i
Barriers and enablers for implementation of Trauma
Society Accreditation in Western Cape Private
Hospitals
AMJ Klette
orcid.org/0000-0003-2735-7176
Dissertation in partial
fulfilment of the requirements for the
degree
Master of Health Sciences
in Transdisciplinary Health
Promotion at the Potchefstroom Campus of the North-West
University
Supervisor:
Prof IM Kruger
Co-supervisor:
Prof P Bester
Graduation: Fall 2020
1 PREFACE
The article format has been chosen for this dissertation. This is the format approved by the North-West University. The dissertation consists of a motivation, literature overview, a manuscript to be submitted to a peer-reviewed journal, namely the African Journal of
Emergency Medicine (AFJEM), and a concluding chapter that summarises the main findings
and recommendations.
The layout of the dissertation is as follows:
Chapter 1: Overview of the research: background, detailed literature study, motivation, aim
and objectives, and methods used to collect data.
Chapter 2: Research article comprising the African Journal of Emergency Medicine (AFJEM)
instructions to authors, and the dissertation article consisting of an abstract, introduction, methods, results, discussion, conclusion, and acknowledgements.
Chapter 3: Discussion of the main findings, limitations, conclusion, and recommendations.
The reference list for each chapter is included at the end of the chapter. Chapters 1 and 3 follow the NWU Harvard style of referencing, while Chapter 2 is set out according to the author instructions of AFJEM.
2 ACKNOWLEDGEMENT
I am grateful and thankful to the following people without whom this Masters would not have been mastered.
Professor Lanthé Kruger, my supervisor, for her support and guidance through the entire
process up to the final submission, for the times when I needed an academic push to get me over my hurdles and laughing with me while I got there.
Professor Petra Bester, co-supervisor, for her invaluable academic support and guidance,
and for believing in me from beginning to end.
The staff members of AUTHeR for showing me how to put my thoughts into (academic)
writing that meant something without losing my personal thoughts and ideas.
All the participants who took part in the research.
My daughters Aileen and Jean. A Master’s degree is a major achievement and a proud
moment but is not comparable to the pride that I have for both of you. You are amazing young ladies and I love you both. Ross, always in my heart.
My husband Alan, your never-ending support and belief in me always amazes me. The fact
3 DECLARATION
I hereby declare that this dissertation is my own work and has not been submitted to any institution before. I declare that this work has not been plagiarised, nor did I violate any copyright restrictions. I declare that I have given due references to all the sources used in the dissertation and that the sources are completely and accurately referenced in the list of references.
25 November 2019
___________________________ _______________
4 ABSTRACT
In 2011 the Trauma Society of South Africa (TSSA) published recommendations for accrediting hospitals with emergency departments (EDs) in the South African Medical Journal (SAMJ). These guidelines were drafted for South Africa following international evidence that an improvement was seen in patient outcomes following the implementation of accreditation. Emergency medical services (EMS) personnel have little to help them decide where to take a patient, other than “the closest, most appropriate facility”. TSSA accreditation is intended to provide an objective grading of expertise and resource availability at a specific facility that would assist the EMS community in making informed decisions. However, few facilities have subsequently sought or achieved TSSA accreditation.
This research aimed to explore the rationale behind the lack of implementation of accreditation in private hospitals in the Western Cape, despite ample international evidence relating trauma accreditation with better patient outcomes. The research details the barriers and enablers for the implementation of the TSSA accreditation in the Western Cape private hospitals. The Western Cape has the highest trauma prevalence in South Africa, yet only two private hospitals and no public hospitals in the province have been accredited according to the TSSA accreditation tool.
The research was qualitative, interpretive descriptive, and contextual in nature. All five private hospital groups in the Western Cape were invited to participate after ethical approval and permissions were obtained. Through purposive quota sampling and predetermined inclusion criteria, three different categories of participants were recruited from each hospital group, namely emergency department unit managers, hospital general managers, and doctors from the emergency department practice. Sixteen semi-structured, individual interviews were conducted with an equal distribution between all three categories. Data collection continued until data saturation was reached (n=16). A first-order thematic analysis followed by a second-order interpretive analysis was concluded with a consensus discussion with a co-coder. Field notes were kept.
Five themes, twenty-one categories and sixty-nine sub-categories emanated from the data analysis. The themes highlighted the contextual realities of EDs within the private health system and that TSSA accreditation cannot be seamlessly applied to this system, without transformation by overcoming identified barriers and implementation of effective enablers. EDs need to be affiliated with tertiary training institutions and should be actively involved in the research. Participants held different understandings of TSSA accreditation, presented different rationales for accreditation, and suggested how accreditation could be facilitated.
5
Enablers were based on organisational strengths whilst barriers highlighted private health system realities and the geographical determinants of trauma care. It was recommended to contextualise the TSSA accreditation tool, and process, to the private hospital environment within the Western Cape. A collaborative approach to tool contextualisation can be used to obtain buy-in. Effective communication informing hospitals that the TSSA has no conflict of interest, may address perceptions about the TSSA accreditation being associated with only a specific hospital group. Whereas implementing a TSSA accreditation roadshow, presenting the propositional value thereof, with evidence of positive patient outcomes associated with the TSSA accreditation process would promote buy-in. Promoting the fact that TSSA accreditation could strengthen public-private collaborations within the eminent National Health Insurance (NHI) system, including enhanced trauma training opportunities to ensure continuous professional development which is a critical component of the TSSA accreditation process.
Key-words: trauma, accreditation, private hospitals, emergency departments (EDs), Trauma
6 LIST OF ABBREVIATIONS
ACLS Advanced cardiac life support
ACS American College of Surgeons
AFJEM African Journal of Emergency Medicine AIDS Acquired Immune Deficiency Syndrome ATLS Advanced Trauma Life Support
AUTHeR Africa Unit for Transdisciplinary Health Research BRICS Brazil, Russia, India, China, and South Africa
CME Continued medical education
DALY Disability-adjusted life years
EDs Emergency departments
EMS Emergency management system
GBD Global burden of disease and injury
HIV Human Immunodeficiency Virus
HIC High-income countries
ICD-10 International Classification of Diseases 10threvision
JTS Joint trauma system
HREC Health Research Ethics Committee
LIC Low-income countries
LMICS Low to middle-income countries
MVCs Motor vehicle crashes
NCDs Non-communicable diseases
7
NWU North-West University
PALS Paediatric advanced life support RTMC Road Traffic Management Corporation
SA South Africa
SAMJ South African Medical Journal
SES Socio-economic status
TB Tuberculosis
TSSA Trauma Society of South Africa
UK United Kingdom
UM Unit manager
US United States
USA United States of America
WHO World Health Organization
WWI World War I
WWII World War II
YLD Years lived with disability
8 TABLE OF CONTENTS PREFACE ……….1 ACKNOWLEDGEMENT ... 2 DECLARATION ... 3 ABSTRACT……… ... 4 LIST OF ABBREVIATIONS ... 6 TABLE OF CONTENTS ... 8
LIST OF CONCEPTUAL DEFINITIONS ... 14
LIST OF TABLES ... 17
LIST OF FIGURES ... 18
CHAPTER 1: INTRODUCTION AND OVERVIEW OF THE RESEARCH ... 19
1.1 Introduction ... 19
1.2 Traumatic injury: a public health challenge ... 20
1.2.1 The magnitude of traumatic injuries ... 21
1.2.2 Trends of injuries seen in South Africa ... 21
1.2.3 Mechanisms of traumatic injury ... 22
1.2.3.1 Unintentional injuries ... 22
1.2.3.2 Intentional injuries ... 22
1.2.4 Risk groups for injuries in South Africa ... 23
1.2.5 Consequences of injuries in South Africa ... 23
1.2.5.1 Morbidity ... 23
9
1.2.6 Trauma in South Africa ... 24
1.3 Trauma in South Africa with a focus on the Western Cape ... 28
1.4 Trauma care systems ... 29
1.4.1 International history of trauma care systems (1861– 1966) ... 29
1.4.2 Fundamental components of a trauma care system (1970) ... 30
1.4.3 Trauma care systems in South Africa ... 33
1.4.4 Advanced trauma life support (1980s) ... 33
1.5 Accreditation of trauma centres ... 34
1.5.1 Accreditation through the Trauma Society of South Africa ... 34
1.5.2 Trauma centre descriptions in South Africa adapted from the American system ... 35
1.5.2.1 Level I (Major trauma referral centre) ... 35
1.5.2.2 Level II (Urban trauma centre) ... 36
1.5.2.3 Level III (Community hospital) ... 36
1.5.2.4 Level IV (Primary health care facility) ... 36
1.6 Motivation for implementation of Trauma Society of South Africa accreditation ... 37
1.7 Problem statement ... 38
1.8 Research questions ... 39
1.8.1 Primary research question ... 39
1.8.2 Secondary research questions ... 39
1.9 Research aim and objectives ... 39
10
1.11 Paradigmatic perspective ... 40
1.11.1 Paradigmatic assumptions ... 40
1.11.2 Work systems theory ... 40
1.12 Research methodology ... 43
1.12.1 Context of the research ... 43
1.12.2 Research design ... 44
1.12.3 Target population ... 45
1.12.4 Sampling techniques and inclusion criteria ... 46
1.12.4.1 Participants ... 48
1.12.5 Determination of sample size ... 49
1.12.6 Participant recruitment ... 49
1.12.7 Data collection ... 49
1.12.8 Data analysis ... 50
1.12.9 Field notes ... 51
1.13 Credibility within the context of interpretive description ... 51
1.14 Ethical considerations ... 53 1.14.1 Permission ... 53 1.14.2 Informed consent ... 53 1.14.3 Anonymity ... 53 1.14.4 Confidentiality ... 54 1.14.5 Justice ... 54
1.14.6 Respect for research participants ... 54
11
1.14.8 Anticipated benefits ... 54
1.14.8.1 Direct and indirect benefits ... 55
1.14.9 Anticipated risks and precautions ... 55
1.14.10 Anticipated risks to the participants and precautions taken... 55
1.14.11 Anticipated risks to the researcher and precautions taken ... 55
1.14.12 Facilities ... 55
1.14.13 Reimbursement of research participants ... 55
1.14.14 Data management ... 56
1.14.15 Dissemination of research results ... 56
1.14.16 Researcher expertise and competence ... 56
1.14.17 Role of members within the research team ... 56
1.15 Conflict of interest ... 57
1.16 Summary ... 57
1.17 Format of the research report ... 57
1.18 References ... 58
CHAPTER 2: MANUSCRIPT ... 66
2.1 Manuscript writing declaration ... 66
2.2 Declaration... 66
2.3 Author guidelines ... 67
2.4 Title Page – Article ... 69
CHAPTER 3: EVALUATION, LIMITATIONS AND RECOMMENDATIONS ... 94
12
3.2 Conclusions ... 94
3.3 Evaluation of the study ... 95
3.3.1 Appropriateness and relevance of the research question ... 95
3.3.2 Research question and objectives ... 95
3.3.3 Methodology, sampling, data analysis, and collection ... 96
3.3.4 Enhancement of justice and rigour ... 96
3.3.5 Ethical consideration ... 97
3.4 Appropriateness of work systems theory ... 97
3.4.1 Information systems ... 97 3.4.2 Business informatics ... 98 3.4.3 Service science ... 98 3.4.4 Marketing ... 98 3.4.5 Organisational behaviour... 98 3.4.6 Management ... 99
3.4.7 Appropriateness and significance of researcher and team ... 99
3.5 Critical self-reflection ... 99
3.6 Recommendations ... 100
3.6.1 Recommendations for private hospitals in the Western Cape Province: ... 100
3.6.2 Recommendations for EDs in private hospitals in the Western Cape Province: ... 100
3.6.3 Recommendations for TSSA: ... 101
13
3.6.5 Recommendations for further research: ... 101
3.7 Summary ... 102
3.8 References ... 103
ANNEXURE 1: TRAUMA SOCIETY OF SOUTH AFRICA ACCREDITATION TOOL104 ANNEXURE 2: ETHICS APPROVAL... 112
ANNEXURE 3: PARTICIPANT INFORMED CONSENT ... 113
ANNEXURE 4: CONFIDENTIALITY AGREEMENT ... 118
14 LIST OF CONCEPTUAL DEFINITIONS
Below is a brief description of the concepts, in alphabetical order, that was central to this research:
Accreditation: A process or action officially identifying someone or something as having a
specific professional standing or being qualified to fulfil a particular activity (Oxford Dictionary, 2017). The term, as applied to this research, implies the process of evaluating private hospital emergency departments (EDs) based on the accreditation tool of the Trauma Society of South Africa (TSSA) to establish what type of patients the ED can safely manage, and then rate them as level I, II, III, or IV Accreditation may assist with the appropriate management of patients within the emergency management system (EMS) and avoid unnecessary delays in patient management. Other terms are also used to describe the process, for example, verification and designation. However, for the purpose of this research, the term accreditation was used.
Barrier: The Merriam-Webster dictionary (2012) defines a barrier as a circumstance or
obstacle that keeps people or things apart or prevents communication or progress (Merriam-Webster, 2012a). In this research, barriers referred to the obstacles hindering the implementation of the TSSA accreditation tool at EDs in private hospitals in the Western Cape.
Emergency: An injury that requires immediate attention, usually provided by a
multidisciplinary team of an emergency department (ED) or trauma centre of a hospital.
Emergency department (ED): The ED is a specialised unit in a hospital dedicated to the
treatment of unforeseen illness and injury that require immediate care (American College of Surgeons, 2014:18). The EDs in this research are positioned within private hospitals.
Enablers: Enablers are all the aspects that allow the realisation of something (Merriam-Webster, 2012b) and, in this research, refer to the dynamics that assisted the implementation of the TSSA accreditation tool at EDs in private hospitals in the Western Cape.
Injuries: The physical damage to the human body, either unintentional (accidentally) or
intentional; an integral part of the daily lives of humans. Injuries are globally organised by the International Classification of Disease, 10th revision (ICD-10) which is the official classification system of the World Health Organizations (WHO). Injuries can affect a single system or multi-systems; the latter is known as major trauma (Department of Health, 2019:6).
Non-natural causes of death: Events leading to death due to external factors such as
intentional, unintentional, and/or accidental injury; poisoning; homicide, or suicide. (Free Medical Dictionary, 2017a). Non-natural deaths include deaths due to violence with the
15
outcomes of the injuries resulting in death; following administration of an anaesthetic or surgical procedure close to the time of the patient’s death; sudden, unexplained death; and any death where there is neglect by medical staff or any other person (Department of Health, 2019). Non-natural causes of death are a reality in South Africa and require a vigorous preventative approach from EMS.
Private hospitals: Hospitals that operate from a fee-for-service business model. These
hospitals are funded by non-governmental providers, including patients; insurers, such as medical aids; or foreign embassies (Free Medical Dictionary, 2017b), as well as faith-based organisations, private ownership and owner-organisations. This research context is based within private hospitals where emergency care is rendered at a fee-for-service and is a substantial cost driver.
Trauma: Trauma is a disease process (Hardcastle et al., 2011:189) that occurs when an injury
is caused by an external object or force to the human body and is a leading cause to unnatural death or disability. These injuries are unexpected, acute, and require immediate medical intervention. Trauma is a consequence of a blunt, penetrating, or burn insult to the body. These injuries can be caused by motor vehicle accidents, falls, sports injuries and any other injuries that can occur at home, on the road, at work, or on the sports field. Natural disasters can also cause traumatic injuries (University of Florida Health, 2018). Traumatic injury in the United States of America, is legally defined as a wound or a condition of the body caused by external force, including injuries inflicted by bullets, explosives, sharp instruments, blunt objects or other physical blows, chemicals, electricity, climatic conditions, infectious diseases, radiation, and bacteria, but excluding stress and strain (US Legal, 2016).
Trauma care system: It has been proven that a systematic approach to [traumatic] injuries,
namely a trauma system, can reduce associated sequela, and mortality. A trauma care system is the structured and organised system that facilitates and coordinates a multidisciplinary system in order to deliver cost-effective service and care to an injured patient (Wanjiku et al., 2017).
Trauma centres: Within the healthcare sector in South Africa, trauma centres are described
according to levels of specialisation, namely as Level I (major trauma referral centre); Level II (urban trauma centre); Level III (community hospital); and Level IV (primary healthcare facility) (TSSA, 2017).
Trauma Society accreditation: A quality improvement process and tool developed by the
TSSA to link the level of a trauma centre with best practice requirements. This accreditation allocates different levels (I, II, III and IV) to hospitals so that emergency services personnel
16
know the capabilities of the hospitals they are transferring patients to and allow for better patient outcomes (TSSA, 2017).
Violence and injuries: Damage that occurs physically to the body by sudden or brief
subjection to intolerable levels of injury can be either intentional or unintentional. Examples of intentional violence and injuries are child abuse, attempted suicides, war-related injuries, and mob violence. Unintentional violence and injuries are, for example, motor vehicle crashes (MVC) drowning, burns, and falls where the intention is absent. Intentional injuries are often associated with violence, whereas unintentional injuries are not (IHME, 2018). The World Health Organisation (WHO) groups violence and injuries as one health indicator. Health indicators are grouped according to themes which can be found in the WHO’s global health observatory. Violence is the threatened or actual, deliberate use of power or physical force against oneself, another person, or against a group or community. It can result in injury, death, psychological harm, deprivation or mal-development (WHO, 2019). An injury occurs following contact with physical agents that exceed what the body can tolerate, these agents being heat, electricity, chemicals, radiation, and the leading source of injury, which is mechanical energy. A sudden lack of vital agents such as heat or oxygen can also cause injury.
17 LIST OF TABLES
Table 1-1: Number of motor vehicle crashes in South Africa during 2015 ... 25
Table 1-2: Top ten most commonly reported causes of death in South Africa
during 2015 ... 26 Table 1-3: Distribution of non-natural causes of death by broad groups in
South Africa ... 27 Table 1-4: Worst ten precincts in South Africa: the highest number of reported
crimes 2016 ... 29 Table 1-5: Inclusion criteria in the selection of hospitals and participants ... 47
Table 2-6: Summary of participants’ (n=16) demographics ... 78
18 LIST OF FIGURES
Figure 1-1: Schematic representation of injuries, trauma, and emergencies
within the context of South Africa ... 20 Figure 1-2: Components of a trauma care system ... 32
Figure 1-3: Work systems theory ... 41
Figure 1-4: Breakdown of hospitals in the Western Cape with emergency
departments ... 44 Figure 1-5: Target population sampling for interview process ... 46 Figure 1-6: Selected emergency departments, TSSA accreditation status and
proposed participants ... 48 Figure 2-7: Summary of the TSSA trauma centre levels and main components
within the TSSA accreditation tool. ... 72 Figure 2-8: Secondary level data analysis ... 83
19
CHAPTER 1: INTRODUCTION AND OVERVIEW OF THE RESEARCH 1.1 Introduction
Patients with traumatic injuries require immediate intervention with appropriate and definitive care, especially within the first hour (called the “golden hour”) after the injury. A significant number of trauma deaths in low- to middle-income countries (LMICs) can be prevented with available and affordable trauma care. “Preventable trauma death” is defined as a death that could have been prevented or avoided if the most optimal care had been provided to the injured person as soon as possible (Reynolds et al., 2017:522). Prevention of death after a traumatic injury can be attributed to several determinants, namely i) event determinant (severity of the injury); ii) patient determinant (physiological reserve of the patient), and iii) care determinant (appropriate and timely care). This research was focussed on the realm of the care determinant (Healthypeople, 2019).
Trauma centres are hospitals designated to receive the more severely injured patients who are at risk of trauma-related death. These facilities are considered to be an integral part of trauma care systems. The departure point of this research is a tabulated breakdown of the concepts of injuries, trauma, and emergency, which are applied to the context of this research and to the South African health context (see Figure 1-1 below).
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Figure 1-1: Schematic representation of injuries, trauma, and emergencies within the context of South Africa; applied to this research and adapted from the World Health Organization’s International Classification of Disease, version 10 (2016)
1.2 Traumatic injury: a public health challenge
Traumatic injuries are the leading cause of death and disability in the first forty years of an individual’s life. Almost 90% of the burden occurs in LMICs (WHO, 2010).
Injury/ies
• An event causing injuries to the human body due to external/mechanical force. • Injuries can lead to loss of limb(s), serious debilitating
effects, severe long-term outcomes and even death. • Patient brought into ED's by
paramedic; injuries severe. • For best survival, patient requires
specialised medical teams ,multi-disciplinary team , trauma surgeon(s), highly trained medical staff and sophisticated
equipment. • Requires immediate care in a
trauma centre, trauma centres categorised according to levels of
specialisation and equipment. • Examples: Traumatic motor
vehicle crashes, gunshot wounds, stab wounds, major burns, serious falls, blunt trauma
and traumatic brain injuries.
Trauma
• Physical damage to the human body due to various external
causes.
• ICD-10 (2016) classification XIX: injury, poisoning and other consequences of external causes
related to single body regions, character level (superfiscial; open
wound; fracture; dislocation; sprain; strain; traumatic amputation; crushing injury; injury
to internal organs; injury to nerves and spinal cord; injuries to
blood vessels; injuries to muscle, fascia and tendons); Injuries to multiple unspecified body regions
and poisoning and other consequences of external
causes.
• ICD-10 (2016) classification XX: External causes of morbidity and
mortality, such as accidents, intentional self-harm, assault,
undertermined intent, legal interventions and operations of
war, complications of medical/surgical care, sequelae
of external causes. • ICD-10 (2016) classification
XVIII: Symptoms, signs, abnormal clinical and laboratory findings not elsewhere classified,
such as physical violence. • Injuries classified according to
the place of occurance and activity during occurance. • Violence and injuries presented
as an epidemiological indicator by the World Health
Organization.
Emergency
• Suddent onset or change of symptoms; needs immediate
medical attention. • Patient or others perceive the
need to obtain immediate medical care by driving to ED or
phoning an ambulance. • Patients arrive at ED (self or by
ambulance) without a prior appointment.
• Patient is assessed within the ED by the multi-disciplinary team. • ED is part of the hospital and
renders general emergency medical care. • Examples: Severe or persistent
vomiting, diarrhoea, severe stomach pain, shortness of breath, possible broken limb(s),
signs of heart attack/stroke, burns, fainting, loss of
21 1.2.1 The magnitude of traumatic injuries
Due to the impact of trauma injuries on LMICs, epidemiological studies have been used to evaluate the advantages of injury prevention since the late 1940s and have mainly been compiled from mortality data. These studies reflect the shifting observation of injuries as preventable incidents and assess the causes of injuries, development, and assessment of trauma injury prevention programmes (Gordon, 1954:564).
The disability-adjusted life year (DALY) measure was developed by Harvard University in 1990 and adopted by WHO in 1996. The DALY measures the burden of disease by combining the total health loss at population level into a single indicator by summarising premature mortality in years of life lost (YLLs), and non-fatal health loss in years lived with disability (YLDs) (Murray & Lopez, 1997:481). The DALY provides a precise gauge of the scale of different health problems so that health planning can take place. This information is vital to assist with policy decision-making amongst countries concerning prevention and control because it can identify links between different diseases and injuries, and the health impact thereof (Haagsma et al., 2016:3).
In the early 1990s, the World Bank and WHO performed the first Global Burden of Disease (GBD) study, which includes a specific measure on injury. The DALY was used in this study to describe the burden of disease of ninety-eight diseases, nine injuries, and ten health risk factors for eight world regions (WHO, 2009). The GBD study and continuous updates by the WHO revealed that injuries were a significant cause of morbidity and mortality in developed and developing countries (Stevens et al., 2018).
1.2.2 Trends of injuries seen in South Africa
Political violence as a cause of injury virtually disappeared in South Africa following the transition to democracy in 1994. An epidemiological transition was then expected to be seen in infectious diseases, conditions related to malnutrition and childbirth, and mainly chronic and degenerative diseases. However, the disease profile was radically altered by the HIV epidemic and the continuity in external causes of death (trauma). This burden of disease profile was anticipated to reduce the average life expectancy to forty-one years of age by 2010 IHME, 2018). In 2018, the country experienced an increase in mining accident-related deaths and interpersonal and self-inflicted injuries (StatsSA, 2016). Of an approximate 59 935 fatalities, 46% were homicides followed by road traffic and self-inflicted injuries, which accounted for 26.7% and 9.1% of the injury mortality respectively. In males, the principal cause of fatal injuries was homicide with traffic injuries placing second. In females, this order was reversed (StatsSA, 2016). South Africa’s murder rate was highest amongst males aged fifteen through
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twenty-nine years, showing nine times the global rate. For women, the highest homicide incidence was in the thirty through forty-four-year-old age group, seven times the global rate. Road traffic mortality rates were almost double the global rate.
Violence has officially been recognised as a global health issue with the WHO reporting that 1.6 million people die annually from violence. South Africa's injury burden is remarkably high, particularly for the category of homicide, which is six times the global average. Interpersonal violence and motor vehicle crashes (MVCs) are the leading causes of injury in South Africa. The country's largest city, Cape Town, is home to almost two-thirds of the Western Cape's population and has the highest homicide rate for the period 2015 through 2016. Cape Town is one of the only places globally, where intentional injuries exceed unintentional injuries (Jabar & Matzopoulos, 2017).
1.2.3 Mechanisms of traumatic injury
As with other diseases, trauma has identifiable causes with established methods of treatment and defined methods of prevention (Ballesteros et al., 2018:6).
There are two types of traumatic injuries, namely unintentional and intentional.
1.2.3.1 Unintentional injuries
Unintentional refers to unplanned injuries that occur in a short space of time – minutes or seconds. Unintentional injuries are events in which a harmful outcome is not intended. They can be the result of a type of physical energy in the environment, e.g. falls, or normal body functions being obstructed by external means, e.g. drowning. The most common unintentional injuries result from MVCs, falls, fires and burns, drowning, poisonings, and aspirations (Maine Center for Disease Control & Prevention, 2018).
1.2.3.2 Intentional injuries
This term refers to decisive human action with the intention of causing harm; whether self-inflicted or interpersonal acts of violence; focused on oneself, or others; resulting in intentional injuries (Maine Center for Disease Control & Prevention, 2018). Examples of intentional injury are youth violence, intimate partner violence, sexual assault, rape, and suicide (Cape Peninsula University of Technology Disability Unit, 2015).
23 1.2.4 Risk groups for injuries in South Africa
Causes of injury can be triggered by human factors such as age and gender; physical and social environments and agents (e.g. drugs); energy (e.g. heat) or vehicles (cars, machinery, and others). (Warren, et.al., 2019). There is a need in South Africa to improve the way in which statistics are gathered. More accurate statistics will enable further research to establish effective preventative measures related to the injuries seen. However, this is beyond the scope of this study. Currently, South Africa sees a high number of injuries related to violence and road traffic accidents. One exception is that injury-related deaths in the age group fifteen through forty-nine has decreased in recent years, but the reason for this is unknown because of limited research (SAPS, 2019). In 2017/2018, the murder rate increased by 6.9%, seeing fifty-seven (57) people killed daily, forty-six of whom were men, eight women and two children. The Western Cape displayed the highest crime rate reported at police stations (Sicetsha, 2019:2).
1.2.5 Consequences of injuries in South Africa
The third leading cause of death and disability in South Africa is injuries. There were 5 404 fatal injuries seen in the Western Cape alone from 2008 to 2011 with the average age of the fatalities being nine years and the majority being male. The only time the mortality rate for girls was higher than boys was in the case of accidental, adolescent, ingestion poisoning suicides (Pretorius & Van Niekerk, 2015:38).
Instances of morbidity and mortality are used together to calculate the occurrence and outcomes of a particular injury or disease (Diffen, 2018).
1.2.5.1 Morbidity
Morbidity is defined as any deviation from a state of psychological or physiological well-being; a diseased condition or state (Mosby's Medical Dictionary, 2009). Injury is seen as a noteworthy cause of disability in the working population aged eighteen through sixty-four years (Kraus et al., 2018). It remains one of the highest causes of morbidity and mortality in both the LIC and middle-income countries (MIC). Factors affecting the cause of injuries are age, gender, region, and time. Much work is still needed to reduce this burden of disease (Haagsma
et al., 2016:12).
The occurrence of disease and injury incidence and YLDs is a critical contributor to global, regional, and national health policies since YLDs are declining more gradually than mortality rates. The number of people living with the consequences of a particular disease or injury is
24
increasing due to the ageing of the world’s population. Consequently, non-fatal aspects of disease and injury will require more and more attention from health systems (Vos et al., 2015:1546).
1.2.5.2 Mortality
Mortality is defined as the condition of being subject to death. The mortality (or death) rate reflects the number of deaths per unit of population in any region, age group, disease, or other classification. It is usually expressed as deaths per 1 000, 10.000, or 100.000 (Mosby's Medical Dictionary, 2009). In South Africa, injury-related mortality accounted for 12% of deaths and 16% of YLL. The primary contributors being high mortality rates from road traffic injuries and homicides, which, respectively, were in the region of twice and eight times the global average (Matzopoulos et al., 2015:304).
1.2.6 Trauma in South Africa
South Africa has a high trauma case prevalence, which is a noteworthy cost driver within the already expensive and overburdened health system. Trauma, in this context, is closely linked with multi-morbidity (Lalkhen & Mash, 2015:135).
There are currently no formal guidelines by the South African Department of Health to indicate the capabilities of EDs (Hardcastle & Brysiewicz, 2013:118). Therefore, emergency services take trauma patients to the closest facility, which is not necessarily the most appropriate facility. There has been a slow uptake of TSSA accreditation in both public and private health facilities in South Africa. This is despite claimed support by the TSSA in 2011 and international evidence from LMICs and high-income countries (HICs) on positive patient outcomes when implementing a system care approach. Reasons for the poor adoption of the TSSA accreditation are unknown despite international evidence of the value proposition thereof. South Africa, as a MIC, has persistent inequities and a history of a deprived majority (Goosen & Veller, 2016:1622) with a continuous communal dialogue on poverty, health, and the divide in access to health systems (Benatar, 2013:153). These factors are strongly linked to the quadruple burden of disease, listed as i) Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (HIV/AIDS); Tuberculosis (TB); ii) high maternal and child mortality rate; iii) poverty-related conditions; high levels of violence and injuries; iv) a growing number of non-communicable diseases (NCDs) (Yerramilli, 2015). In addition, South Africa has one of the highest MVC rates globally, and pedestrians account for more than half of all road traffic fatalities (Naidoo, 2013:613). An added factor to the burden is the financial implication of the volume of road traffic accidents. In 2015, a total of 832 431 MVCs were
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reported with 11 144 fatalities recorded by the road traffic management corporation (RTMC) (see Table 1-1 below). MVCs are ranked ninth in terms of DALYs lost worldwide and are predicted to rise to the third position globally by 2020. As defined earlier the reader is reminded that DALYs are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the YLD for people living with ill-health or its consequences (Salomon, 2014). Years of healthy life lost to premature death and disability are referred to as Disability-adjusted life years (DALYs). DALYs are the sum of years of life lost (YLLs) and years lived with disability (YLDs) (Haagsma et al., 2016:4).
Table 1-1: Number of motor vehicle crashes in South Africa during 2015 (Labuschagne, 2016)
MVC severity Fatal Major Minor Damage only Total
Number of MVC 11 144 40 117 132 609 648 560 832 431
MVC outcomes Death Serious Slight No injury Total
Number of persons 13 591 62 520 202 509 1 429 794 1 708 414
According to Statistics South Africa (Stats SA, 2016:50), mortality and causes of death in South Africa during 2015 correspond with its multi-morbidity profile and external causes of death are listed among the top ten reasons (see Table 1-2).
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Table 1-2: Top ten most commonly reported causes of death in South Africa during 2015 (Statistics South Africa, 2016:50)
Causes of death (based on ICD-10, 2016) Mortality number Percentage of population (%)
Other forms of heart disease 54 017 11,7
Hypertensive diseases 51 928 11,3
Tuberculosis 51 871 11,3
Ill-defined and unknown causes of mortality 51 297 11,1
Influenza and pneumonia 43 991 9,6
Cerebrovascular diseases 34 742 7,5
Other external causes of accidental injuries* 33 420 7,3
Diabetes mellitus 28 872 6,3
Other viral diseases 27 615 6,0
Renal failure 27 114 5,9
*Please refer to Figure 1-1 for the classification of injuries
Traumatic injuries in LMICs are caused mostly by violence or transport-related incidents (Norton & Kobusingye 2013:1723), and mostly in young, healthy males of low socio-economic status. This is often further aggravated by alcohol or drug misuse (Ramsoomar & Morojele, 2012:610). South Africa has a high incidence of fatal and non-fatal injuries that result from interpersonal violence, MVCs (many involving pedestrians), burns, falls, and other unintentional injuries (Hinsberger et al., 2016:1). Close to 50 000 people are killed per annum by non-natural causes of death (see Table 3), with external causes of accidental injuries, for example, transport accidents and assault, ranking third and fourth among the top ten non-natural causes of death in South Africa. Intentional and unintentional injuries were the second-leading cause of loss of healthy life in 2017, accounting for 14.3% of all DALYs in South Africa. Motor vehicle-related injuries were, in the 2017 stats, the leading cause of injury globally, with South Africa having exceedingly high numbers - double the global rate.
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Table 1-3: Distribution of non-natural causes of death by broad groups in South Africa (Statistics SA, 2016:50)
Causes of death (based on ICD-10, 2016) Mortality number Percentage of non-natural causes Percentage of all-cause mortality (N = 460 236)
Other external causes of accidental injury 32 006 62,5 7
Event of undetermined intent 3 415 6,7 0,7
Transport accidents 6 300 12,3 1,4
Assault 7 201 14,1 1,6
Complications of medical and surgical care 1 732 3,4 0,4
Intentional self-harm 485 0,9 0,1
Sequelae of external causes of morbidity and mortality*
86 0,2 < 0,0
Legal intervention and operations of war 2 < 0,0 < 0,0
Total 51 227 100,0% 11,2%
*Please refer to Figure 1-1 for the classification of injuries
The overall positive outcomes of trauma centres are based on timeous care rendered at the correct level and provided by the appropriate healthcare team. This team is to be led by trauma surgeons and is linked to fire and emergency pre-hospital care right through to rehabilitation (Hardcastle et al., 2011:189). In 2011, the TSSA, a professional body of trauma experts, published recommendations to accredit the EDs of hospitals according to one of four levels of trauma centre capabilities (Hardcastle et al., 2011:189-194). A trauma centre (called an emergency centre by the National Department of Health) is the fastest entry point for patients needing emergency services. It is a devoted area in a hospital managed and structured to deliver quality emergency (acute, urgent) care to all patients (South Africa, 2014:8).
In South Africa, EDs are linked to hospitals and are presented as part of a cluster of services associated with hospi-centric care. A typical private South African ED contains the following areas: ambulance bay, ambulance reception area, decontamination area, disaster and decontamination store, triage, patient registration and reception area, waiting room, security area, trauma and resuscitation rooms, isolation rooms, acute treatment cubicles, private sexual assault area, plaster room, procedure room, relatives room, staff work-stations,
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department corridors, sluice room, equipment and store-room, medication and clean utility room, administration area, staff tea room, and staff amenities (Department of Health, 2014:27). These departments are expensive cost drivers for a hospital, and there is insufficient information on their efficiencies in South Africa. There have been media accounts of increasing concerns about the pressure on EDs, for example, overcrowding and increased waiting times resulting in compromised patient care (Mahomed et al., 2015:429). The discrepancy between the number of patients arriving at the ED and its capacity to manage the volume and severity of injuries can contribute to poor patient flow and overcrowding, resulting in poor quality of care and subsequent poor patient outcomes (Jarvis, 2016:64).
Another challenge in South Africa is the absence of designated ED governance to determine the anticipated number of major trauma patients and the resources (inclusive of the number and level of the trauma centres in an area) required to manage those patients (Hardcastle et
al., 2011:190). Currently, EDs in private hospitals provide specialised care in the absence of
clearly stipulated criteria for appropriateness to manage specific types and amounts of trauma events. In addition, the National Department of Health’s regulations relating to categories of hospitals does not include EDs (Gray & Jack, 2013). At the time of the study, private hospital EDs functioned autonomously from the Department of Health’s services and according to the perceived market needs for trauma care.
1.3 Trauma in South Africa with a focus on the Western Cape
Autonomous functioning is especially applicable in the Western Cape, one of the nine provinces in South Africa with the highest crime incidents in the country in 2016 (see Table 1-4).
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Table 1-4: Worst ten precincts in South Africa: the highest number of reported crimes 2016
Area Province Number of crimes
Mitchells Plain Western Cape 19 499
Cape Town Central Western Cape 17 785
Johannesburg Central Gauteng 14 606
Durban Central KwaZulu-Natal 13 735
Honeydew Gauteng 12 889
Kraaifontein Western Cape 11 939
Park Road Free State 11 489
Pretoria Central Gauteng 11 444
Phoenix KwaZulu-Natal 11 206
Hillbrow Gauteng 10 933
Total 135 525
*(Council of International Investigators, 2016) 1.4 Trauma care systems
1.4.1 International history of trauma care systems (1861– 1966)
Trauma care systems were first implemented during the American Civil War (1861–1865). This system, although basic compared to trauma systems today, was considered the precursor for managing the injured years later during World War I (WWI) and World War II (WWII) (Smith, 2015: 2771). The first “trauma manual”, which documented how to care for the injured, was written during the Civil War by President Abraham Lincoln. Researchers were taken to the battlefields to document the findings following patient care (Smith, 2015: 2771). The first “Accident Service” (emergency departments) were developed after WWII in 1911 by a surgeon named Arnold Griswold who also trained health officers and equipped police and fire vehicles with equipment so that they could manage patients in transit to the hospital (Smith, 2015: 2771). In 1922, the American College of Surgeons (ACS) identified the need for a structured approach to trauma and formed the Committee on Treatment of Fractures which became the Committee on Trauma in the 1950s (Lee, 2013:259). The United States of
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America military services adopted principles from the civilian trauma system and developed the Joint Trauma System (JTS) to enhance and better coordinate care on the battlefield (Smith, 2015: 2771). It was anticipated that the development of a trauma system (within this trauma committee) would improve the overall survival of severely injured patients (Chow et
al., 2012:460). The Committee on Trauma provided leadership in advocating and forming the
concepts for trauma systems. The realisation that traumatic injuries required specialised, experienced, multidisciplinary treatment and specialised resources forced the nascent of trauma centres. Inadequate trauma support by hospitals in the UK led to the opening of the world’s first official trauma centre when the Birmingham Accident Hospital and Rehabilitation Centre came into existence in 1941 in England. It was initiated by the British Medical Association’s Committee on Fractures and the Interdepartmental Committee (British Trauma Society, 2017).
In comparison, the USA only gave national attention to trauma systems in 1966 (Boyd, 2010:132). A year before, in 1965, the interstate highway (constructed in the 1950s) claimed 49 000 lives attributed to MVC. Of these deaths, 107 000 were accidental injuries, while more than 10 million people were temporarily disabled and 400 000 people were permanently disabled. This led to the ground-breaking report, “Accidental Death and Disability: The
neglected disease of modern society”. It was published by the Committee on Shock and the
Committee on Trauma of the Division of Medical Sciences of the National Academy of Science in 1966 and described traumatic injuries as a national epidemic. This led to the first inclusive trauma unit in the USA in 1966, developed by Drs Freeark and Baker. This trauma unit provided prevention and pre-hospital services, critical care and surgery, rehabilitation, and extensive follow up care (American Association for the Surgery of Trauma, 2013).
1.4.2 Fundamental components of a trauma care system (1970)
In 1973 the USA’s, Emergency Medical Services Systems Act of 1973 identified trauma systems as one of fifteen essential components of an emergency management system (EMS) and allocated federal funds to support the development of regional EMS (Celso et al., 2006:371). Hospitals in the USA confirmed that the in-hospital mortality rate was significantly lower at trauma centres than at non-trauma centres (MacKenzie et al., 2006:371). In 1976, the ACS released the “Optimal Hospital Resources for the Injured Patient” manual, outlining the criteria for the ideal trauma centre according to the resources required. The core components for the continuum of care of the [traumatic] injured patient were also set out in this manual (American College of Surgeons, 2014).
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At the heart of such a comprehensive trauma care system is the continuum of care, which includes:
Injury prevention;
Pre-hospital care and retrieval services; Acute care services and facilities; and Post-hospital care (rehabilitation).
The potential to reduce the burden of injury on our health care system lies in trauma injury prevention. Injury prevention also has the ability to reduce resulting morbidity and mortality. Unfortunately, there is limited financial support for trauma injury prevention initiatives (Institute of Medicine (US) Committee on Injury Prevention and Control, 1999). The continuum of trauma care is depicted in the figure below (Fig 1-2). Interestingly, trauma injury prevention is not depicted as part of this figure.
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Figure 1-2: Components of a trauma care system (National Academies of Sciences, Engineering and Medicine, 2016:90)
33 1.4.3 Trauma care systems in South Africa
In South Africa, the advancement of nursing, surgery and pre-hospital care has been connected to trauma care. Trauma was inherent with political violence throughout South Africa’s struggle towards democracy. The first trauma centre, known as the “Accident Service”, under the guidance of Dr A.E. Wilkinson and the University of Witwatersrand, was established at the Johannesburg Hospital in 1962, preceding the USA trauma centres by years. Other units followed, namely Grootte Schuur (1982), Tygerberg Hospital (1987), Pelonomi (2006), and Baragwanath (built in 1941) (Hardcastle & Brysiewicz, 2013:119).
The TSSA was formed in 1983. It is a professional body of experts with membership by trauma surgeons; registered paramedics; professional nurses with a specialisation in trauma and/or intensive care; and allied health practitioners dealing with injuries.
1.4.4 Advanced trauma life support (1980s)
Another ACS initiative aimed at organising and planning the care of patients with critical injuries involved the advanced trauma life support (ATLS) principles. These principles have been accepted as the standard for trauma care since the official inception of the ATLS course in 1980. Staff who completed the ATLS course were found to better manage simulated trauma cases (Wanjiku et al., 2019:7). ATLS is currently recognised as the gold standard of trauma care in trauma centres (Jayaraman et al., 2014:2). Trauma teams who have been trained in ATLS show improved patient outcomes (Härgestam et al., 2016:34) since early activation and participation of experienced medical staff are known to improve patient management (Tiel Groenestege-Kreb et al., 2014:258). It is deemed as good practice that all EDs are able to stabilise and resuscitate any patient according to ATLS principles. The first ATLS course with TSSA as the custodian was run in South Africa in 1992 as a post-basic course. ATLS was the recommended course for doctors and nurses interested in trauma following the introduction of trauma systems to South Africa in 2011 (Hardcastle & Brysiewicz, 2013:118), most of these courses are, unfortunately, self-funded and expensive.
Emergency care priorities in South Africa are based on procedure-orientation; this requires the specialist knowledge and skills that are taught in ATLS to manage trauma patients (Brasel, 2013:1363). ATLS indicates priorities related to proficiency in managing the trauma patient as well as ensuring prompt and appropriate emergency care (Van Hoving et al., 2015:206).
34 1.5 Accreditation of trauma centres
In addition to the “Optimal Resources Manual”, the ACS initiated the classification process for hospitals as Levels I, II, III, or IV. In the 1980s. Hospitals seeking classification were assessed on-site by the ACS which also offered assistance to hospitals implementing the verification process. This establishment of trauma centres in the USA was successful.
Studies have shown that trauma standards and verification do save lives. A 2006 study published in The New England Journal of Medicine indicated that patients treated at trauma centres had a 25% lower chance of dying than patients treated at non-trauma centres (MacKenzie et al., 2006:367).
1.5.1 Accreditation through the Trauma Society of South Africa
The accreditation of trauma centres within a trauma care system is an internationally preferred intervention and was adopted by the TSSA, who was at the forefront of developing a system for accreditation of both private and public EDs in South Africa (Hardcastle et al., 2011:194). The TSSA awards levels of accreditation to hospitals that have met the criteria stipulated in its accreditation tool. The accreditation tool is a functional mechanism to recognise the value of comprehensive centres of care where medical practitioners and allied healthcare professionals provide initial assessment, quality resuscitation, and definitive care in order to speed the recovery of patients with appropriate rehabilitation services.
The TSSA accreditation tool (Hardcastle et al., 2011:191) was revised, using best care principles, in 2011 to align with the modern scope of emergency care. Furthermore, the TSSA is the leading stakeholder in terms of directing, monitoring, and strengthening trauma care in South Africa. It has contextualised the accreditation tool for South African EDs and has announced its willingness to support EDs in their implementation of this tool. This tool is made up of the following sections:
Hospital organisation showing which disciplines are available at the facilities and what types of emergencies can be managed there.
Clinical capabilities where the doctors and nurses working at the facility have to be up to date with relevant courses, advanced trauma life support (ATLS), adult cardiac life support (ACLS), and paediatric advanced life support (PALS).
Hospitals/resources displaying evidence of 24-hour availability of X-rays and laboratories with documented agreed-upon turnaround times.
Quality assurance/quality improvement; morbidity and mortality meetings including documented patient discussions and appropriateness of patient outcomes.
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Outreach programmes; inviting neighbouring ED staff from private and provincial hospitals to join a continued medical education (CME) evening.
Preventative/public education including trauma injury prevention programme collaboration.
Trauma research programmes displaying evidence of research meetings, publications, and presentations from the facility related to trauma.
Trauma service support personnel incorporating a trauma programme manager who is essential in a Level I trauma centre.
Organ procurement activity with evidence of discussion about the appropriate referral pattern of the facility to organ procurement.
Helipad access (only essential at Level I).
These criteria are broken down further into individual measures that are classified as either essential or desirable and are evaluated according to the level of the facility. Accreditation is not awarded if any element of essential criteria is not met, and a time frame of six months is permitted to meet the missing criteria. Following this, accreditation is awarded should the criteria be met. A summary of the various levels of classification is discussed below.
1.5.2 Trauma centre descriptions in South Africa adapted from the American system
1.5.2.1 Level I (Major trauma referral centre)
A Level I facility is a regional resource trauma centre, with a tertiary care facility usually central to the trauma care system. Ultimately, all patients who require the resources of these centres should have access to it. It must be capable of providing leadership and total care for every aspect of injury, from prevention to rehabilitation, and all major specialities must be available twenty-four hours a day. In its central role, the centre must have an adequate depth of resources. Most Level I trauma centres are university-based teaching hospitals because of the large number of personnel and facility resources required for patient care, education, and research. However, other hospitals willing to commit the required resources could meet the criteria for Level I recognition. Level I trauma centres are also responsible for providing leadership in education, research, and system planning that extends to all hospitals caring for injured patients in their region. Medical education programmes should include undergraduate and postgraduate training in trauma for doctors and nurses and must also be involved with the training of pre-hospital care providers. Education may include continuing medical education, personnel exchanges, outreach, and other approaches appropriate to the local situation. Research and prevention programmes are essential for a Level I trauma centre.
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1.5.2.2 Level II (Urban trauma centre)
The Level II trauma centre is expected to provide twenty-four hours initial, definitive trauma care regardless of the severity of the injury. Depending on location, patient volume, personnel, and resources, the Level II trauma centre may be unable to provide the same comprehensive care as a Level I trauma centre. Patients with complex injuries may need to be transferred to a Level I centre. Educational outreach, research, and prevention programmes are similar to those required for a Level I trauma centre, with the exception that research is not an essential criterion. In areas where there is no Level I centre; the Level II centre will be responsible for education and system leadership.
1.5.2.3 Level III (Community hospital)
The Level III trauma centre serves communities that do not have immediate access to a Level I or II institution. Level III trauma centres can provide prompt assessment, resuscitation, basic emergency operations, stabilisation, and arrange for possible transfer to a facility that provides definitive trauma care. Such centres must ensure the prompt availability of general surgeons or general practitioners with surgical expertise. Planning for the care of injured patients requires established early transfer systems and standardised treatment protocols. Level III trauma centres are generally not appropriate in an urban or suburban area with adequate Level I and or Level II resources. Most rural hospitals, and perhaps some smaller urban hospitals would typically be Level III facilities.
1.5.2.4 Level IV (Primary health care facility)
Level IV trauma facilities provide basic trauma life support before patients are transferred for definitive care. Most will exist in remote areas where no higher level of care is available; perhaps a clinic rather than a hospital; and may or may not have a doctor available. However, because of geographical isolation, the Level IV trauma facility is the primary care provider. The Level IV trauma facility should be integral to the inclusive trauma care system if willing to make the commitment to provide optimal care, given its resources. A Level IV trauma facility must have a good working relationship with the nearest Level I, II, or III trauma centre to develop a rural trauma system with realistic standards based on available resources. Optimal care in rural areas can be provided through the skilful use of existing professional and institutional resources and supplemented by treatment guidelines that result in enhanced education, resource allocation, and appropriate designation for all levels of providers. The Level IV facility must have a committed health care provider who can provide leadership and sustain affiliation with other centres.
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This would create a system of accredited trauma centres throughout South Africa. The level of trauma centre would determine which type of trauma patients could be received and managed appropriately, ensuring the best possible outcomes for patients (Hardcastle et al., 2011).
Trauma systems can bring quality and process advancements through organisational change (Cole et al., 2016:5). Although a contextualised guide for the overall structure and management of EDs and trauma centres is often lacking (Institute of Medicine, 2007:73), execution of an accreditation process and activating cost-effective trauma systems could provide South African EDs and trauma centres with the structure needed, benefitting the South African public (Hardcastle & Brysiewicz, 2013:118). Major trauma (implying multi-systems injuries) differs from other emergencies in that it almost always requires surgical intervention. Not all EDs are hospital-based or can provide the necessary major trauma care a patient might require. Each hospital’s ability to manage trauma needs to be independently assessed so that it can be appropriately selected and assigned within the greater trauma system of a country (Hardcastle et al., 2011:190). The full network of hospitals required to care for injured patients should be taken into account when planning the trauma system of a country.
After identifying the hospitals involved in the trauma system, national and state legislative decisions led to the implementation of emergency medical systems and provided communities with modern ambulances and trained pre-hospital care personnel (Lee, 2013:259). These systems were based on a military approach to managing trauma care that had been developed and tested in military settings in Northern America (Williamson et al., 2011:44).
1.6 Motivation for implementation of Trauma Society of South Africa accreditation
YLDs are declining more gradually than mortality rates implying that the non-fatal aspects of disease and injury will require more and more attention from health systems The occurrence of disease and injury incidence and YLDs is, therefore, a critical factor for global, regional, and national health policies (Vos, et al., 2015). The number of people living with the consequences of a particular disease or injury is increasing as a result of the ageing of the world’s population (Nojilana, Bradshaw, Pillay-van Wyk, Msemburi, Laubscher & Somdyala, et al., 2016:478). Countries that can least afford the global burden of current and anticipated road traffic injuries are those that cannot meet the challenges presented to their respective health services, economy and society. It is necessary to suitably address these disproportions with the available evidence and prevention plans if this global health problem is to be expansively addressed (Ameratunga, et al., 2006:1533).
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International evidence confirms that trauma systems are effective in reducing the trauma burden in LMICs and that they can and have been reproduced in many other LICs (Mwandri
et al., 2017:2). Brazil has the advantage of upholding the quality of healthcare by implementing
ED accreditation and by consolidating, through communication, the multidisciplinary team. Their process of accreditation is voluntary and does not need Brazil state accountability (Oliveira & Matsuda, 2016:2). In China EDs function as autonomous small hospitals even though the Republic of China’s government does not support a systems approach to emergency care (Xiang-Jun & Liu, 2018:81). In other LMICs, for instance, Pakistan, fundamental data on the burden of disease is not readily accessible, making it difficult to comment on the pressures experienced in their EDs (Puvanachandra et al., 2015:1).
Positive patient outcomes are similarly linked to high-income countries (HIC). In the USA, Level I trauma centres show better patient outcomes in patients with high mortality and poor functional outcomes than lower-level centres (Demetriades et al., 2005:516; Moran et al., 2018:15; Haal, Smith & Doorslaer, 2018:240). In Australasia, another HIC, hospital length of stay was reduced by 18% and patients admitted from the ED within eight hours showed a 20% improvement following the introduction of accreditation of hospitals (Castillo et al., 2013:1534). In Australia, an improvement has been noted in patients’ outcomes following the emphasis placed on the refinement of coordinating the movement of appropriate patients to major trauma centres (Gabbe et al., 2012:1010; Warren et al., 2019:2).
To date, South Africa has responded to the need for trauma systems by establishing major trauma services in the public health sector in Gauteng, Western Cape (Groote Schuur Hospital, Tygerberg Hospital), Free State (Pelonomi Hospital), and KwaZulu-Natal (Inkosi Albert Luthuli Central Hospital), as well as in limited private hospitals led by trauma surgeons (Hardcastle et al., 2011:189). Passivity seems to prevail as is evident by the fact that only one provincial hospital has applied for TSSA accreditation. While an individual private hospital group has requested and attained TSSA accreditation in many of their EDs; other hospital groups have only indicated interest but have not as yet applied. At present, only one public hospital and fifteen private hospitals have obtained TSSA accreditation, with twelve positioned within Gauteng and three in KwaZulu-Natal.
1.7 Problem statement
As a country, South Africa has a high trauma case prevalence. Trauma is a major cost driver within an already expensive and overburdened health system. This burden is increased because trauma in the South African context is closely linked with multi-morbidity (Lalkhen, 2015:135). The Department of Health currently has formal guidelines as to the basic
