Crystalloid resuscitation is associated with decreased treatment delays and improved systolic blood pressures in a blood-constrained setting.

Objectives: We analyzed resuscitation practices in Cameroonian patients with trauma as a first step toward developing a context-appropriate resuscitation protocol. We hypothesized that more patients would receive crystalloid-based (CB) resuscitation with a faster time to administration than blood product (BL) resuscitation. Methods: We included patients enrolled between 2017 and 2019 in the Cameroon Trauma Registry (CTR). Patients presenting with hemorrhagic shock (systolic blood pressure (SBP) <100 mm Hg and active bleeding) were categorized as receiving CB, BL, or no resuscitation (NR). We evaluated differences between cohorts with the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. We compared time to treatment with the Wilcoxon rank sum test. Results: Of 9635 patients, 403 (4%) presented with hemorrhagic shock. Of these, 278 (69%) patients received CB, 39 (10%) received BL, and 86 (21%) received NR. BL patients presented with greater injury severity (Highest Estimated Abbreviated Injury Scale (HEAIS) 4 BL vs 3 CB vs 1 NR, p<0.001), and lower median hemoglobin (8.0 g/dL BL, 11.4 g/dL CB, 10.6 g/dL NR, p<0.001). CB showed greater initial improvement in SBP (12 mm Hg CB vs 9 mm Hg BL vs 0 NR mm Hg, p=0.04) compared with BL or no resuscitation, respectively. Median time to treatment was lower for CB than BL (12 vs 131 min, p<0.01). Multivariate logistic regression adjusted for injury severity found no association between resuscitation type and mortality (CB adjusted OR (aOR) 1.28, p=0.82; BL aOR 1.05, p=0.97). Conclusions: CB was associated with faster treatment, greater SBP elevation, and similar survival compared with BL in Cameroonian patients with trauma with hemorrhagic shock. In blood-constrained settings, treatment delays associated with blood product transfusion may offset the physiologic benefits of an early BL strategy. CB prior to definitive hemorrhage control in this resource-limited setting may be a necessary strategy to optimize perfusion pressure. Level of evidence and study type: III, retrospective study.

Feasibility and acceptability of mobile phone-based triage tool to identify discharged trauma patients in need of further care in Cameroon.

Background: Lack of routine follow-up for trauma patients after hospital discharge likely contributes to high rates of injury-related complications in Cameroon. Mobile phone contact may facilitate timely follow-up and reduce disability for high-risk patients. A previous single-center study showed promising feasibility of mobile health (mHealth) triage, but generalizability remains unknown. We evaluated the feasibility and acceptability of implementing a postdischarge mHealth triage tool at four hospitals in Cameroon. Methods: Trauma patients from four Cameroonian hospitals were contacted at 2 weeks, 1, 3, and 6 months postdischarge. Program feasibility was assessed by calculating the proportion of successful contacts and overall cost. Odds of successful contact were compared using generalized estimating equations across patient socioeconomic status. Acceptability was assessed using a structured patient survey at 2 weeks and 6 months postdischarge. Results: Of 3896 trauma patients, 59% were successfully contacted at 2 weeks postdischarge. Of these, 87% (1370/1587), 86% (1139/1330), and 90% (967/1069) were successfully reached at the 1-month, 3-month, and 6-month timepoints, respectively. The median cost per patient contact was US$3.17 (IQR 2.29-4.29). Higher socioeconomic status was independently associated with successful contact; rural poor patients were the least likely to be reached (adjusted OR 0.11; 95% CI 0.04 to 0.35). Almost all surveyed patients reported phone-based triage to be an acceptable follow-up method. Conclusion: Telephone contact is a feasible and acceptable means to triage postdischarge trauma patients in Cameroon. While scaling an mHealth follow-up program has considerable potential to decrease injury morbidity in this setting, further research is needed to optimize inclusion of socioeconomically marginalized groups. Level of evidence: Level III, prospective observational study.

Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon.

INTRODUCTION: Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants' perceptions on leadership, medical errors, and the QI process in Cameroon. METHODS: Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation. RESULTS: A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants' perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4. CONCLUSIONS: These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.

Baseline Patient Safety Culture in Cameroon: Setting a Foundation for Trauma Quality Improvement.

BACKGROUND: Trauma quality improvement (QI) has resulted in decreased trauma mortality and morbidity in high-income countries and has the potential to do the same in low- and middle-income countries. Effective implementation of QI programs relies on a foundational culture of patient safety; however, studies on trauma-related patient safety culture in Sub-Saharan Africa remain scarce. This study assesses baseline patient safety culture in Cameroon to best identify opportunities for improvement. MATERIALS AND METHODS: Over a 3-week period, the Hospital Survey on Patient Safety Culture was administered in three hospitals in the Littoral region of Cameroon. Percentages of positive responses (PPRs) were calculated across 42 items in 12 survey dimensions. A mixed-effects logistic regression model was used to summarize dimension-level percentages and confidence intervals. RESULTS: A total of 179 trauma-related hospital personnel were surveyed with an overall response rate of 76.8%. High PPRs indicate favorable patient safety culture. Of the 12 dimensions evaluated by the Hospital Survey on Patient Safety Culture, nine had a PPR below 50%. Dimensions particularly pertinent in the context of QI include Nonpunitive Response to Errors with a PPR of 25.8% and Organization Learning-Continuous Improvement with a PPR of 64.7%. CONCLUSIONS: The present study elucidates an opportunity for the development of trauma patient safety culture in Cameroon. Low PPR for Nonpunitive Response to Errors indicates a need to shift cultural paradigms from ascribing individual blame to addressing systemic shortcomings of patient care. Moving forward, data from this study will inform interventions to cultivate patient safety culture in partnering Cameroonian hospitals.