom
akutsjukvård. Journalstudierna inkluderade genomgång av alla journaler från augusti och september
2017 med trafikolyckor som inklusionskriterium.
Totalt observerades 31 olycksfall. Alla trafikolycksfall omhändertas initialt på ortoped- eller

kirurgakuten. De flesta patienterna anlände till sjukhuset med egen transport (anhöriga, taxi, gång).
Det initiala omhändertagandet var i nästan hälften av fallen ostrukturerat och många viktiga
undersökningar utfördes inte alls i flera fall (utvärdering av luftvägar, cirkulation, ryggradsskador).
I samtliga fall där ryggbräda och nackkrage användes gjordes detta inkorrekt. Majoriteten av alla
läkare som svarade på enkäten (21) hade både teoretiska och praktiska kunskaper inom de områden
som efterfrågades.
Organisationen av traumavård har enligt erfarenheter från andra länder visats kunna påverka
patientutfallet. Runt om i världen har införandet av traumateam förbättrat dödligheten, men effekten
av detta är dåligt studerat i låg- och medelinkomstländer. På HEODRA-sjukhuset i León, tas de
flesta traumapatienter omhand av nyligen examinerade läkare på kirurg- och ortopedakuten och det
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observerades att struktur saknades vid omhändertagandet. Eftersom införandet av traumateam är
resurskrävande, kan fortbildning av vårdpersonal leda till förbättrad kompetens och organisation av
den initiala vården. Ett led i att uppnå säker och effektiv vård är att etablera goda
kommunikationsmöjligheter med ambulanssjukvården. Dessutom behövs relevanta instrument
finnas nära till hands för att optimera det akuta omhändertagandet. Att etablera ett protokoll att följa
minskar risken att missa kritiska tillstånd samt ger stöd i bedömning och beslutsfattande.
4
Background
The global and Nicaraguan situation concerning road traffic injuries
Road traffic injuries are a leading cause of death globally (1–6). Over 1.2 million people die due to
traffic accidents each year and up to 50 million suffer from non-fatal injuries and other health issues
caused by traffic accidents (2,7). Road traffic injuries are now estimated to be the ninth leading
cause to death globally among all age groups (2). By 2030 it is estimated to possibly become the
seventh leading cause to death if the increase continues with the current speed (2). The heaviest
affected group is those aged 15-29, where road traffic injuries is the leading cause of death globally
(2). Moreover, road traffic injuries is among top three leading causes of death in people aged 5-44
(7). In response to the growing epidemic with fatal injuries due to traffic accidents – and the
positive fact that most accidents are both preventable and predictable (2) – a resolution made by the
United Nations General Assembly in 2010 lead to the establishment of “Decade of Action on Road
Safety 2011-2020” (2,7). Its main goal on national, regional and global levels, is to stabilize the
level of fatalities and eventually reduce the number of forecasted deaths due to crashes (7). All
member states are asked to increase activities including road safety management, road
infrastructure, vehicle safety, road user safety, and post-crash response (7).
Deaths caused by traffic

accidents occur to an extent of
90 % in low- and middle-
income countries (4,7,8) even
though claiming barely half of
the total number of registered
vehicles in the world (2,7).
Figure 1 shows the relationships
between population, deaths due
to traffic accidents and Figure 1. Relationship between population, road traffic deaths and
number of registered vehicles in low-, middle- and high-income
registered vehicles (2). This countries according to “Global status on road safety” by WHO (2).
discrepancy in number of
vehicles and deaths occurring is partially due to rapid motorization together with infrastructural
developments, policy changes and enforcement levels that have lost track (2). This is true especially
in countries with more urgent developmental needs, since road traffic injuries hit hard on the
economics both on a national (health care, insurance and legal systems are heavily burdened) and a
household level (2).
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More importantly, the mortality rates due to traffic
accidents around the world show notable variation, again
striking hardest on low- and middle-income countries (1)
as the death rate per 100 000 population is 24.1 in low-
income countries, compared to 9.2 in high-income
countries (2), as shown in figure 2. There is also a heavy
burden of extremity disabilities in low-income countries
in addition to the high mortality rates (1).
In developed countries the higher survival rates can

partially be explained by access to advanced medical
techniques and high cost equipment (1). Beyond this,
human resources such as staffing and training for
medical personnel as a part of trauma care systems must
be considered. However, a big part of the improvements
Figure 2. Comparison on deaths due to in patient survival is the result of improvements of

road traffic accidents per 100 000
trauma care services organization – a way of improving
population by country income statusa
according to “Global status on road health outcomes that should be affordable in every
safety” by WHO (2).
setting in the world (1).
Nicaragua had a gross national income (GNI) per capita of 2050 US dollars 2016 according to the
World Bank and is classified as a lower middle income country (9,10). Road injuries account for
3,1 % of total deaths in all age groups and both sexes 2016, rising to 11,3 % in ages 5-14 and 10,0
% in ages 15-49 (11). According to a study conducted by WHO on road safety the total number of
fatalities during 2013 reached 577 based on data from the National Police (2). However, no
standardized criteria has been used to define traffic accident deaths and there is a big discrepancy
between the reported fatalities (577) and the estimates made by WHO (931, 95% CI 843-1020) –
indicating a huge underreporting (2). Furthermore, there was a negative trend in reporting of deaths
caused by road traffic, meaning that fewer fatalities due to traffic accidents were reported 2013
compared to 2012 according to data from the National Police (2).
Considering the escalating problem with fatalities due to traffic accidents and the higher mortality
rates in low- and middle-income countries, it becomes important to study the circumstances around
the deaths to find ways to prevent and predict the incidents leading to the most severe and fatal
injuries – which, in most cases is possible; not only to identify the incidents but also to predict and
reduce their severity (3). The most common data sources on injuries around the world are vital
statistics, hospital statistics, police records, occupational statistics, insurance statistics and
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newspapers, with varying availability and reliability (4). Nicaragua is one of the countries lacking
adequate death registration data (2) and has a low coverage in vital statistics (4). Data from different
sources are essential to get a deeper understanding of the road traffic injury situation in general, but
also for predictive and preventive work, system improvements, monitoring of trends and assessing
progress, and comparison (2). In addition, injury data is especially important for the health care
system to be able to evaluate the effectiveness and quality of injury management and treatment as
well as plan for a good trauma care (5). In the case of Nicaragua, it has been shown that police
records are a more valid data source concerning injuries due to traffic accidents compared to
newspapers and data from Ministry of Health (MINSA) (4). The police records were also shown to
provide better quality of information about the circumstances of the injury occurrence, as well as
being valid and reliable for measurement of burden of traffic injury mortality (4). The hospital data
is also considered as one of the more reliable data sources on traffic accident injuries in Nicaragua,
although when compared to the police records they were shown to report more children and non-
motorized users whereas police records over-reported adults and motorized users (4). Neither of
them alone or when linked together cover the injury burden due to traffic accidents adequately (4).
The post-crash response and hospital care
The post-crash response plays a great role for the patient outcome and includes several important
steps such as activation of the prehospital care system, care at the scene, transportation and
emergency care at a hospital or another health care providing unit (12). It is critical to take the
patient as quick as possible to a health care unit that can provide the needed care in order to
minimize time to treatment and therefore increase the chance for a better outcome and to more
effectively utilize limited resources (12). As mentioned above, the organization of trauma care
services accounts for a big part of the improvements seen in patient outcome (1). Also, the
disparities between high-income and low- and middle-income countries have a direct relation to the
level of care given at the scene as well as at a health care facility (2). Effective emergency care is a
crucial part and includes personnel with specific training in emergency and trauma care assigned to
the emergency area or unit, a systematic approach to every injured person, essential equipment for
diagnosis and treatment as well as access to operative care (12). However, studies has implicated
that a lot of patients does not get the recommended care and that medical errors are especially
common among patients with critical conditions – some of them preventable (13).
Quality of care and how it is measured
In order to improve care and identify gaps in quality of care there is a need to in the first place,
collect information and measure quality (13). Quality of care is a complex concept with a variety of
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definitions depending on who is asked (14,15). Donabedian used the following definition back in
1987: “In any given situation, the highest level of quality is represented by the strategy of care that
achieves the greatest improvement in health, within limits of current knowledge and the patient’s
capacity to improve; within these same limits, lesser degrees of improvement represent
proportionately lower levels of quality” (16). Campbell et al. use the definition of quality of care for
single individuals “whether individuals can access the health structures and processes which they
need and whether the care received is effective” (14). Here it is claimed that quality comprises the
two domains access and effectiveness (14). Another definition of medical quality is ‘‘the care health
professionals would want to receive if they got sick’’ (15). According to Institute of Medicine the
core of health care quality comprises the following six areas: safe (avoiding harm), effective (on
scientific basis selecting patients who are likely to benefit from the care and those who are not),
patient-centered (respectful and responsive to the individual’s preferences, needs, values etc.),
timely (reducing waits), efficient (minimizing waste of any kind, including equipment, supplies
etc.), and equitable i.e. same care to every individual (17–19). Of these factors safety and
effectiveness have been addressed more often than others (18). Unfortunately, there is no
standardized model for measuring the single components of quality of care, and, in addition, the
different quality areas requires different methodical approaches when measured (14).
Good emergency care has been described with the following seven criteria: 1) available around the
clock seven days a week, 2) convenient and easy to access, 3) patient-centered, 4) timely and
consistent, 5) right on first time, 6) results in good clinical outcome considering recovery, survival
and lack of unfavorable events, and 7) a good experience for the patient (20). Quality indicators can
serve as a guide in clinical settings to measure quality of care, but should not be a limiting factor in
obtaining quality of care since all aspect of health care should be considered (19). Time has
commonly been used as a quality indicator in emergency medicine, in terms of waiting times but
also transit times to a health care facility, time to assessment and to treatment (19–21). Pain control
is another suggested quality indicator that is directly linked to the given care; unplanned re-
attenders can indicate poor or missed diagnosis, a condition that is getting worse or a unrelated
second condition, and has been suggested as a quality indicator in emergency medicine (20). Safety
is one of the most commonly assessed areas in quality of care generally (18) and an aspect of this is
patients who leave the emergency department without been seen by a health care professional
(20,21). In addition, complaints, service experience, performing evidence-based medicine,
satisfaction among staff and trainees and seniors signing off are factors suggested to affect the
quality of emergency care (20). Back in 1987, many of these factors were already mentioned by
Donabedian et al. as attributes for quality assessment in a hospital emergency setting (16), seen in
its whole in box 1.
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Box 1. Attributes for evaluation for quality assessment according to Donabedian
et al. (16).
1. Expeditiousness, timeliness, and duration of care.
2. Appropriateness of diagnostic and therapeutic interventions as judged by the greatest net
benefit at lowest cost.
3. The validity of diagnostic tools.
4. Skill in the execution of diagnostic and therapeutic interventions.
5. Reliability and validity of diagnostic information and monitoring data.
6. Appropriateness of referral.
7. Maintenance of continuity in care through successful linkage with, and transfer of
adequate information to, a more stable source of care.
8. Appropriate recording and management of information.
9. Patient education and motivation with view to prevention.
10. Discharge of legitimate organizational and social obligations with due to regard to
responsibilities toward individual patients.
Investigations made in Thailand on trauma quality improvement identified several common

problem areas, such as delayed or inadequate diagnosis, inadequate resuscitation, airway
management and administration of intravenous fluids and delays in operative care to mention a few
(22). Care of good quality needs both human resources and physical resources as well as a well-
functioning organization (1). In Thailand the solutions to the identified problems were, among
others, to have senior surgeons stationed at the emergency department during the busiest hours to
better be able to supervise younger colleagues, and the establishment of an emergency physician
program and a trauma team that quickly can be at the scene to help at the emergency department
when needed (22). In Nicaragua, according to data from 2013, a training for doctors in medical
emergency is available, i.e. a residency program or a specialist certification in emergency medicine
(23). No data is available on if a similar training exists for nurses (23). However, the post-crash
response starts already at the scene, before reaching the hospital or other health care facility,
provided optimally by a system allowing a rapid response with adequately equipped ambulances
with trained health care providers (12). The prehospital responders in Nicaragua do not have
sufficient staffing and have low access to adequate equipment and resources in order to provide
health care of high quality (24,25). It has been suggested that implementation of prehospital care in
low- and middle-income countries can reduce the risk of death by as much as 25 % in injured
patients (12).
The elements of essential trauma care
Three main areas have been suggested as the basic needs for the patient in an emergent situation,
namely 1) appropriate treatment of life-threatening injuries, 2) appropriate treatment of injuries that
9
are potentially disabling to minimize impairment and 3) minimizing pain and physiological
suffering (1). Within these three categories several specific goals can be identified; opening of
obstructed airways, supporting impaired breathing, recognition and reliving of pneumothorax and
hemothorax, stopping of bleeding, recognition and treatment of shock, appropriate management of
traumatic brain injuries, recognition and repairment of abdominal injuries, correct management of
potentially unstable spinal cord, treating pain etc. (1). To assess and fulfill these goals effectively
one can use the model of ABCDE (airways, breathing, circulation, disability, exposure), a structural
concept on initial assessment of patients in acute situations, available in several versions but all with
the same base and intent (26,27). In addition, several courses on practicing trauma care are available
around the world to train health care workers in the essential parts when attending trauma patients
(1). Improving trauma care organization has been shown to be effective in lowering mortality rates
and shortening times to important treatment and actions; several examples can be mentioned from
around the world (6,22). In this study the WHO “Guidelines for essential trauma care” (1) have
been used to assess the quality of care according to the essential human and physical resources
needed to fulfill the above mentioned goals on a specialist level of care.
Theoretical framework on assessment of quality of care in an emergency setting
There is a lack of defined evidence-based, universally accepted quality indicators in emergency

medicine (13) and as stated above there are various definitions of quality of care (14,15). The below
shown theoretical framework (Fig. 3) is in most parts developed from observations made during the
study as well as from influences from the Donabedian model of quality of care (14,28) and “Quality
Indicators in Emergency Medicine” (20). It suggests four main components essential for good
quality of care; organization, communication, process and medical knowledge. The organization is
suggested to contribute to quality of care by organizational work such as planning for sufficient
staffing at the emergency room, a plan for younger colleagues to get help when needed, aiming at a
system for cooperation with prehospital workers etc. The communication refers to the reporting and
communication between prehospital and hospital staff, between colleagues at the emergency room
during and after the care taking process, as well as the communication to patients and relatives. But
it also refers to communication to higher levels from the staff on the working environment, staffing,
suggestions of improvements, changes and so on. The process refers to the care-giving process, i.e.
what is done, who is doing it, how it is done, what equipment is available, what diagnostic tools are
available, the diagnostic process etc. The medical knowledge is essential for practicing evidence-
based medicine as well as it is a practical skill and part of being able to do clinical assessments,
evaluations and decision-making. This education starts in medical school and continues for the rest
of the working career.
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Figure 3. Theoretical framework on quality of care partly inspired from the Donabedian model (14,28) and
“Quality Indicators in Emergency Medicine” (20) showing the four main characteristics of quality of care and
examples of what can be included in each of the four main characteristics. Included are also arrows showing
the study’s data collection methods in which each of the characteristics has been evaluated with examples of
variables.
Aim
The main aim is to investigate and document the trauma care on patients suffering from traffic
accident injuries and to assess the quality of emergency care using WHO guidelines for trauma care
as benchmark.
Specific objectives
➢ To document what equipment is accessible at the emergency department and how it is used
➢ To describe the organization of the emergency care with focus on traumas due to traffic
accidents
➢ To describe the physicians self-assessed theoretical knowledge and practical skills in trauma
care
➢ Assess the quality of emergency care using WHO “Guidelines for essential trauma care” (1)
and its association to level of organization, equipment, knowledge and skills in the
emergency care in HEODRA, León, Nicaragua
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Research questions
What is the quality of hospital traffic accident trauma care and how is it associated to given
available organization, equipment and resources?
Method
This study is a mixed method explorative study taking place at the HEODRA hospital in the city of
León, Nicaragua, mainly at the emergency department between 25th September to 10th November
2017. The theoretical framework presented in the introduction has been used to evaluate and assess
the quality of care in the setting of the emergency room at the HEODRA hospital in León,
Nicaragua. Four main data collection methods were used; interview guide (Appendix 1), checklist
(Appendix 2), questionnaire (Appendix 3) and retrospective reviews of records. Both the checklist
and the questionnaire are based on a WHO report (1) and were piloted to best suit the demands of
this study and its specific settings.
Setting
Situated in Central America, Nicaragua is one of the least developed countries in the area. With its
6 million inhabitants (2015) access to basic services remains a daily challenge. What is positive
though, is that general poverty dropped from 42,5 % to 29,6 % in five years (2009-2014) and the
growth levels are generally higher compared to other countries in Latin America and the Caribbean,
still, poverty levels remain high (29).
León is the second largest city and urban center in Nicaragua, located in the northwest part of the
country about 90 km from the capital Managua. In the municipality of León there is one public
hospital named Hospital Escuela Dr. Oskar Danilo Rosales Argüello (HEODRA), which is also a
teaching hospital (4).
This study is part of a bigger ongoing project run by CIDS, UNAN-León (Center for Research on
Demography and Health, Autonomous University León, Nicaragua) together with the Pan-
American Health Organization (PAHO), Ministry of Health (MINSA) and the National Police. This
study will concentrate on the care given at the emergency room at the HEODRA hospital in León.
Data collection
Data collection took part at the emergency department at HEODRA hospital in the city of León.
Data was collected mainly through four instruments in addition to general observations; 1)
interview guide, 2) checklist, 3) questionnaire, and 4) retrospective reviews of records criteria.
1) The interview guide was used to serve as a basis for discussion at interviews conducted with
the subdirector, a surgeon and an orthopedist at the emergency department at the HEODRA
hospital, León. The interview guide consisted of in total ten questions and its purpose was to
12
gain information and deeper knowledge about the organization of the emergency care. The
questions were asked in Spanish, notes were taken and translated to English.
2) The checklist is based on a WHO report (1), where the criteria considered as “essential” for
specialist care has been extracted from relevant tables (tables 7, 10, 11, 12, 13, 14 have been
excluded). Some additions (a first page and the table called “Basic care”) and minor
adjustments were done after piloting the checklist. The checklist was used to evaluate the
actual given care, and to assess its quality, on each patient attending the emergency unit due
to a traffic accident trauma. Each of the questions in the table “Basic care” were answered
by “yes”, “no” or “non-applicable” and the rest assessed as “non-applicable” (not relevant
for the case), “absent” (required but not performed), “partially adequate” (performed but not
correctly) and “adequate” (performed correctly). There is also an inventory list (Appendix 4)
based on the tables named “Equipment and supplies” in the checklist to gain deeper insight
to what resources are available and, together with the checklist, investigate if they were used
correctly or not. The inventory list was filled once during the study period.
3) The questionnaire is a complement to the checklist and consists of 61 statements from the
tables named “Knowledge and skills” and “Resources” from the checklist that were
translated to Spanish. The questionnaires were handed personally to the physicians working
at the surgery and orthopedic emergency units at the HEODRA hospital, León, during the
planned working shifts for the study (Appendix 5). In total 21 answered and 3 physicians
did not participate due to busy working shifts. They were asked to answer “yes” or “no” to
what theoretical knowledge and practical skills they themselves considered to have in the
requested areas.
4) The records were retrospectively reviewed according to specific criteria. All records from
the emergency department during August 1st – September 30th 2017 was sorted through
manually, and all records with traffic accident traumas were selected and further reviewed.
The inclusion criteria were any type of injury due to a traffic accident. The following data
was collected; age, sex, diagnosis, severity of injury, total time spent in the emergency
department, total time of care, outcome of care and medical competence and specialty of the
care-taking physician (intern, resident, specialist). In total 3 243 records were reviewed, 1
784 from August and 1 459 from September 2017. In the case of the hospitalized patients
during the same period, the number of patients was first extracted from a database at the
hospital statistical office and the records were then found at the admission center. Totally 18
patients were hospitalized according to data collected from the statistical office. The records
from five patients could not be found in the data system. Of the remaining 13 patients the
records from four patients could not be found in the admission center and one was
13
hospitalized in March 2017 and did therefore not meet the inclusion criteria. The remaining
eight records were reviewed and the following data was collected: age, gender, dates of
hospitalization, diagnosis, reason to hospitalization, use of severity scoring system and
admitting clinic. In addition, some general observations were made when reviewing these
records, described in the results under “Records – observations during reviewing”.
Study population
Interviews were conducted with the subdirector, a surgeon and an orthopedist at the HEODRA
hospital.
For the checklists all patients suffering from injuries due to traffic accidents, whether direct or
indirect injuries, that needed medical care at the emergency department (surgery and orthopedic
units) at the HEODRA hospital in León during the scheduled shifts during October 2nd – November
4th 2017 (Appendix 5) were included in the study. Patients who perished before reaching the
hospital were excluded.
Physicians (interns, residents, specialists) working at the surgery and orthopedic emergency units
during the scheduled shifts were asked to fill in the questionnaire.
Data analyses
The interviews and the general observations made during the data collection is described by a
narrative telling the general structure and organization of the emergency care of traffic accident
patients at HEODRA hospital, León, Nicaragua.
The results from questionnaires, checklists and records is analyzed by descriptive statistics using the
R commander program (30).
Ethical consideration
The study was conducted according to the Helsinki Declaration (31). An ethical approval was
obtained from the ethical review board of medical research at UNAN-León, Nicaragua
(FWA00004523/IRB00003342 ACTA No. 51).
The personnel working at the emergency room at the HEODRA hospital was given oral information
about the study in Spanish via translators and also written information in Spanish. The information
was on the aim of the study, which was to collect knowledge about the care given to persons
suffering from traffic accidents as a base for future research and interventions. No names were
collected, and confidentiality was ensured by coded data. Participation was voluntary and could be
ended at any time without explanation.
14
Results
Availability of material for emergency care
The inventory list was filled once during the study period together with the head nurse responsible
for all materials. Table 1 shows results from the inventory. (Total list can be seen in appendix 4).
Table 1. Availability of material at the emergency department in HEODRA hospital, León,

Nicaragua
Basic care Yes No Airways: Equipment Yes No Circulation: Equipment Yes No
and supplies and supplies
Hand disinfectant X Oral or nasal airway X FLUID RESISCUTATION
Gloves X Suction device: at least X Crystalloid X

manual (bulb) or foot
pump
Thermometer X Suction tubing X Blood transfusion X
capabilities
Clock or watch X Yankauer or other stiff X Intravenous infusion set X
suction tip (lines and cannulas)
Face mask X Laryngoscope X Intraosseous needle or X
equivalent
Stethoscope X Endotracheal tube X Central venous lines X
Saturation monitor X Oesophageal detector X MONITORING
device
Oxygen X Bag-valve-mask X Urinary catheter X
Blood pressure X Basic trauma pack X Laboratory facilities for X
hemoglobin or hematocrit
C-collar X Magill forceps X OTHERS
Gauze and X Breathing: equipment Nasogastric (NG) tube X
bandage and supplies
Arterial tourniquet in X Nasal prongs, face X Weighing scale for X*
extreme situations mask, associated children
tubing
Spine board X Needle and syringe X *(only in pediatrics)
Chest tubes X
Underwater seal bottle X
(or equivalent)
Inventory date: 2017-10-12
Organization of emergency care based on interviews and observation

The emergency department at the HEODRA hospital consists of six units, gynecology, orthopedic,
surgery, pediatrics, internal medicine and UAF (unit for attention of febrile patients). The UAF-unit
is recently established and always has a specialist attending patients with fever. Common
diagnostics that UAF deals with are malaria, dengue fever, chikungunya and zica-virus. All traffic
accidents are taken care of in the surgery and orthopedic units. Minor traumas such as mild
fractures usually go directly to the orthopedics unit, while multiple and/or major traumas pass
directly to the surgery unit. Severe head traumas are transported to the capital Managua, where the
hospitals have access to more advanced diagnostic tools, such as a CT-scan (computer-tomography)
and EEG (electroencephalography). The HEODRA hospital has access only to an X-ray device as
well as an ultra sound device.
Generally, there are one surgeon and one physician in training (resident) working at the surgery
unit. In the orthopedic unit there are one orthopedist and two residents. In addition, there are
15
generally one intern in each of the surgery and orthopedic units as well as one nurse working for
both units. The shifts during weekdays are divided into three; morning shift (7 am – 3 pm), evening
shift (3 pm – 9 pm) and night shift (9 pm – 7 am). The shifts during weekends are longer. Totally
there are 25 physicians (interns not included) rotating monthly at the emergency departments, the
operating theater as well as the different hospital clinics.
Approximately 120 patients attend the surgery unit each day (all causes). During a weekday there
are 1-3 traffic accidents and 5-10 a day in a weekend attending the surgery unit. Severe traumas are
seen 3-5 times a month. The orthopedic unit has about 30 patients in a week attending for traffic
accidents. The surgery and orthopedic emergency units share eight beds for observation for a
maximum time of 24 hours. There is an intensive care unit and two operational theaters at the
hospital.
There is no trauma team available at the hospital. According to the subdirector and surgeon
interviewed ATLS (Advanced Trauma Life Support)-principles are well known and used among the
physicians at the surgery emergency department when attending trauma patients. National as well as
regional simulations trainings are held two to three times a year for health care professionals
(physicians, nurses, prehospital workers, orderlies) as well as patients and the general population to
prepare for natural disasters (earthquakes, extreme rain, fires, floods and so on). Different
committees are responsible for arranging the simulations.
Observations
Most of the times the patients suffering from traffic accidents are attended immediately by the
working physician, especially when the patient arrived by any of the prehospital organizations
(Voluntary Firefighters, Red Cross, National Firefighters) or the Police. First, it is notable that little
or no reporting take place upon arrival. Important findings during the transportation are seldom
shared, with the risk of delaying care or even missing diagnoses. Second, there is no general use of
a triage system. Generally, the patients are attended in the order they arrive to the hospital. In the
case of several trauma patients arriving simultaneously the most severe is prioritized. A practical
problem is that the emergency room does not fit many patients at the same time, making it
challenging to work effectively and difficult to have an overview of the patients. On the other hand,
residents and specialists are quickly at the scene in case of severe traumas and/or many victims at
the same time when more personnel and more competence are needed. Notably, there is generally
no or little respect for personal integrity and privacy even in situations when it would have been
possible.
16
The assessment of the patient is seldom structured according to ATLS-principles, ABCDE (Airway,
Breathing, Circulation, Disability, Exposure) or similar, but generally include the most important
factors at some point. Upon arrival many patients come on a spine board and has a C-collar, though
incorrectly used. Even more alarming, some patients did not arrive on a spine board or with a C-
collar in cases they should have (high energy trauma etc.). In every single case during the
observation period no neurological assessment was made before releasing the C-collar or taking
away the spine board.
Traffic accident care observed and assessment of quality of care

One checklist was filled in for every injured person that
25,8
arrived at the emergency unit during the scheduled FEMALE:
26,3
working shifts. Totally 31 checklists were filled in,
74,2
MALE:
equaling 31 patients and 26 accidents. The data is based 73,7
on observations during the care-giving process, 0 20 40 60 80
completed with questions to the nurse and/or doctor if Checklist Records
needed.
Figure 4. Sex proportions (%) of traffic
accident victims according to data from
Of the patients suffering from traffic accidents and checklists and records.
attending the emergency room 74,2 % were men and
50
25,8 % females, similar proportions as in the data
40
Poportion (%)
collected from the records (Fig. 4). The mean age was 30
31,1 (median 27,0, min 14,0, max 60,0) years, similar 20

10
for data collected from emergencies and records. The
0
type of accident was distributed as follows: 16/31 (51,6
%) by motorcycle, 9/31 (29,0 %) by car, 1/31 (3,2 %)
pedestrian, and 5/31 (16,1 %) by bicycle. Most patients
arrived at the hospital by own transport, i.e. taxi, by
familiars, walking etc. followed by transport by Figure 5. Transportation to hospital.
Voluntary Firefighters and Red Cross (Fig. 5) and the
9,7% 6,4%
3,2%
mean time from accident to arrival was 45 minutes Nurse
(median 27, min 7, max 342 minutes). The mean Medical

student
waiting time was 6,7 minutes (median 0, min 0, max 60 Intern
32,2%
minutes) and the mean total time in emergency Resident

48,4%
department was 100 minutes (median 83, min 20, max Specialist
225 minutes). Most accidents, 22/31 (71,0 %), occurred
in the evening and 9/31 (29,0 %) in the night (data not Figure 6. First care-taking person upon
arrival at emergency room.
17
shown). The accidents observed during the study period occurred on weekends and was primarily
taken care of by an intern (48,4 %) or by a resident (32,2 %) (Fig. 6). The emergency unit that the
patient attended primarily was the surgery unit (77,4 %) and the main outcomes were going home
or observation differing between observed emergencies and records, where going home with or
without medicines were the most common outcomes (Fig. 7). Use of a trauma severity scoring
system could not be observed in any of the emergencies, and 91/95 (95,8 %) of the cases according
to the records did not report any trauma severity score.
The most common diagnoses according to the checklists were wounds (35,5 %) followed by
fractures (32,2 %) and head trauma (12,9 %), compared to the most common diagnoses groups
collected from the records; head trauma (23,1 %), contusion (22,1 %) and polytrauma (21,0 %),
80 50
Proportion (%)
70
Proportion (%)
40
60
50 30
40
20
30
20 10
10
0
0
Records Checklist Records Checklists
Figure 7. Emergency unit and main outcomes according to records and checklists.
Missing:
Trauma thorax/back:
Pain/hematoma:
Diagnosis group
Contusion:
Fracture/fissure:
Wounds:
Extremity injury:
Head trauma:
Polytrauma:
0 5 10 15 20 25 30 35 40
Proportion (%)
CHECKLIST RECORDS
Figure 8. Proportion of diagnoses according to data collection methods through checklist and records.
18
shown in figure 8. A complete list of diagnoses according to data from checklists and records
respectively can be seen in table 6 and table 7 in appendix 6.
In one case of the total 31, the person taking care of the patient washed hands before attending the
patient. None of the health care professionals used hand disinfectant. Hand gloves was used in
20/31 (64,5 %) and not used in 6/31 (19,3 %). Use of thermometer, clock or watch as well as face
mask were not applicable in most cases.
In 11/31 (35,5 %) the initial given care followed some structure but not perfectly according to
ATLS or ABCDE, while 14/31 (45,2 %) did not follow any structure (Table 2). Assessment of
airway compromise was absent in 11/31 (35,5 %) and assessment of respiratory distress and
adequacy of ventilation absent in 12/31 (38,7 %) (Fig. 9). Only one patient (3,2 %) was
administrated oxygen while in 7/31 (22,6 %) it would have been desirable (Table 2). None of the
patients needed actions such as manual maneuvers to help keep the airway open, oral or nasal
airways, assisted ventilation with bag-valve-mask and in only one case the use of suction would
have been desirable (data not shown). Assessment of shock was adequately done in 7/31 (22,6 %)
and absent in 6/31 (19,3 %) (Fig. 9). Compression for controlling hemorrhage was adequately and
partially adequately done in 2/31 (6,4 %) respectively but non-applicable in 27/31 (87,1 %) of the
cases (data not shown). The majority of patients, 22/31 (71,0 %), got a peripheral intravenous
access and intravenous fluids (data not shown). Recognition of altered consciousness was absent in
8/31 (25,8 %) of the cases and none of the patients were assessed in order to recognize presence or
risk for spinal injury (Fig. 9). General for all cases was also that immobilization equipment (C-
collar and spine board) were incorrectly used in all cases and absent in 5/31 (16,1 %) (Fig. 9).
Immobilization: C-collar, backboard
Assessment – recognition of presence or

risk of spinal injury
Recognition of neurovascular compromise;
disability-prone injuries
Recognize altered consciousness;
lateralizing signs, pupils Adequate
Partially adequate
Assessment of shock
Absent
Assessment of respiratory distress and
adequacy of ventilation Non-applicable
Assessment of airway compromise
0 20 40 60
Figure 9. Proportions of care given to patients and assessment of the quality according to checklists.
19
For the full list of characteristics of the health care given see table 8 in appendix 7. The
characteristics in table 2 and figure 9 have been selected and extracted from the original tables
according to the principle of ABCDE, i.e. what is considered as most important for the patient in an
emergent situation.
Table 2. Characteristics of instruments, material and health care given to patients at the
emergency room according to checklists.
n/N (%)
Stethoscope No 5/31 (16,1)
Yes 22/31 (71,0)
Non-applicable 4/31 (12,9)
Missing 0/31 (0,0)
Saturation monitor No 13/31 (41,9)
Yes 13/31 (41,9)
Missing 1/31 (3,2)
Oxygen No 12/31 (38,7)
Yes 1/31 (3,2)
Missing 1/31 (3,2)
Blood pressure No 6/31 (19,3)
Yes 21/31 (67,7)
Missing 0/31 (0,0)
C-collar No 7/31 (22,6)
Yes 7/31 (22,6)
Missing 0/31 (0,0)
Spine board No 5/31 (16,1)
Yes 8/31 (25,8)
Missing 0/31 (0,0)
Pain control No 12/31 (38,7)
Yes 4/31 (12,9)
Missing 5/31 (16,1)
Follow ATLS/ABCDE No 14/31 (45,2)
Yes 11/31 (35,5)
Missing 1/31 (3,2)
Administration of oxygen Non-applicable 23/31 (74,2)
Absent 7/31 (22,6)
Partially adequate 0/31 (0,0)
Adequate 1/31 (3,2)
Missing 0/31 (0,0)
Urinary catheter Non-applicable 16/31 (51,6)
Absent 8/31 (25,8)
Adequate 6/31 (19,3)
Missing 0/31 (0,0)
Laboratory facilities for hemoglobin or hematocrit Non-applicable 13/31 (41,9)
Absent 0/31 (0,0)
Adequate 18/31 (58,1)
Missing 0/31 (0,0)
Basic immobilization (sling, splint) Non-applicable 19/31 (61,3)
Absent 3/31 (9,7)
Missing 0/31 (0,0)
Monitoring of neurological function Non-applicable 24/31 (77,4)
Absent 5/31 (16,1)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
20
Quality of emergency care and its association to self-assessed theoretical knowledge and practical
skills in trauma care at different professional levels
Totally 21 physicians responded to the questionnaire; 11 from the orthopedic and 10 from the
surgery section. The level of competence varied from interns (9) to residents (10) and specialists
(2). The questions were assessed according to theoretical knowledge and practical skills.
Table 3 shows the variables and the frequencies of the self-assessed theoretical knowledge and
practical skills both in total and divided on each competence level. In the table a sample of the
statements have been selected and extracted from the full list of questions that can be seen in its
total in table 9, appendix 8. The inclusion criteria for the statements were those considered
important for the patient in the acute situation from a medical perspective according to ABCDE-
structure.
Table 4 shows characteristics of the health care given assessed through checklists compared to the
self-assessed theoretical knowledge and practical skills among the doctors working at the
emergency room. The selection of statements from the original full list were done according to
which ones were considered as the most important for the health care in an acute situation.
The theoretical knowledge on assessing airway compromise was 20/21 (95,2 %) but 2/21 (9,5 %)
lack the practical skills. Likewise, 2/21 (9,5 %) lack theoretical knowledge and 3/21 (14,3 %) the
practical skills regarding assessment of respiratory distress and adequacy of ventilation. Concerning
shock and its assessment the majority have both the theoretical and practical knowledge, 1/21 (4,8
%) and 3/21 (14,3 %) lack theoretical knowledge and practical skills respectively. Recognition of
altered consciousness was absent in 8/31 (25,8 %) of the cases but only 3/21 (14,3 %) lack
theoretical knowledge and 4/21 (19,0 %) the requested practical skills. Total 17/21 (81,0 %)
considered themselves to have both the theoretical knowledge and practical skills on recognizing
changed degree of consciousness.
The two single statements with the highest frequency of missing theoretical knowledge and/or
practical skills were “Spine-board” and “Use of suction”. Also “Insertion of oral or nasal airway”
had high frequency of reported lack of practical skills as shown in Table 3 and 4.
21
Table 3. Self-assessed theoretical knowledge and practical skills on different medical
areas extracted from the questionnaires according to the ABCDE-principles, showing
frequencies in total as well as divided into each professional level (int = intern, res =
resident, spe = specialist).
Theoretical knowledge Physician Practical skills Physician
INT RES SPE INT RES SPE
n/N (%) N=9 N=10 N=2 n/N (%) N=9 N=10 N=2
Assessment of No 0/21 (0,0) 0 0 0 No 2/21 (9,5) 1 1 0
airway Yes 20/21 (95,2) 8 10 2 Yes 19/21 (90,5) 8 9 2
compromise Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
Manual No 0/21 (0,0) 0 0 0 No 3/21 (14,3) 2 1 0
maneuvers (chin Yes 20/21 (95,2) 8 10 2 Yes 18/21 (85,7) 7 9 2
lift, jaw thrust, Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
recovery
position etc.)
Insertion of oral No 1/21 (4,8) 0 1 0 No 7/21 (33,3) 3 4 0
or nasal airway Yes 19/21 (90,5) 8 9 2 Yes 13/21 (61,9) 5 6 2
Missing 1/21 (4,8) 1 0 0 Missing 1/21 (4,8) 1 0 0
Use of suction No 4/21 (19,0) 2 2 0 No 9/21 (42,8) 6 3 0
Yes 16/21 (76,2) 6 8 2 Yes 11/21 (52,4) 2 7 2
Missing 1/21 (4,8) 1 0 0 Missing 1/21 (4,8) 1 0 0
Assisted No 0/21 (0,0) 0 0 0 No 4/21 (19,0) 2 2 0
ventilation using Yes 21/21 (100,0) 9 10 2 Yes 16/21 (76,2) 6 8 2
bag-valve-mask Missing 0/21 (0,0) 0 0 0 Missing 1/21 (4,8) 1 0 0
respiratory Yes 18/21 (85,7) 7 9 2 Yes 17/21 (81,0) 7 8 2
distress and Missing 1/21 (4,8) 1 0 0 Missing 0/21 (4,8) 0 0 0
adequacy of
ventilation
Administration No 0/21 (0,0) 0 0 0 No 1/21 (4,8) 1 0 0
of oxygen Yes 20/21 (95,2) 8 10 2 Yes 20/21 (95,2) 8 10 2
Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
shock Yes 19/21 (90,5) 7 10 2 Yes 18/21 (85,7) 6 10 2
Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
Compression for No 0/21 (0,0) 0 0 0 No 2/21 (9,5) 2 0 0
control of Yes 20/21 (95,2) 8 10 2 Yes 19/21 (90,5) 7 10 2
haemorrhage Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
Peripheral No 2/21 (9,5) 2 0 0 No 2/21 (9,5) 2 0 0
percutaneous Yes 19/21 (90,5) 7 10 2 Yes 18/21 (85,7) 6 10 2
intravenous Missing 0/21 (0,0) 0 0 0 Missing 1/21 (4,8) 1 0 0
access
Recognize No 3/21 (14,3) 2 1 0 No 4/21 (19,0) 2 2 0
altered Yes 17/21 (81,0) 6 9 2 Yes 17/21 (81,0) 7 8 2
consciousness; Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
lateralizing
signs, pupils
Recognition of No 5/21 (23,8) 3 2 0 No 11/21 (52,4) 7 3 1
neurovascular Yes 16/21 (76,2) 6 8 2 Yes 9/21 (42,8) 1 7 1
compromise; Missing 0/21 (0,0) 0 0 0 Missing 1/21 (4,8) 1 0 0
disability-prone
injuries
Basic No 0/21 (0,0) 0 0 0 No 3/21 (14,3) 3 0 0
immobilization Yes 20/21 (95,2) 8 10 2 Yes 18/21 (85,7) 6 10 2
(sling, splint) Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
Spine board No 6/21 (28,6) 3 3 0 No 11/21 (52,4) 6 4 1
Yes 15/21 (71,4) 6 7 2 Yes 9/21 (42,8) 2 6 1
Missing 0/21 (0,0) 0 0 0 Missing 1/21 (4,8) 1 0 0
Assessment – No 2/21 (9,5) 1 1 0 No 4/21 (19,0) 3 1 0
recognition of Yes 19/21 (90,5) 8 9 2 Yes 16/21 (76,2) 5 9 2
presence or risk Missing 0/21 (0,0) 0 0 0 Missing 1/21 (4,8) 1 0 0
of spinal injury
Immobilization: No 3/21 (14,3) 2 1 0 No 5/21 (23,8) 4 1 0
C-collar, Yes 17/21 (81,0) 6 9 2 Yes 16/21 (76,2) 5 9 2
backboard Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
Monitoring of No 3/21 (14,3) 2 1 0 No 4/21 (19,0) 3 1 0
neurological Yes 17/21 (81,0) 6 9 2 Yes 17/21 (81,0) 6 9 2
function Missing 1/21 (4,8) 1 0 0 Missing 0/21 (0,0) 0 0 0
22
Table 4. Assessment on health care quality given to patients at the emergency room
according to variables extracted from the original checklist following ABCDE-principles
compared with the physician’s self-assessed theoretical knowledge and practical skills in
the same areas according to questionnaires.
CHECKLISTS (N = 31) QUESTIONNAIRES (N = 21)
Theoretical knowledge Practical skills
n/N (%) n/N (%) n/N (%)
Spine board No 5/31 (16,1) No 6/21 (28,6) No 11/21 (52,4)
Yes 8/31 (25,8) Yes 15/21 (71,4) Yes 9/21 (42,8)
Non-applicable 18/31 (58,1) Missing 0/21 (0,0) Missing 1/21 (4,8)
Missing 0/31 (0,0)
Assessment of Non-applicable 5/31 (16,1) No 0/21 (0,0) No 2/21 (9,5)
airway compromise Absent 11/31 (35,5) Yes 20/21 (95,2) Yes 19/21 (90,5)
Partially adequate 3/31 (9,7) Missing 1/21 (4,8) Missing 0/21 (0,0)
Adequate 12/31 (38,7)
Missing 0/31 (0,0)
Manual maneuvers Non-applicable 31/31 (100,0) No 0/21 (0,0) No 3/21 (14,3)
(chin lift, jaw thrust, Absent 0/31 (0,0) Yes 20/21 (95,2) Yes 18/21 (85,7)
recovery position Partially adequate 0/31 (0,0) Missing 1/21 (4,8) Missing 0/21 (0,0)
etc.) Adequate 0/31 (0,0)
Missing 0/31 (0,0)
Insertion of oral or Non-applicable 31/31 (100,0) No 1/21 (4,8) No 7/21 (33,3)
nasal airway Absent 0/31 (0,0) Yes 19/21 (90,5) Yes 13/21 (61,9)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
Use of suction Non-applicable 30/31 (96,8) No 4/21 (19,0) No 9/21 (42,8)
Absent 0/31 (0,0) Yes 16/21 (76,2) Yes 11/21 (52,4)
Adequate 0/31 (0,0)
Missing 1/31 (3,2)
Assisted ventilation Non-applicable 31/31 (100,0) No 0/21 (0,0) No 4/21 (19,0)
using bag-valve- Absent 0/31 (0,0) Yes 21/21 (100,0) Yes 16/21 (76,2)
mask Partially adequate 0/31 (0,0) Missing 0/21 (0,0) Missing 1/21 (4,8)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
respiratory distress Absent 12/31 (38,7) Yes 18/21 (85,7) Yes 17/21 (81,0)
and adequacy of Partially adequate 3/31 (9,7) Missing 1/21 (4,8) Missing 0/21 (4,8)
ventilation Adequate 11/31 (35,5)
Missing 0/31 (0,0)
Administration of Non-applicable 23/31 (74,2) No 0/21 (0,0) No 1/21 (4,8)
oxygen Absent 7/31 (22,6) Yes 20/21 (95,2) Yes 20/21 (95,2)
Adequate 1/31 (3,2)
Missing 0/31 (0,0)
shock Absent 6/31 (19,3) Yes 19/21 (90,5) Yes 18/21 (85,7)
Missing 0/31 (0,0)
Compression for Non-applicable 27/31 (87,1) No 0/21 (0,0) No 2/21 (9,5)
control of Absent 0/31 (0,0) Yes 20/21 (95,2) Yes 19/21 (90,5)
haemorrhage Partially adequate 2/31 (6,4) Missing 1/21 (4,8) Missing 0/21 (0,0)
Adequate 2/31 (6,4)
Missing 0/31 (0,0)
Peripheral Non-applicable 8/31 (25,8) No 2/21 (9,5) No 2/21 (9,5)
percutaneous Absent 0/31 (0,0) Yes 19/21 (90,5) Yes 18/21 (85,7)
intravenous access Partially adequate 1/31 (3,2) Missing 0/21 (0,0) Missing 1/21 (4,8)
Adequate 22/31 (71,0)
Missing 0/31 (0,0)
Recognize altered Non-applicable 13/31 (41,9) No 3/21 (14,3) No 4/21 (19,0)
consciousness; Absent 8/31 (25,8) Yes 17/21 (81,0) Yes 17/21 (81,0)
lateralizing signs, Partially adequate 3/31 (9,7) Missing 1/21 (4,8) Missing 0/21 (0,0)
pupils Adequate 7/31 (22,6)
Missing 0/31 (0,0)
Recognition of Non-applicable 14/31 (45,2) No 5/21 (23,8) No 4/21 (19,0)
neurovascular Absent 12/31 (38,7) Yes 16/21 (76,2) Yes 17/21 (81,0)
compromise; Partially adequate 4/31 (12,9) Missing 0/21 (0,0) Missing 0/21 (0,0)
disability-prone Adequate 1/31 (3,2)
injuries Missing 0/31 (0,0)
Basic immobilization Non-applicable 19/31 (61,3) No 0/21 (0,0) No 3/21 (14,3)
(sling, splint) Absent 3/31 (9,7) Yes 20/21 (95,2) Yes 18/21 (85,7)
Missing 0/31 (0,0)
23
Assessment – Non-applicable 17/31 (54,8) No 2/21 (9,5) No 4/21 (19,0)
recognition of Absent 14/31 (45,2) Yes 19/21 (90,5) Yes 16/21 (76,2)
presence or risk of Partially adequate 0/31 (0,0) Missing 0/21 (0,0) Missing 1/21 (4,8)
spinal injury Adequate 0/31 (0,0)
Missing 0/31 (0,0)
Immobilization: C- Non-applicable 17/31 (54,8) No 3/21 (14,3) No 5/21 (23,8)
collar, backboard Absent 5/31 (16,1) Yes 17/21 (81,0) Yes 16/21 (76,2)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
Monitoring of Non-applicable 24/31 (77,4) No 3/21 (14,3) No 4/21 (19,0)
neurological function Absent 5/31 (16,1) Yes 17/21 (81,0) Yes 17/21 (81,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
Records
Records – observations during reviewing
All the records kept at the hospital are handwritten, and often very difficult to read since they are
written under time pressure and stress. At the emergency unit special forms are used, while for the
hospitalized patients there are other more complete forms that also include medical history,
medicines, allergies etc. The records at the emergency room are usually kept very short and provide
very little information on what happened to the patient and what care was given to the patient upon
arrival.
The records for the hospitalized patients are generally more complete. Mostly they include a more
complete history on what happened to the patient, a whole-body status, descriptions on how the
patient is feeling (fever, pain etc.), lists for given fluids, medicines, antibiotics, what blood tests
were taken and their results, nurse notes, the surgery story in cases surgery was needed, trauma
severity score level (less often) and sometimes if an X-ray was done. Indications for antibiotic
therapy are often missing. X-rays and/or other assessments such as using ultra sound, and part of
body investigated was often written but not the results or if the results had any impact on the
continuing care or condition of the patient.
Results – records
Totally 9 days in August and 11 days in September were missing the records. The numbers of
records reviewed from the surgery and orthopedic unit each day of the months are shown in figure
10a and 10b. The numbers of accidents were 57 in August and 38 in September 2017. The
distribution of the accidents throughout the months can be seen in figure 11a and 11b respectively.
24
80
Number of records 70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Days in August
Orthopedic unit Surgery unit
Figure 10a. Numbers of records reviewed in August 2017 in the orthopedic and surgery emergency units.
80
70
Number of records
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Days in September
Orthopedic unit Surgery unit
Figure 10b. Numbers of records reviewed in September 2017 in the orthopedic and surgery emergency
units.
10
10
9 9
Number of accidents
8 8
Number of accidents
7 7
6 6
5 5
4 4
3 3
2 2
1 1
0 0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Days in August Days in September
Figure 11a. Distribution of accidents in August Figure 11b. Distribution of accidents in September
2017 (N = 57). 2017 (N = 38).
25
The highest incident of accidents was the 23rd in both months. In August 34/57 (59,6 %) of the
accidents occurred on a weekday (Mon – Thu) and 23/57 (40,3 %) on weekends. In September
11/38 (28,9 %) of the accidents occurred on a weekday and 27/38 (71,0 %) on weekends (data not
shown).
Of the eight patients hospitalized, five (62,5 %) were men and three (37,5 %) women. The mean
age was 37 years and the length of hospitalization varied from one to nine days (Table 5). The most
common diagnosis was head trauma, and the two other diagnoses presented were wounds and
fractures/fissures (data not shown). Surgery and/or need for surgical washing, general observation
and fracture surgery were the most common causes to hospitalization (data not shown).
Table 5. Characteristics of the patients hospitalized

Mean Median Min 1st Qu 3rd Qu Max
1. Number of days in hospital 4,9 4,5 1,0 2,0 7,5 9,0
2. Age 37,4 33,5 12,0 22,8 48,2 74,0
Discussion
According to the framework presented in the introduction, the four parts organization,
communication, process and medical knowledge are considered as important parts of quality of
care. In this study all four of them has been assessed to a greater or lesser extent using the four
different data collection methods. The discussion that follows is organized according to this
theoretical framework on quality of care.
Organization
The trauma care organization could be considered as the highest level impacting the actual trauma
care. In this study the organization was assessed through conducting interviews with the hospital
subdirector as well as a surgeon and an orthopedist at the emergency department. Most traffic
accident victims were primarily taken care of at surgery and orthopedic emergency units, thus these
units have a big load of patients suffering from traffic accident injuries. Most emergency cases
(77,4 %) first attended the surgery unit, but often surgeons and orthopedists attended the patient
simultaneously. This high demand implicates the range of the problem and the need for optimizing
trauma care. The emergency department was usually staffed with physicians of different
competence levels, most commonly interns, explaining why most of the traffic accident victims
were primarily taken care of by an intern. The hospital has only access to an X-ray device and an
ultra sound devise, which were used frequently. In case a computer tomography scan (CT-scan) was
needed the patients were referred to the hospital in the capital Managua. No special trauma team is
currently available at the hospital.
26
Evidence for effectiveness and improvements in the trauma care organization comes almost entirely
from developed countries (1). The top two activities that has led to a better organization have in
most cases been shown to be verification of trauma services through hospital inspections and
systems for trauma management (1). In this study both the organizational system of emergency care
as well as the action of care have been assessed. It was noted that there seem to be mismatch
between expected and actual knowledge especially regarding ATLS-performance, where leaders
and specialists claim it is general knowledge among all physicians, but clinical outcomes showed
shortcomings in following structure according to ATLS or similar. Possible explanations to this was
not assessed in this study and can only be speculated around. Among the planning and
implementation of systems for trauma management political jurisdictions, mobile emergency
services, prehospital triage, criteria for transfer to other health care facilities and transfer
arrangements between hospitals are included (1). These kind of improvements has been shown to
not require more than relatively small economical inputs compared to the already existing system of
care and could be a way to relatively easy implement new routines that also has been shown to
decrease mortality rates (1). Political jurisdictions are questions that fell outside of this study, as
well as the pre-hospital parts. Regarding referrals a few patients attending the emergency room
were referrals from other hospitals, and some patients were referred to Managua from HEODRA in
León. No investigation has been made on the referral routines in this study.
Trauma teams are the organization of personnel with pre-assigned roles and a protocol guiding the
operation of the team (1). In Qatar, where trauma and road traffic injuries are common and causes
many deaths and disabilities, a specific trauma service was implemented to optimize outcome for
injured patients consisting of different health care professionals with interest and skills in trauma
care (22). All trauma surgeons in the trauma service teams had completed ATLS-courses and
together with other implementations such as a trauma activation protocols that alerted the trauma
team, the operating theater and the blood bank, the trauma service created a more organized
delivery of trauma care (22). Unfortunately, the adaptation of trauma teams in smaller hospitals has
been poorly addressed (1). Where trauma teams cannot be afforded, the importance of in-service
training for health care professionals is not to be underestimated as part of strengthening
organization and planning for trauma care services, even in low- and middle-income countries (6).
According to the interviews national as well as local simulation trainings are held two to three times
a year for health care professionals in the different municipalities, to prepare for different kinds of
catastrophes. Whether special trauma simulation trainings or courses are held is currently not
known.
27
Communication
Communication in the theoretical framework refers to all types of communication but here
especially to the communication taking part at the emergency room. During observations at the
emergency department it was noticed that very little reporting from the prehospital workers took
place, as well as what seemed like little communication between the staff in the emergency room.
Moreover, the information to the patients and their relatives were sometimes inadequate or totally
missing. The importance of the communication for overall satisfaction and good patient experience
was assessed in a Swedish study on quality of care in an emergency department that found that
“information, respect and empathy” was one of five areas for improvement in emergency care
according to patient questionnaires (19). Improving communication can be a way to minimize
delays in the care-giving process as well as minimize errors, mistakes and misunderstandings and
increase clarity for the staff attending the patient. An example of a success story concerning
communication problems comes from Thailand, where radios were provided to all physicians on
duty which, though not being the only action taken to improve trauma care quality, resulted in
decreased delays and an overall improvement in the process of care (22). In Qatar, the
establishment of radio contact between the ambulance personnel and the Trauma Resuscitation Unit
allowed for preparation and activation of trauma services before arrival of the patient (22). It was
found in this study that the major part of the patients arrived at the hospital by own transport, some
of them with quite severe diagnoses. Reasons to this, as well as the availability to prehospital care,
are important to highlight, but falls outside the aims of this study. Implementation of a whole
trauma team takes lot of effort in terms of time, planning and staffing, but introducing a
communication system between the prehospital workers and emergency department could be a first
step in improving the trauma care system. This would allow for preparation at the receiving health
care unit with equipment, staffing, space and prioritizing patients. Thus, communication between
the health care professionals (prehospital as well as in-hospital) is important to ensure the
effectiveness and safeness of the health care given. Also, communication concerns the one taking
part between the physician and the patient. Quality of care comprises the part “patient centeredness”
which includes communication with the patient and decision-making guided by patient values (18).
Hence, communication with the patient improves the patient’s participation in the care to the most
possible extent in each given situation and provides medically important facts to the physicians in
diagnosing and treatment.
The records and documentation in general could be considered as another aspect of communication.
Records could be used as a tool for health care professionals, but also provide information that can
be used for research. At the HEODRA hospital in León, the records are handwritten and as
observed when reviewing, provide variable amount of useful data on the care given and the injury
28
situation. Data provided by the health care system are required in order to estimate magnitude,
evaluate the impact of interventions, evaluate the effectiveness of injury management and treatment,
plan for trauma care services and provide epidemiological data on the traffic accident load (5).
Thus, working for an effective and useful way of collecting data, whether in form of medical
records, police records, national registries etc., can provide important information for quality of care
improvements as well as preventive and predictive work.
Process
The care-giving process itself at the emergency room is referred to as process in the framework.
According to the Donabedian model “process” is the actual given care and receiving of care (14). In
this study the process was measured through observation of emergencies according to factors such
as use of medical equipment, hygiene routines, structure of the given care (such as ATLS,
ABCDE), assessment of the patient’s condition, what diagnostic tools were used, effectiveness,
waiting times and so on. Hygiene routines such as washing hands and use of hand disinfectant were
absent almost in all cases. To improve this, soap and hand disinfectant should be easily available in
the emergency room. Also, hand gloves are relatively cheap and easy to have accessible for general
use in the emergency room.
It was found that only in 11/31 cases the care-giving process followed some structure according to
ATLS or ABCDE. Notably, in almost half of the cases no structure was followed. In the lead of this
it was found that important clinical assessments were missing in many cases, such as assessment of
airways, shock, neurological function, the spine and so on. This leads to a higher risk of missing
diagnoses or missing conditions that needs treatment. Successful performance of severely injured
patients depend on securing airways, supporting breathing and restoring circulation and requires
optimal pre-planning, coordination, prehospital and hospital caring of the patient, equipment,
personnel and so on (1). As mentioned before, it was found in this study that assessment of airways
and circulation were missing in several cases. The importance of the timing in this initial care
cannot be sufficiently emphasized since the survival of severely injured patients strongly depends
on the quick re-establishment of adequate tissue oxygenation (1). These initial steps in the
evaluation of the patient, for example according to the ATLS-principles or similar, only require
little amount of time and equipment and provide important information about the condition of the
patient. It also helps to guide the clinicians in the prioritizing process of patients and in the
decisions of level of care required to establish the patient. To optimize the care-giving process it is
indicated to have the most commonly used instruments easily available at a strategic place in the
emergency room, for example a saturation monitor, blood pressure cuff, stethoscope, fluids and a
trauma pack (recommended to include a scalpel, clamps, scissors, gauze, suture, syringe and
29
needles according to WHO (1). In this way delays to treatment and forgetting important clinical
assessments are minimized.
It was found that the mean waiting time to see a doctor was 6,7 minutes, indicating that most
patients were taken care of fast upon arrival. The importance of timing in the initial care was
claimed above and again, in order to prioritize patients a first evaluation must be done. Triage is a
system used to classify patients according to injury severity to decide how quickly they need care
(3). The goal is to give the best opportunity for survival to all patients involved, and several more or
less complex systems and algorithms have been developed for use in an emergency setting and are
used around the world (32). The use of triage is not only important for the prehospital care when
deciding when, how and where the patient will be transported, but also upon arrival at the hospital
to focus the attention on patients according to injury severity and urgency (3) – especially when
several patients attend simultaneously (32). In this study it was noted during observations that there
is no consequent use of triage systems on trauma patients, if used at all. Though long waiting times
does not seem to be a problem at the HEODRA hospital in León, developing a triage system for
trauma patients and emergency patients in general, could be a way to further improve quality of
trauma care in terms of prioritizing patients and to guide physicians in decision-making regarding
level of care, urgency etc. Moreover, using a prehospital triage system could provide the physicians
at the hospital at arrival with several important facts on the condition of the patient.
Medical knowledge
The medical knowledge was overall considered good according to the self-assessment among the
physicians. The three areas with the lowest reported theoretical knowledge and/or practical skills
were use of spine-board, use of suction and insertion of oral or nasal airway. This was seen in the
clinic in that the use of spine-board was incorrect every time and no assessment on presence or risk
for spinal injury was done before releasing the spine-board. This may indicate that the purpose of
using a spine-board is not clear among the physicians at the emergency department nor among the
prehospital workers, and this issue is especially concerning prehospital workers. This can also serve
as an example where missing a condition or diagnosis can have disastrous consequences such as
lifelong disabilities due to paralysis after a spinal injury. These injuries are not always visible but
still important to assess and rule out to improve outcome for trauma patients.
This study is part of a bigger ongoing project with mapping and understanding the traffic accident
load in Nicaragua. It provides knowledge and understanding for the hospital trauma care service
currently available at the HEODRA hospital in León, Nicaragua. Most importantly, the initiative to
this study derives from the understanding of the impact traffic accidents has on the health care
systems in the country and shows a willingness to make difference. Recent statistics provided by the
30
newspapers report 791 fatalities totally in 2016 (33) and the first semester of 2017 was reported to
have 425 deaths due to traffic accidents, an increase with 17,2 % compared to the same period in
2016 (34). These numbers implicate the importance of the problem, and a first step to make
difference is understanding the situation.
Methological consideration
This explorative mixed method study, consisted of mainly four different data collection methods;
interviewing with help of an interview guide, checklist, questionnaire and retrospective reviewing
of records. Both qualitative and quantitative data were provided.
There are no standardized and clearly defined quality indicators to measure quality of trauma care
(13). In this study the checklist and questionnaires were adapted from a WHO study on Guidelines
for essential trauma care (1) and piloted to suit this specific setting to evaluate the given care on
traffic accident traumas. First, the limitations must be addressed. The assessments are based on
subjective observations made by the investigator, who therefore plays a crucial role. Medical
knowledge, clinical experience, personal preferences and routines may impact the assessment and
therefore the results. Moreover, the risk of being inconsequent in the evaluation also may impact the
data. To avoid this one would need several persons evaluating the same situation to therefore not
depend on only one person’s view. It must also be considered that being scrutinized may impact the
physician’s performance, either by doing more than normally would have been done to make sure to
be “correct” or forgetting things due to nervousness or similar. Moreover, the checklists are only
based on observations, sometimes of several patients at the same time. This may have caused that
some observations of the given care were missed out or that observations were mixed between the
patients. There may have been more information in the records providing important information
about the quality of care, for example use of trauma severity scoring system, or observations made
by the physicians that were not communicated aloud but written down in the records. Hence, the
observations provide some information about the given care but should not be considered as the
only truth. Furthermore, the observations were limited to the emergency room and only the initial
care given. When the patients were hospitalized or moved to observation, no more observations
were made, and the patient was considered as done. Therefore, no data were provided on the long-
term outcomes, complications, length of hospitalization or similar.
The assessment of quality of care in this study are mainly based on 31 cases of traffic accident
victims during a limited period with a certain number of health care professionals attending the
patients. Hence, the external validity can be discussed due to the relatively low number of patients
and health care professionals in the study. Even though studying the quality of care in this specific
setting lowers the generalizability since the observations are subjective and suited for this study, the
31
instruments are based on WHO studies and can be adapted to and used in almost any setting in the
world.
The interview guide was developed during the ongoing observational process and very little was
known about the routines at the emergency department on beforehand. The purpose was to serve as
a base for discussion allowing for deeper investigation of certain important questions. Due to
limited time for the interviews not many questions beyond the original ones were asked. The
answers provided important information about the organization and system, some of them that
would have been desirable to use in the checklists and/or questionnaires. Conducting the interviews
on an earlier stage in the study could have revealed important facts interesting to assess, such as the
self-assessed theoretical knowledge and practical skills on ATLS/ABCDE to give an example.
The reviewing of records had, due to limited time and resources, to be kept superficial and easy.
Again, during the reviewing process it was observed several important and interesting variables that
could have provided important information about the quality of care, such as vital parameters, given
medicines, if any X-rays were taken and their results, blood tests, and physical exams made. But
due to little knowledge about the records on beforehand and limited time only the most basic
variables were collected and in addition some general observations were made. Records for several
dates were missing in each month and were nowhere to be found in the admission center at the
hospital. Due to this important data could possibly be missing.
Among the strengths of this study are the different methods used to assess the same phenomenon
from different angels. This opens for the possibility to find explanations to certain problems or
deficiencies in the given care. The instruments (checklist, questionnaire) were developed from the
same WHO guidelines (1) and could therefore provide important information when paired together.
Through this suggestions to the roots of the problems could possibly be found. Still it is important
to remember that they do not give the whole picture. For example, concerning ATLS/ABCDE it is
claimed that the system is well known among the physicians, but the results show that it is not
practiced in the clinics. This would have been interesting to further assess, as well as to assess the
need and willingness for practical trainings among physicians in skills that are important especially
in trauma care but also in emergency care in general.
Conclusions and own experiences

The aim of this study was to investigate and document the trauma care on patients suffering from
traffic accident injuries and to assess the quality of emergency care. In conclusion, many of the
desirable parts to obtain good quality of emergency care as defined in the theoretical framework are
already available. In concordance with other findings (6), in-service trainings are desirable to ensure
32
safe and effective initial care-taking of trauma patients. Development of a trauma care protocol
would provide a guide to physicians, especially younger colleagues, when attending trauma patients
and thus increasing structure and patient safety and minimizing risks of missing critical and/or
treatable conditions. To better be prepared for trauma patients, especially in cases with several
injured patients simultaneously, better communication between prehospital and hospital health care
takers is needed. Implementation of a special trauma team needs to be further assessed in low- and
middle-income countries before any recommendations regarding its constellation and practical
management can be made.
Conducting this study has been very educative and interesting. It was very striking and encouraging
to meet the enthusiasm and interest among health care professionals at the hospital and in the
research group. Traffic accidents is a major problem not only in Nicaragua, but also worldwide and
therefore a very important research area.
This study has concentrated on the health care given at the emergency room. No assessment or
investigations has been made on what happens after the emergence room, such as surgery processes,
waiting time to surgery, observation times, longer term patient outcomes, complications, mortality
and morbidity, disabilities etc. In order to move forward these are examples of topics in interest for
future research to further map and document the quality of trauma care.
Recommendations
Regardless of the limitations of this study, several recommendations can be made on steps that can
be taken to further improve the trauma care quality. These are summarized in Box 2 below.
33
Box 2. Summary of recommendations.
➢ Organization and development of in-service trauma education for health care

professionals on a regular basis to increase overall knowledge on trauma care.
➢ Further assessment of the need of and access to senior colleagues at the
emergency departments, especially during peak injury hours/days.
➢ Investigate the willingness and need for trauma education and training as part of
the internship.
➢ Improvement of communication systems between prehospital and hospital workers
in order to increase organization of trauma care and possibilities to preparedness
at the hospital.
➢ Implementation of a structured system for reporting upon arrival at the hospital to
improve trauma care effectiveness and safety, and to minimize the risk of missing
treatable conditions/diagnoses.
➢ Develop a trauma protocol to improve structure and effectiveness of trauma care to
be used as a guide for physicians and nurses when attending a trauma patient.
➢ Evaluate theoretical knowledge and practical skills in performing ATLS/ABCDE as
well as use of triage systems among prehospital and hospital health care
professionals.
Acknowledgements
I wish to thank all of you who have contributed to this study. Especially I want to give my warmest
thanks to my supervisors Carina Källestål and William Ugarte for excellent guiding and wise
advice. I also want to thank Gabriela Nárvaez and Scarlette Téllez for all your help during the
study. Thank you Fidel García and Kiara Lira, for providing some extra help when needed.
34
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Appendix 1: Interview Guide
INTERVIEW GUIDE
Emergency department
UNIVERSIDAD NACIONAL AUTÓNOMA DE NICARAGUA

CENTRO DE INVESTIGACIÓN EN DEMOGRAFÍA Y SALUD
UPPSALA UNIVERSITY, SWEDEN
Evaluation of traffic accident trauma care at the emergency unit at the HEODRA hospital,
León, Nicaragua
Structure
1. What emergency care units are there?
2. Where are the traffic accident victims taken care of in the first place?
3. How is the crew at the emergency department organized concerning shifts and personnel categories?
4. How is the work force distributed throughout a day?
5. Is there a plan of action in case of severe traumas or equivalent?
6. What does the communication between the emergency unit and prehospital care-takers (Cruz Roja,
Bomberos, Bomberos Voluntarios) and the police look like?
7. How is the required care for each patient financed?
Process
1. Is there a protocol for trauma care that they follow?
2. Is there a trauma team?
3. Do they use any trauma severity scoring system?
38
Appendix 2: Checklist
Checklist
Based on “Guidelines for essential trauma care”. Geneva: World Health Organization
(WHO); 2004.

UPPSALA UNIVSERSITY, SWEDEN
León, Nicaragua
Traffic accident number: ________________________________________________________________

Gender: male female
Age: ________________________________________________________________
Number of victims: ________________________________________________________________
Type of accident: car motorcycle pedestrian bicycle other
Diagnosis: ________________________________________________________________
Outcome of care: observation hospitalization home
Time of accident: daytime (8am-4pm) evening (4pm-12am) night (12am-8am)
Day: weekday (Mon-Thu) weekend (Fri-Sun)
Transportation: Cruz Roja Bomberos Bomberos Policía Own Referred

voluntarios general
First care-taking person: nurse medical intern resident specialist

student
Time from accident to arrival at hospital: __________________________________________________________
Time from arrival to see a doctor: _______________________________________________________________
Total time in emergency room: _________________________________________________________________
Emergency unit: orthopedic surgery other: _________________________________
Use of trauma severity scoring system: □ Yes: ____________________________________________

□ No
BASIC CARE Yes No Non applicable
Washing hands
Hand disinfection
Hand gloves
39
Thermometer
Clock or watch with second hand
Face mask
Stethoscope
Saturation monitor
Oxygen
Blood pressure
C-collar
Gauze and bandage
Arterial tourniquet in extreme situations
Spine board
Pain control
Follow ATLS/ABCDE
AIRWAY MANAGEMENT
Knowledge and skills Non Absent Partially Adequate

applicable adequate
Manual maneuvers (chin lift, jaw thrust, recovery

position etc.)
Insertion of oral or nasal airway
Use of suction
Assisted ventilation using bag-valve-mask
Endotracheal intubation
Cricothyroidotomy (with or without tracheostomy)
Non-applicable: not relevant for the case

Absent: required but not performed
Partially adequate: performed but not correctly
Adequate: performed correctly
AIRWAY MANAGEMENT
Equipment and supplies Non- Absent Partially Adequate

applicable adequate
Oral or nasal airway
Suction device: at least manual (bulb) or foot pump
Suction tubing
Yankauer or other stiff suction tip
Laryngoscope
Endotracheal tube
40
Oesophageal detector device
Bag-valve-mask
Basic trauma pack
Magill forceps
BREATHING – MANAGEMENT OF RESPIRATORY DISTRESS

Breathing: knowledge and skills Non- Absent Partially Adequate
applicable adequate
Assessment of respiratory distress and
adequacy of ventilation
Administration of oxygen
Needle thoracotomy
Chest tube insertion
Three-way dressing
Breathing: equipment and supplies Non- Absent Partially Adequate

applicable adequate
Nasal prongs, face mask, associated tubing
Needle and syringe
Chest tubes
Underwater seal bottle (or equivalent)
Bag-valve-mask
CIRCULATION AND SHOCK
Knowledge and skills Non- Absent Partially Adequate

applicable adequate
ASSESSMENT AND CONTROL OF EXTERNAL HEMMORRHAGE
Assessment of shock
Compression for control of haemorrhage
Splinting of fractures for haemorrhage control
Pelvic wrap for haemorrhage control
41
FLUID RESUSCITATION
Knowledge of fluid resuscitation
Peripheral percutaneous intravenous access
Peripheral cutdown access
Central venous access for fluid administration
Intraosseous access for children under 5 years
Transfusion knowledge and skills
MONITORING
Knowledge of resuscitation parameters
OTHER
Differential diagnosis of causes of shock
Use of fluids and antibiotics for septic shock
Recognition of hypothermia
External rewarming in hypothermia
Use of warm fluids
Knowledge of core rewarming
Circulation: Equipment and supplies Non- Absent Partially Adequate

applicable adequate
FLUID RESISCUTATION
Crystalloid
Blood transfusion capabilities
Intravenous infusion set (lines and cannulas)
Intraosseous needle or equivalent
Central venous lines
MONITORING
Urinary catheter
42
Laboratory facilities for hemoglobin or hematocrit
OTHERS
Nasogastric (NG) tube
Weighing scale for children
HEAD INJURY
Resources Non- Absent Partially Adequate

applicable adequate
Recognize altered consciousness; lateralizing signs, pupils
Maintain normotension and oxygenation to prevent

secondary brain injury
Avoid overhydration in the presence of raised ICP (with
normal BP)
Maintenance of requirements for protein and calories
NECK INJURY

applicable adequate
Recognize platysmal penetration
External pressure for bleeding
Surgical skills to explore neck
CHEST INJURY

applicable adequate
Adequate pain control for chest injuries/rib fractures
Respiratory therapy for chest injuries/rib fractures
Rib block or intrapleural block
EXTREMITY INJURY

applicable adequate
Recognition of neurovascular compromise;
disability-prone injuries
Basic immobilization (sling, splint)
Wrapping of pelvic fractures of haemorrhage control
43
Skin traction
Closed reduction
Skeletal traction
Operative wound management
External fixation (or its functional equivalent: pins and

plaster)
Internal fixation
Tendon repair
Hand injury; assessment and basic splinting
Hands: debride, fix
Amputation
X-ray
Proper management of immobilized patient to prevent

complications
SPINAL INJURY

applicable adequate
Assessment – recognition of presence or risk of spinal injury
Monitoring of neurological function
Maintain normotension and oxygenation to prevent

secondary neurological injury
Holistic approach to prevention of complications – especially
pressure scores and urinary retention/infection
Non-surgical management of spinal injury (as indicated)
This checklist is based on Guidelines for essential trauma care by WHO (World Health Organization), 2004. The criteria
considered “essential” (E) for specialist care have been extracted to these tables.
Ref: WHO. Guidelines for essential trauma care [Internet]. Geneva: World Health Organization; 2004. Available from:
44
Appendix 3: Questionnaire
Questionnaire
Based on “Guidelines for essential trauma care”. Geneva: World Health Organization
(WHO); 2004.

UPPSALA UNIVSERSITY, SWEDEN
León, Nicaragua
This is a questionnaire that asks questions about your knowledge and skills in different areas in medicine especially
important in trauma care. The purpose of this questionnaire is to identify areas in emergency medicine in interest for
closer investigation to be able to do improvements in emergency and trauma care. The information will only be used in
this project and the answers are collected anonymously. Participation is voluntary and can be cancelled at any time
without explanation. Please be honest when answering.
Questionnaire number: _____________
Medical competence: □ medical student

□ intern
□ resident
□ specialist: ___________________________________________________
Do you consider yourself having the knowledge and skills to practice the following?
THEORETICAL PRACTICAL
Airway management: Knowledge and skills KNOWLEDGE SKILLS
Yes No Yes No
Manual maneuvers (chin lift, jaw thrust, recovery

position etc.)
Insertion of oral or nasal airway
Use of suction
Assisted ventilation using bag-valve-mask
Endotracheal intubation
Cricothyroidotomy (with or without tracheostomy)
45
Breathing: knowledge and skills KNOWLEDGE SKILLS
Yes No Yes No
Assessment of respiratory distress and adequacy of ventilation
Administration of oxygen
Needle thoracotomy
Chest tube insertion
Circulation and Shock: Knowledge and skills KNOWLEDGE SKILLS
Yes No Yes No
Assessment of shock
Compression for control of haemorrhage
Splinting of fractures for haemorrhage control
Pelvic wrap for haemorrhage control
Knowledge of fluid resuscitation
Peripheral percutaneous intravenous access
Peripheral cutdown access
Central venous access for fluid administration
Intraosseus access for children under 5 years
Transfusion knowledge and skills
Knowledge of resuscitation parameters
Differential diagnosis of causes of shock
Use of fluids and antibiotics for septic shock
Recognition of hypothermia
External rewarming in hypothermia
Use of warm fluids
Knowledge of core rewarming
46
THEORETICAL PRACTICAL SKILLS
Head injury: Resources KNOWLEDGE
Yes No Yes No
Recognize altered consciousness; lateralizing signs, pupils
Maintain normotension and oxygenation to prevent secondary brain

injury
Avoid overhydration in the presence of raised ICP (with normal BP)
Maintenance of requirements for protein and calories

Neck injury: Resources KNOWLEDGE
Yes No Yes No
Recognize platysmal penetration
External pressure for bleeding
Surgical skills to explore neck

Chest injury: Resources KNOWLEDGE
Yes No Yes No
Adequate pain control for chest injuries/rib fractures
Respiratory therapy for chest injuries/rib fractures
Rib block or intrapleural block

Extremity injury: Resources KNOWLEDGE
Yes No Yes No
Recognition of neurovascular compromise; disability-prone injuries
Basic immobilization (sling, splint)
Spine board
Wrapping of pelvic fractures of haemorrhage control
Skin traction
Closed reduction
Skeletal traction
Operative wound management
External fixation (or its functional equivalent: pins and plaster)
Internal fixation
47
Tendon repair
Hand injury; assessment and basic splinting
Hands: debride, fix
Amputation
X-ray
Proper management of immobilized patient to prevent complications

Spinal injury: Resources KNOWLEDGE
Yes No Yes No
Assessment – recognition of presence or risk of spinal injury
Monitoring of neurological function
Maintain normotension and oxygenation to prevent secondary

neurological injury
Holistic approach to prevention of complications – especially pressure
scores and urinary retention/infection
Non-surgical management of spinal injury (as indicated)
Thank you for your participation!
This questionnaire is based on Guidelines for essential trauma care by WHO (World Health Organization), 2004. The criteria
considered “essential” (E) for specialist care have been extracted from the original tables and this questionnaire consists of the
tables named “Knowledge and Skills” only.
Reference: WHO. Guidelines for essential trauma care [Internet]. Geneva: World Health Organization; 2004. Available from:
48
Appendix 4: Inventory List
INVENTORY LIST
Emergency department

UPPSALA UNIVERSITY, SWEDEN
León, Nicaragua
BASIC CARE Yes No
Hand disinfectant
Gloves
Soap
Thermometer
Clock or watch
Face mask
Stethoscope
Saturation monitor
Oxygen
Blood pressure
C-collar
Gauze and bandage
Airways: Equipment and supplies Yes No
Oral or nasal airway
Suction device: at least manual (bulb) or foot pump
Suction tubing
Yankauer or other stiff suction tip
Oxygen
49
Laryngoscope
Endotracheal tube
Oesophageal detector device
Bag-valve-mask
Basic trauma pack
Magill forceps
Breathing: equipment and supplies Yes No
Nasal prongs, face mask, associated tubing
Needle and syringe
Chest tubes
Underwater seal bottle (or equivalent)
Circulation: Equipment and supplies Yes No
FLUID RESISCUTATION
Crystalloid
Blood transfusion capabilities
Intravenous infusion set (lines and cannulas)
Intraosseous needle or equivalent
Central venous lines
MONITORING
Urinary catheter
Laboratory facilities for hemoglobin or hematocrit
OTHERS
Nasogastric (NG) tube
Weighing scale for children
50
Appendix 5: Time Plan
October/November 2017
Mon Tue Wed Thu Fri Sat Sun
1
2 3 4 5 6 7 8
Meeting Inventory Pilot Observations Observations Data Data
2:00 pm list, finish questionnaire, 7 am – 3 pm night collection collection
checklist/que meeting with 7 pm – 2 am 7 pm – 2 7 pm – 2
stionnaire Dr. Rocha am am
7 am – 3 pm 7 am – 3 pm
9 10 11 12 13 14 15
Preparation Data Data collection Data Data Data Data
collection 8 am – 2 pm collection collection collection collection
8 am – 2 pm 8 am – 3 pm 7 pm – 3 am 7 pm – 3 7 pm – 2
am am
16 17 18 19 20 21 22
Preparation Records Records Records Data Data Data
collection collection collection
7 pm – 6 am 7 pm – 3 7 pm – 2
am am
23 24 25 26 27 28 29
Preparation Data Data Data Data Data Data
collection, collection, collection, collection collection collection
records records records 7 pm – 2 am 7 pm – 4 7 pm – 2
9 am – 3 pm 9 am – 3 pm 9 am – 3 pm am am
30 31 1/11 2/11 3/11 4/11 5/11
Analysis Records Data collection Analysis Data Data
10 am – 1 pm collection collection
7 pm – 2 am 8 pm – 3 am 8 pm – 2
am
6/11 7/11 8/11 9/11 10/11
Write Write Meeting with Preparation HOME!
the for pres-
subdirector of entation of
HEODRA preliminary
hospital results
51
Appendix 6: Complete list of diagnoses
Table 6. Diagnoses according to checklists GROUP*

Multiple wounds in forehead + pain in leg Wounds
Polytrauma + wounds in face and thorax + pain in leg Wounds
Polytrauma + wounds in arms and face + closed tibia fracture Fracture/fissure
Superficial wounds Wounds
Clavicle fracture + rib fracture Fracture/fissure
Wounds in face and mouth + pain in shoulder Wounds
Wounds in face + 2 metacarpal fractures in right hand Fracture/fissure
Open fracture in lower leg + fracture in left wrist + abdominal trauma + wounds in face and Fracture/fissure
head
Open femur fracture + superficial wounds in hand and arm Fracture/fissure
Pain in right ankle; contusion Contusion
Superficial wounds in mouth and thorax + pain in left arm and shoulder Wounds
Wounds in face + deep dislocated wound in skin in upper arm Wounds
Superficial wounds in face + 2 intercostal fractures Fracture/fissure
Pain and contusion in leg Contusion
Superficial wounds on knees Wounds
Superficial wounds in legs and feet + deep open skin dislocation in scalp + mild Head trauma
cranioencephalic trauma
Femur fracture Fracture/fissure
Wounds in face and head + comminute fracture in nose Fracture/fissure
Wounds in face and legs + ocular trauma + polytrauma Head trauma
Abandoned -
Superficial wounds in legs and face + gash in hand Wounds
Wound in eyebrow and around eye + maceration in upper and lower lip and chin + wound on Wounds
thorax
Swelling in temple + wound on knee + clavicle fracture Fracture/fissure
Pain in shoulder and arm, no fracture Pain/hematoma
Wounds in face + mild cranioencephalic trauma Head trauma
Pain in legs, thorax, head + 10 min episode of unconsciousness + fracture in knee Head trauma
Finger trauma with involvement of nail + dislocation of fingertip, no fracture Wounds
Open fracture in patella + open wound on lower leg + clinical fracture in metatarsal 1 Fracture/fissure
Wound in forehead and arm + pain in shoulder Wounds
Superficial wounds in face + pain in head, thorax and leg + knock in the hand Pain/hematoma
Hit in the shoulder and knee left side + superficial wound Extremity injury
*Categorized according to the most severe diagnosis
Table 7. Diagnoses according to records GROUP*

Fissure trochanter major and acetabulum Fracture/fissure
Polytrauma Polytrauma
Hip contusion Contusion
Dislocated fracture in the lateral malleolus Fracture/fissure
Did not attend doctor -
Polytrauma + mild cranioencephalic trauma Head trauma
Thorax trauma + mild cranioencephalic trauma Head trauma
Sprain in ankle Fracture/fissure
52
Closed fracture in wrist Fracture/fissure
Shoulder contusion Contusion
Mild cranioencephalic trauma Head trauma
Hand trauma Extremity injury
Lumbar trauma Trauma thorax/back
Ankle contusion Contusion
Polytrauma + hip and thigh contusion Contusion
Gluteal hematoma Pain/hematoma
Knee contusion Contusion
Pain in the arm and head Pain/hematoma
Moderate cranioencephalic trauma Head trauma
Mild cranioencephalic trauma + superficial wound dig 5 + abdominal and thoracical pain Head trauma
Wrist fracture (right) Fracture/fissure
Polytrauma + shoulder contusion Contusion
Shoulder contusion Contusion
Polytrauma + lesion on chin + wound toe 5 Wounds
Contusion on knee Contusion
Wound on leg and fissure in calcaneus Fracture/fissure
Wound in forearm Wounds
Missing -
Polytrauma + open temporal wound + mild cranioencephalic trauma Head trauma
Polytrauma + multiple excoriations + open wound in neck and hand Polytrauma
Polytrauma + excoriations in forearm Polytrauma
Polytrauma + contusions in whole body Contusion
Polytrauma + parietal wound + foot lesion Wounds
Moderate cranioencephalic trauma + clavicle fracture Head trauma
Polytrauma + wound on nose Polytrauma
Thorax trauma Trauma thorax/back
IDEM + mild cranioencephalic trauma + facial wound Head trauma
Contusion on leg and knee Contusion
Contusion on knee and elbow Contusion
Polytrauma + contusion on both legs and left knee Contusion
Trauma to metacarpal bones on right hand + wound 2 cm right hand Extremity injury
Cut in knee + contusion in elbow Contusion
Polytrauma + fracture radius + metacarpal semi-luminous luxation + fracture in 4th Fracture/fissure
metatarsal bone (left)
Polytrauma in frontal part of radius + fracture in 4th metatarsal bone (left) Fracture/fissure
Polytrauma; thorax trauma + hematoma Polytrauma
Polytrauma + nose fracture Fracture/fissure
Facial pain + hematoma Pain/hematoma
Severe cranioencephalic trauma Head trauma
53
Mild cranioencephalic trauma + thorax trauma Head trauma
Fracture in metacarpal 1 Fracture/fissure
Contusions in left ankle and left elbow Contusion
Trauma in right elbow Extremity injury
Contusion in knee Contusion
Excoriations in index finger + hematoma + pain Pain/hematoma
Lumbar contusion Contusion
Abandoned -
Multiple contusions Contusion
Missing -
Unreadable -
Polytrauma + moderate cranioencephalic trauma + facial trauma Head trauma
Fracture in left clavicula Fracture/fissure
Contusion in right wrist and right hip Contusion
Moderate cranioencephalic trauma + closed muscular contracture Head trauma
Hit in the head Head trauma
Trauma to upper right limb + exclude fracture in elbow Extremity injury
Fracture of second grade at the level of left patella Fracture/fissure
Contusion in left knee Contusion
Severe cranioencephalic trauma + bronchospasm Head trauma
Polytrauma + sprain first grade Fracture/fissure
Fracture left caput metacarpal 5 Fracture/fissure
Contusion in left leg Contusion
Contusion on right knee Contusion
*Categorized according to the most severe diagnosis
54
Appendix 7: Health care characteristics according to checklists
Table 8. Assessment on quality of care on traffic accident victims at the

emergency room according to checklists.
n/N (%)
Gender Male: 23/31 (74,2)
Female: 8/31 (25,8)
Age Min: 14,0
1st Qu: 24,0
Median: 27,0
Mean: 31,1
3rd Qu: 34,5
Max: 60
Number of victims Min: 1,0
1st Qu: 1,0
Median: 1,0
Mean: 1,9
3rd Qu: 2,0
Max: 6,0
Type of accident Car: 9/31 (29,0)
Motorcycle: 16/31 (51,6)
Pedestrian: 1/31 (3,2)
Bicycle: 5/31 (16,1)
Other: 0/31 (0,0)
Diagnosis Wounds 11/31 (35,5)
Fractures 10/31 (32,2)
Contusion 2/31 (6,4)
Head trauma 4/31 (12,9)
Pain/hematoma 2/31 (6,4)
Extremity injury 1/31 (3,2)
Missing 1/31 (3,2)
Outcome Observation: 13/31 (41,9)
Hospitalization: 9/31 (29,0)
Home: 7/31 (22,6)
Missing: 2/31 (6,4)
Time of accident Day (8 am – 4 pm) 0/31 (0,0)
Evening: (4 pm – 12 pm) 22/31 (71,0)
Night: (12 am -8 am) 9/31 (29,0)
Day Weekday (Mon – Thu): 0/31 (0,0)
Weekend (Fri – Sun): 31/31 (100,0)
Transportation Red Cross: 5/31 (16,1)
Voluntary Firefighters: 7/31 (22,6)
Own: 15/31 (48,4)
Referred: 4/31 (12,9)
Police: 0/31 (0,0)
First care-taker Nurse: 2/31 (6,4)
Medical student: 1/31 (3,2)
Intern: 15/31 (48,4)
Resident: 10/31 (32,2)
Specialist: 3/31 (9,7)
Time from accident to arrival (minutes) Min: 7,0
1st Qu: 20,0
Median: 27,0
Mean: 45,1
3rd Qu: 40,0
Max: 342,0
Time from arrival to doctor attending (minutes) Min: 0,0
1st Qu: 0,0
Median: 0,0
Mean: 6,7
3rd Qu: 4,0
Max: 60,0
Total time in emergency room (minutes) Min: 20,0
1st Qu: 60,0
Median: 83,0
Mean: 100,1
3rd Qu: 140,2
55
Max: 225,0
Emergency unit Orthopedic: 7/31 (22,6)

Surgery: 24/31 (77,4)
Other: 0/31 (0,0)
Use of trauma severity scoring system No: 31/31 (100,0)
Yes: 0/31 (0,0)
1. Washing hands No 29/31 (93,5)
Yes 1/31 (3,2)
Missing 1/31 (3,2)
2. Hand disinfection No 30/31 (96,8)
Yes 0/31 (0,0)
Missing 1/31 (3,2)
3. Hand gloves No 6/31 (19,3)
Yes 20/31 (64,5)
Missing 1/31 (3,2)
4. Thermometer No 3/31 (9,7)
Yes 0/31 (0,0)
Missing 1/31 (3,2)
5. Clock or watch with second hand No 3/31 (9,7)
Yes 6/31 (19,3)
Missing 1/31 (3,2)
6. Face mask No 7/31 (22,6)
Yes 1/31 (3,2)
Missing 0/31 (0,0)
7. Stethoscope No 5/31 (16,1)
Yes 22/31 (71,0)
Missing 0/31 (0,0)
8. Saturation monitor No 13/31 (41,9)
Yes 13/31 (41,9)
Missing 1/31 (3,2)
9. Oxygen No 12/31 (38,7)
Yes 1/31 (3,2)
Missing 1/31 (3,2)
10. Blood pressure No 6/31 (19,3)
Yes 21/31 (67,7)
Missing 0/31 (0,0)
11. C-collar No 7/31 (22,6)
Yes 7/31 (22,6)
Missing 0/31 (0,0)
12. Gauze and bandage No 2/31 (6,4)
Yes 15/31 (48,4)
Missing 2/31 (6,4)
13. Arterial tourniquet in extreme situations No 0/31 (0,0)
Yes 0/31 (0,0)
Missing 1/31 (3,2)
14. Spine board No 5/31 (16,1)
Yes 8/31 (25,8)
Missing 0/31 (0,0)
15. Pain control No 12/31 (38,7)
Yes 4/31 (12,9)
Missing 5/31 (16,1)
16. Follow ATLS/ABCDE No 14/31 (45,2)
Yes 11/31 (35,5)
56
Missing 1/31 (3,2)
17. Assessment of airway compromise Non-applicable 5/31 (16,1)
Absent 11/31 (35,5)
Adequate 12/31 (38,7)
Missing 0/31 (0,0)
18. Manual maneuvers (chin lift, jaw thrust, recovery position Non-applicable 31/31 (100,0)
etc.) Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
19. Insertion of oral or nasal airway Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
20. Use of suction Non-applicable 30/31 (96,8)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 1/31 (3,2)
21. Assisted ventilation using bag-valve-mask Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
22. Endotracheal intubation Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
23. Cricothyroidotomy (with or without tracheostomy) Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
24. Oral or nasal airway Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
25. Suction device: at least manual (bulb) or foot pump Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
26. Suction tubing Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
27. Yankauer or other stiff suction tip Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
28. Laryngoscope Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
29. Endotracheal tube Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
30. Oesophageal detector device Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
57
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
31. Bag-valve-mask Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
32. Basic trauma pack Non-applicable 17/31 (54,8)
Absent 14/31 (45,2)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
33. Magill forceps Non-applicable 25/31 (80,6)
Absent 0/31 (0,0)
Missing 0/31 (0,0)
34. Assessment of respiratory distress and adequacy of Non-applicable 5/31 (16,1)
ventilation Absent 12/31 (38,7)
Adequate 11/31 (35,5)
Missing 0/31 (0,0)
35. Administration of oxygen Non-applicable 23/31 (74,2)
Absent 7/31 (22,6)
Adequate 1/31 (3,2)
Missing 0/31 (0,0)
36. Needle thoracotomy Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
37. Chest tube insertion Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
38. Three-way dressing Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
39. Nasal prongs, face mask, associated tubing Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
40. Needle and syringe Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
41. Chest tubes Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
42. Underwater seal bottle (or equivalent) Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
43. Bag-valve-mask Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
44. Assessment of shock Non-applicable 16/31 (51,6)
Absent 6/31 (19,3)
58
Missing 0/31 (0,0)
45. Compression for control of haemorrhage Non-applicable 27/31 (87,1)
Absent 0/31 (0,0)
Adequate 2/31 (6,4)
Missing 0/31 (0,0)
46. Arterial tourniquet in extreme situations Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
47. Splinting of fractures for haemorrhage control Non-applicable 27/31 (87,1)
Absent 0/31 (0,0)
Adequate 3/31 (9,7)
Missing 0/31 (0,0)
48. Pelvic wrap for haemorrhage control Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
49. Knowledge of fluid resuscitation Not assessed -
50. Peripheral percutaneous intravenous access Non-applicable 8/31 (25,8)
Absent 0/31 (0,0)
Adequate 22/31 (71,0)
Missing 0/31 (0,0)
51. Peripheral cutdown access Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
52. Central venous access for fluid administration Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
53. Intraosseous access for children under 5 years Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
54. Transfusion knowledge and skills Not assessed -
55. Knowledge of resuscitation parameters Not assessed -
56. Differential diagnosis of causes of shock Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
57. Use of fluids and antibiotics for septic shock Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
58. Recognition of hypothermia Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
59. External rewarming in hypothermia Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
60. Use of warm fluids Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
59
61. Knowledge of core rewarming Not assessed -
62. Crystalloid Non-applicable 8/31 (25,8)
Absent 0/31 (0,0)
Adequate 22/31 (71,0)
Missing 0/31 (0,0)
63. Blood transfusion capabilities Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
64. Intravenous infusion set (lines and cannulas) Non-applicable 8/31 (25,8)
Absent 0/31 (0,0)
Adequate 23/31 (74,2)
Missing 0/31 (0,0)
65. Intraosseous needle or equivalent Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
66. Central venous lines Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
67. Urinary catheter Non-applicable 16/31 (51,6)
Absent 8/31 (25,8)
Missing 0/31 (0,0)
68. Laboratory facilities for hemoglobin or hematocrit Non-applicable 13/31 (41,9)
Absent 0/31 (0,0)
Adequate 18/31 (58,1)
Missing 0/31 (0,0)
69. Nasogastric (NG) tube Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
70. Weighing scale for children Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
71. Recognize altered consciousness; lateralizing signs, Non-applicable 13/31 (41,9)
pupils Absent 8/31 (25,8)
Missing 0/31 (0,0)
72. Maintain normotension and oxygenation to prevent Non-applicable 31/31 (100,0)
secondary brain injury Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
73. Avoid overhydration in the presence of raised ICP (with Non-applicable 31/31 (100,0)
normal BP) Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
74. Maintenance of requirements for protein and calories Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
75. Recognize platysmal penetration Non-applicable 30/31 (96,8)
Absent 0/31 (0,0)
Adequate 1/31 (3,2)
60
Missing 0/31 (0,0)
76. External pressure for bleeding Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
77. Surgical skills to explore neck Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
78. Adequate pain control for chest injuries/rib fractures Non-applicable 28/31 (90,3)
Absent 2/31 (6,4)
Adequate 0/31 (0,0)
Missing 1/31 (3,2)
79. Respiratory therapy for chest injuries/rib fractures Non-applicable 29/31 (93,5)
Absent 1/31 (3,2)
Adequate 0/31 (0,0)
Missing 1/31 (3,2)
80. Rib block or intrapleural block Non-applicable 29/31 (93,5)
Absent 1/31 (3,2)
Adequate 0/31 (0,0)
Missing 1/31 (3,2)
81. Recognition of neurovascular compromise; disability- Non-applicable 14/31 (45,2)
prone injuries Absent 12/31 (38,7)
Adequate 1/31 (3,2)
Missing 0/31 (0,0)
82. Basic immobilization (sling, splint) Non-applicable 19/31 (61,3)
Absent 3/31 (9,7)
Missing 0/31 (0,0)
83. Wrapping of pelvic fractures of haemorrhage control Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
84. Skin traction Non-applicable 22/31 (71,0)
Absent 1/31 (3,2)
Missing 0/31 (0,0)
85. Closed reduction Non-applicable 29/31 (93,5)
Absent 1/31 (3,2)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
86. Skeletal traction Non-applicable 28/31 (90,3)
Absent 1/31 (3,2)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
87. Operative wound management Non-applicable 17/31 (54,8)
Absent 1/31 (3,2)
Adequate 11/31 (35,5)
Missing 0/31 (0,0)
88. External fixation (or its functional equivalent: pins and Non-applicable 24/31 (77,4)
plaster) Absent 1/31 (3,2)
Missing 0/31 (0,0)
89. Internal fixation Non-applicable 26/31 (83,9)
Absent 0/31 (0,0)
61
Missing 0/31 (0,0)
90. Tendon repair Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
91. Hand injury; assessment and basic splinting Non-applicable 27/31 (87,1)
Absent 1/31 (3,2)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
92. Hands: debride, fix Non-applicable 27/31 (87,1)
Absent 1/31 (3,2)
Adequate 2/31 (6,4)
Missing 0/31 (0,0)
93. Amputation Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
94. X-ray Non-applicable 0/31 (0,0)
Absent 3/31 (9,7)
Adequate 26/31 (83,9)
Missing 0/31 (0,0)
95. Proper management of immobilized patient to prevent Non-applicable 26/31 (83,9)
complications Absent 3/31 (9,7)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
96. Assessment – recognition of presence or risk of spinal Non-applicable 17/31 (54,8)
injury Absent 14/31 (45,2)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
97. Immobilization: C-collar, backboard Non-applicable 17/31 (54,8)
Absent 5/31 (16,1)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
98. Monitoring of neurological function Non-applicable 24/31 (77,4)
Absent 5/31 (16,1)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
99. Maintain normotension and oxygenation to prevent Non-applicable 31/31 (100,0)
secondary neurological injury Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
100. Holistic approach to prevention of complications – Non-applicable 31/31 (100,0)
especially pressure scores and urinary Absent 0/31 (0,0)
retention/infection Partially adequate 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
101. Non-surgical management of spinal injury (as indicated) Non-applicable 31/31 (100,0)
Absent 0/31 (0,0)
Adequate 0/31 (0,0)
Missing 0/31 (0,0)
62
Appendix 8: Self-assessed knowledge according to questionnaires
Table 9. Self-assessed theoretical knowledge and practical skills according to

questionnaires.
n/N (%)
Interns: 9/21 (42,8)
Residents: 10/21 (47,6)
Specialists: 2/21 (9,5)
Theoretical knowledge Practical skills

n/N (%) n/N (%)
1. Assessment of airway compromise No 0/21 (0,0) No 2/21 (9,5)
Yes 20/21 (95,2) Yes 19/21 (90,5)
Missing 1/21 (4,8) Missing 0/21 (0,0)
2. Manual maneuvers (chin lift, jaw No 0/21 (0,0) No 3/21 (14,3)
thrust, recovery position etc.) Yes 20/21 (95,2) Yes 18/21 (85,7)
Missing 1/21 (4,8) Missing 0/21 (0,0)
3. Insertion of oral or nasal airway No 1/21 (4,8) No 7/21 (33,3)
Yes 19/21 (90,5) Yes 13/21 (61,9)
Missing 1/21 (4,8) Missing 1/21 (4,8)
4. Use of suction No 4/21 (19,0) No 9/21 (42,8)
Yes 16/21 (76,2) Yes 11/21 (52,4)
Missing 1/21 (4,8) Missing 1/21 (4,8)
5. Assisted ventilation using bag-valve- No 0/21 (0,0) No 5/21 (23,8)
mask Yes 21/21 (100,0) Yes 16/21 (76,2)
Missing 0/21 (0,0) Missing 1/21 (4,8)
6. Endotracheal intubation No 6/21 (28,6) No 14/21 (66,7)
Yes 15/21 (71,4) Yes 6/21 (28,6)
Missing 0/21 (0,0) Missing 1/21 (4,8)
7. Cricothyroidotomy (with or without No 9/21 (42,8) No 17/21 (81,0)
tracheostomy) Yes 12/21 (57,1) Yes 3/21 (14,3)
Missing 0/21 (0,0) Missing 1/21 (4,8)
8. Assessment of respiratory distress No 2/21 (9,5) No 3/21 (14,3)
and adequacy of ventilation Yes 18/21 (85,7) Yes 17/21 (81,0)
Missing 1/21 (4,8) Missing 0/21 (4,8)
9. Administration of oxygen No 0/21 (0,0) No 1/21 (4,8)
Yes 20/21 (95,2) Yes 20/21 (95,2)
Missing 1/21 (4,8) Missing 0/21 (0,0)
10. Needle thoracotomy No 9/21 (42,8) No 17/21 (81,0)
Yes 12/21 (57,1) Yes 3/21 (14,3)
Missing 0/21 (0,0) Missing 1/21 (4,8)
11. Chest tube insertion No 4/21 (19,0) No 15/21 (71,4)
Yes 17/21 (81,0) Yes 5/21 (23,8)
Missing 0/21 (0,0) Missing 1/21 (4,8)
12. Assessment of shock No 1/21 (4,8) No 3/21 (14,3)
Yes 19/21 (90,5) Yes 18/21 (85,7)
Missing 1/21 (4,8) Missing 0/21 (0,0)
13. Compression for control of No 0/21 (0,0) No 2/21 (9,5)
haemorrhage Yes 20/21 (95,2) Yes 19/21 (90,5)
Missing 1/21 (4,8) Missing 0/21 (0,0)
14. Arterial tourniquet in extreme No 0/21 (0,0) No 5/21 (23,8)
situations Yes 21/21 (100,0) Yes 15/21 (71,4)
Missing 0/21 (0,0) Missing 1/21 (4,8)
15. Splinting of fractures for No 2/21 (9,5) No 7/21 (33,3)
haemorrhage control Yes 18/21 (85,7) Yes 14/21 (66,7)
Missing 1/21 (4,8) Missing 0/21 (0,0)
16. Pelvic wrap for haemorrhage control No 11/21 (53,4) No 13/21 (61,9)
Yes 10/21 (47,6) Yes 7/21 (33,3)
Missing 0/21 (0,0) Missing 1/21 (4,8)
17. Knowledge of fluid resuscitation No 1/21 (4,8) No 2/21 (9,5)
Yes 19/21 (90,5) Yes 19/21 (90,5)
Missing 1/21 (4,8) Missing 0/21 (0,0)
18. Peripheral percutaneous intravenous No 2/21 (9,5) No 2/21 (9,5)
access Yes 19/21 (90,5) Yes 18/21 (85,7)
Missing 0/21 (0,0) Missing 1/21 (4,8)
19. Peripheral cutdown access No 9/21 (42,8) No 13/21 (61,9)
Yes 12/21 (57,1) Yes 7/21 (33,3)
Missing 0/21 (0,0) Missing 1/21 (4,8)
63
20. Central venous access for fluid No 6/21 (28,6) No 14/21 (66,7)
administration Yes 15/21 (71,4) Yes 6/21 (28,6)
Missing 0/21 (0,0) Missing 1/21 (4,8)
21. Intraosseous access for children No 11/21 (52,4) No 16/21 (76,2)
under 5 years Yes 10/21 (47,6) Yes 4/21 (19,0)
Missing 0/21 (0,0) Missing 1/21 (4,8)
22. Transfusion knowledge and skills No 1/21 (4,8) No 7/21 (33,3)
Yes 19/21 (90,5) Yes 14/21 (66,7)
Missing 1/21 (4,8) Missing 0/21 (0,0)
23. Knowledge of resuscitation No 1/21 (4,8) No 4/21 (19,0)
parameters Yes 20/21 (95,2) Yes 16/21 (76,2)
Missing 0/21 (0,0) Missing 1/21 (4,8)
24. Differential diagnosis of causes of No 2/21 (9,5) No 6/21 (28,6)
shock Yes 19/21 (90,5) Yes 14/21 (66,7)
Missing 0/21 (0,0) Missing 1/21 (4,8)
25. Use of fluids and antibiotics for No 5/21 (23,8) No 7 /21 (33,3)
septic shock Yes 16/21 (76,2) Yes 13/21 (61,9)
Missing 0/21 (0,0) Missing 1/21 (4,8)
26. Recognition of hypothermia No 1/21 (4,8) No 5/21 (23,8)
Yes 19/21 (90,5) Yes 16/21 (76,2)
Missing 1/21 (4,8) Missing 0/21 (0,0)
27. External rewarming in hypothermia No 7/21 (33,3) No 12/21 (57,1)
Yes 14/21 (66,7) Yes 8/21 (38,1)
Missing 0/21 (0,0) Missing 1/21 (4,8)
28. Use of warm fluids No 9/21 (42,8) No 12/21 (57,1)
Yes 12/21 (57,1) Yes 7/21 (33,3)
Missing 0/21 (0,0) Missing 2/21 (9,5)
29. Knowledge of core rewarming No 10/21 (47,6) No 12/21 (57,1)
Yes 11/21 (52,4) Yes 8/21 (38,1)
Missing 0/21 (0,0) Missing 1/21 (4,8)
30. Recognize altered consciousness; No 3/21 (14,3) No 4/21 (19,0)
lateralizing signs, pupils Yes 17/21 (81,0) Yes 17/21 (81,0)
Missing 1/21 (4,8) Missing 0/21 (0,0)
31. Maintain normotension and No 2/21 (9,5) No 5/21 (23,8)
oxygenation to prevent secondary Yes 18/21 (85,7) Yes 16/21 (76,2)
brain injury Missing 1/21 (4,8) Missing 0/21 (0,0)
32. Avoid overhydration in the presence No 3/21 (14,3) No 8/21 (38,1)
of raised ICP (with normal BP) Yes 18/21 (85,7) Yes 12/21 (57,1)
Missing 0/21 (0,0) Missing 1/21 (4,8)
33. Maintenance of requirements for No 8/21 (38,1) No 11/21 (52,4)
protein and calories Yes 13/21 (61,9) Yes 9/21 (42,8)
Missing 0/21 (0,0) Missing 1/21 (4,8)
34. Recognize platysmal penetration No 13/21 (61,9) No 13/21 (61,9)
Yes 8/21 (38,1) Yes 7/21 (33,3)
Missing 0/21 (0,0) Missing 0/21 (0,0)
35. External pressure for bleeding No 5/21 (23,8) No 6/21 (28,6)
Yes 16/21 (76,2) Yes 14/21 (66,7)
Missing 0/21 (0,0) Missing 1/21 (4,8)
36. Surgical skills to explore neck No 9/21 (42,8) No 16/21 (76,2)
Yes 12/21 (57,1) Yes 4/21 (19,0)
Missing 0/21 (0,0) Missing 1/21 (4,8)
37. Adequate pain control for chest No 3/21 (14,3) No 9/21 (42,8)
injuries/rib fractures Yes 17/21 (81,0) Yes 12/21 (57,1)
Missing 1/21 (4,8) Missing 0/21 (0,0)
38. Respiratory therapy for chest No 5/21 (23,8) No 9/21 (42,8)
injuries/rib fractures Yes 15/21 (71,4) Yes 12/21 (57,1)
Missing 1/21 (4,8) Missing 0/21 (0,0)
39. Rib block or intrapleural block No 12/21 (57,1) No 17/21 (81,0)
Yes 9/21 (42,8) Yes 3/21 (14,3)
Missing 0/21 (0,0) Missing 1/21 (4,8)
40. Recognition of neurovascular No 5/21 (23,8) No 11/21 (52,4)
compromise; disability-prone injuries Yes 16/21 (76,2) Yes 9/21 (42,8)
Missing 0/21 (0,0) Missing 1/21 (4,8)
41. Basic immobilization (sling, splint) No 0/21 (0,0) No 3/21 (14,3)
Yes 20/21 (95,2) Yes 18/21 (85,7)
Missing 1/21 (4,8) Missing 0/21 (0,0)
42. Spine board No 6/21 (28,6) No 11/21 (52,4)
Yes 15/21 (71,4) Yes 9/21 (42,8)
Missing 0/21 (0,0) Missing 1/21 (4,8)
64
43. Wrapping of pelvic fractures of No 7/21 (33,3) No 11/21 (52,4)
haemorrhage control Yes 13/21 (61,9) Yes 10/21 (47,6)
Missing 1/21 (4,8) Missing 0/21 (0,0)
44. Skin traction No 3/21 (14,3) No 8/21 (38,1)
Yes 18/21 (85,7) Yes 12/21 (57,1)
Missing 0/21 (0,0) Missing 1/21 (4,8)
45. Closed reduction No 3/21 (14,3) No 10/21 (47,6)
Yes 18/21 (85,7) Yes 10/21 (47,6)
Missing 0/21 (0,0) Missing 1/21 (4,8)
46. Skeletal traction No 3/21 (14,3) No 10/21 (47,6)
Yes 18/21 (85,7) Yes 9/21 (42,8)
Missing 0/21 (0,0) Missing 2/21 (9,5)
47. Operative wound management No 4/21 (19,0) No 8/21 (38,1)
Yes 16/21 (76,2) Yes 13/21 (61,9)
Missing 1/21 (4,8) Missing 0/21 (0,0)
48. External fixation (or its functional No 3/21 (14,3) No 6/21 (28,6)
equivalent: pins and plaster) Yes 17/21 (81,0) Yes 15/21 (71,4)
Missing 1/21 (4,8) Missing 0/21 (0,0)
49. Internal fixation No 7/21 (33,3) No 13/21 (61,9)
Yes 14/21 (66,7) Yes 7/21 (33,3)
Missing 0/21 (0,0) Missing 1/21 (4,8)
50. Tendon repair No 5/21 (23,8) No 10/21 (47,6)
Yes 16/21 (76,2) Yes 10/21 (47,6)
Missing 0/21 (0,0) Missing 1/21 (4,8)
51. Hand injury; assessment and basic No 2/21 (9,5) No 3/21 (14,3)
splinting Yes 18/21 (85,7) Yes 18/21 (85,7)
Missing 1/21 (4,8) Missing 0/21 (0,0)
52. Hands: debride, fix No 4/21 (19,0) No 8/21 (38,1)
Yes 16/21 (76,2) Yes 13/21 (61,9)
Missing 1/21 (4,8) Missing 0/21 (0,0)
53. Amputation No 6/21 (28,6) No 11/21 (52,4)
Yes 15/21 (71,4) Yes 9/21 (42,8)
Missing 0/21 (0,0) Missing 1/21 (4,8)
54. X-ray No 0/21 (0,0) No 0/21 (0,0)
Yes 20/21 (95,2) Yes 21/21 (100,0)
Missing 1/21 (4,8) Missing 0/21 (0,0)
55. Proper management of immobilized No 0/21 (0,0) No 2/21 (9,5)
patient to prevent complications Yes 19/21 (90,5) Yes 18/21 (85,7)
Missing 2/21 (9,5) Missing 1/21 (4,8)
56. Assessment – recognition of No 2/21 (9,5) No 4/21 (19,0)
presence or risk of spinal injury Yes 19/21 (90,5) Yes 16/21 (76,2)
Missing 0/21 (0,0) Missing 1/21 (4,8)
57. Immobilization: C-collar, backboard No 3/21 (14,3) No 5/21 (23,8)
Yes 17/21 (81,0) Yes 16/21 (76,2)
Missing 1/21 (4,8) Missing 0/21 (0,0)
58. Monitoring of neurological function No 3/21 (14,3) No 4/21 (19,0)
Yes 17/21 (81,0) Yes 17/21 (81,0)
Missing 1/21 (4,8) Missing 0/21 (0,0)
59. Maintain normotension and No 3/21 (14,3) No 6/21 (28,6)
oxygenation to prevent secondary Yes 17/21 (81,0) Yes 15/21 (71,4)
neurological injury Missing 1/21 (4,8) Missing 0/21 (0,0)
60. Holistic approach to prevention of No 7/21 (33,3) No 10/21 (47,6)
complications – especially pressure Yes 13/21 (61,9) Yes 11/21 (53,4)
scores and urinary retention/infection Missing 1/21 (4,8) Missing 0/21 (0,0)
61. Non-surgical management of spinal No 9/21 (42,8) No 12/21 (57,1)
injury (as indicated) Yes 12/21 (57,1) Yes 8/21 (38,1)
Missing 0/21 (0,0) Missing 1/21 (4,8)
65

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Traffic Accident Care at the HEODRA

hospital in the city of León, Nicaragua:

Degree project 30 c, Medicine Program Uppsala University

International Maternal and Child Heath (IMCH), Department of Women´s

Totalt observerades 31 olycksfall. Alla trafikolycksfall omhändertas initialt på ortoped- eller

The global and Nicaraguan situation concerning road traffic injuries

Deaths caused by traffic

In developed countries the higher survival rates can

Figure 2. Comparison on deaths due to in patient survival is the result of improvements of

The post-crash response and hospital care

Quality of care and how it is measured

Investigations made in Thailand on trauma quality improvement identified several common

The elements of essential trauma care

Theoretical framework on assessment of quality of care in an emergency setting

There is a lack of defined evidence-based, universally accepted quality indicators in emergency

Table 1. Availability of material at the emergency department in HEODRA hospital, León,

Gloves X Suction device: at least X Crystalloid X

Organization of emergency care based on interviews and observation

Traffic accident care observed and assessment of quality of care

on observations during the care-giving process, 0 20 40 60 80

completed with questions to the nurse and/or doctor if Checklist Records

31,1 (median 27,0, min 14,0, max 60,0) years, similar 20

(median 27, min 7, max 342 minutes). The mean Medical

minutes) and the mean total time in emergency Resident

Records Checklist Records Checklists

Immobilization: C-collar, backboard

Assessment – recognition of presence or

Assessment of airway compromise

Orthopedic unit Surgery unit

Orthopedic unit Surgery unit

Table 5. Characteristics of the patients hospitalized

Conclusions and own experiences

➢ Organization and development of in-service trauma education for health care

4. Tercero F. Measuring Injury Magnitude and Patterns in a Low-Income Country: Experiences

6. Mock C, Nguyen S, Quansah R, Arreola-Risa C, Viradia R, Joshipura M. Evaluation of

26. SWESEMs Utbildningsutskott. Initialt omhändertagande [Internet]. Swedish Society for

28. Donabedian A. Evaluating the Quality of Medical Care. Milbank Q. 2005;83(4):691–729.

UNIVERSIDAD NACIONAL AUTÓNOMA DE NICARAGUA

UNIVERSIDAD NACIONAL AUTÓNOMA DE NICARAGUA

Traffic accident number: ________________________________________________________________

Number of victims: ________________________________________________________________

Type of accident: car motorcycle pedestrian bicycle other

Outcome of care: observation hospitalization home

Time of accident: daytime (8am-4pm) evening (4pm-12am) night (12am-8am)

Day: weekday (Mon-Thu) weekend (Fri-Sun)

Transportation: Cruz Roja Bomberos Bomberos Policía Own Referred

First care-taking person: nurse medical intern resident specialist

Time from accident to arrival at hospital: __________________________________________________________

Time from arrival to see a doctor: _______________________________________________________________

Total time in emergency room: _________________________________________________________________

Emergency unit: orthopedic surgery other: _________________________________

Use of trauma severity scoring system: □ Yes: ____________________________________________

Knowledge and skills Non Absent Partially Adequate

Manual maneuvers (chin lift, jaw thrust, recovery

Assisted ventilation using bag-valve-mask

Cricothyroidotomy (with or without tracheostomy)

Non-applicable: not relevant for the case

Equipment and supplies Non- Absent Partially Adequate

Suction device: at least manual (bulb) or foot pump

Yankauer or other stiff suction tip

Basic trauma pack

BREATHING – MANAGEMENT OF RESPIRATORY DISTRESS

Chest tube insertion

Breathing: equipment and supplies Non- Absent Partially Adequate