Brain Injury, March 2013; 27(3): 262–272

REVIEW

Strengthening neurotrauma care systems in low and middle

income countries

ANDRES M. RUBIANO1,2, JUAN C. PUYANA3,4, CHARLES N. MOCK5,6,

M. ROSS BULLOCK7, & P. DAVID ADELSON8
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1
Trauma and Emergency Division, Neiva University Hospital, Neiva, Huila, Colombia, 2Neurosciences, South
Colombian University, Neiva, Huila, Colombia, 3Department of Surgery, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA, 4University of Pittsburgh, Pittsburgh, PA, USA, 5Surgery, University of Washington,
Washington, WA, USA, 6Epidemiology and Global Health, Harborview Injury Prevention Center, Seattle, WA, USA,
7
Department of Neurosurgery, University of Miami, Miami, FL, USA, and 8Phoenix Children’s Neuroscience Institute,
Phoenix, AZ, USA

(Received 30 December 2011; revised 24 September 2012; accepted 14 November 2012)

For personal use only.

Abstract
Primary objective: To review basic elements to be considered in the development of effective neurotrauma care systems in
low- and middle-income countries. Neurotrauma occurs more frequently in developing countries. The survival rate among
neurotrauma patients depends in large part on the degree of sophistication of the trauma system.
Research design: A critical review of the literature was undertaken.
Results: In developing countries, there are difficulties in fully integrating the resources for care if the local and regional
trauma systems are poorly structured. Factors like inadequate emergency and neurointensive care, low compensation
compared with elective procedures or high medico-legal risks may result in a lack of interest from the few available
neurosurgeons to be fully integrated in neurotrauma care. Appropriate structuring of trauma systems according to countries
needs and their functionality is a key element that would facilitate the optimal use of resources for integral neurotrauma
care.
Conclusions: In order to implement an efficient trauma system, organization of low cost resources such as trauma registries
and quality control programmes are required. The participation of medical associations in legislative and government
processes is also an important factor for the appropriate development and organization of an effective trauma system in
under-privileged areas.

Keywords: Trauma systems, neurotrauma, trauma surgery, trauma registry, traumatic brain injury
13
20

Introduction
countries and thus generate preventive policies with
Trauma has increased significantly in the last several the objective of minimizing trauma-related morbid-
decades. Worldwide, 16 000 people die every day ity and mortality [1]. Motor vehicle-related collisions
as a result of some traumatic injury and for each one (MVC) are the second most common cause of death
of these deaths many others are severely disabled [1]. worldwide in the age range of 15–30 years and
The World Health Organization (WHO), through interpersonal violence is the sixth most common
the Department of Violence and Injury Prevention cause of death for 15–30 year-olds. Ninety per cent
and Disability (VIP), has begun to generate epide- of the mortality and morbidity caused by trauma is
miological data to identify tendencies in the different concentrated in low- and middle-income countries

Correspondence: Andres M. Rubiano, MD, PhD, Calle 5 # 11-19 MEDITECH, Neiva (Huila), Colombia. Tel: þ57 (88) 721010. Fax: þ57 (88) 723885.
E-mail: [email protected]; [email protected]
ISSN 0269–9052 print/ISSN 1362–301X online ß 2013 Informa UK Ltd.
DOI: 10.3109/02699052.2012.750742
 Strengthening neurotrauma care 263

(70% of the global population) [1–3]. In these foundations of a comprehensive health model
countries key factors such as diminished availability (including trauma care). These documents are best
of healthcare resources, poor compliance to preven- generated with mutual participation and contribu-
tion policies and greater risk factors (social armed tion of national scientific associations that are
conflicts and diminished occupational health safety) involved in trauma care [6, 7]. Commitment at all
are identified. levels is necessary to ensure appropriate resources
Traumatic brain injuries (TBI) represent one of necessary for the delivery of optimal care.
the leading contributors to death and disability Documents like these should help in regulating the
within these worldwide trauma statistics [1–3]. flow of patients within the healthcare facilities and
This constitutes a great challenge for the people in throughout the system and concentrate the most
charge of providing neurotrauma care within a critical patients in the more specialized institutions.
trauma system. Unfortunately, significant traumatic This structure needs to take into account the real
deaths and disability are found in low- and middle- situation of the availability of local and regional
income countries due to increased risk factors, resources. These documents should provide the
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including a lack of prevention programmes, low basis for the foundation of the ‘Trauma Systems’
level of development of pre-hospital and hospital concept.
care for the patient with injuries and the lack of The evidence supporting the creation and devel-
rehabilitative services. This review is focused on a opment of regionalized trauma care has been widely
detailed description of the ‘Trauma System’ concept published. Nathens and colleagues [8–10] demon-
and its application in low- and middle-income strated that high volume trauma centres (>650 cases
countries with an emphasis on neurotrauma aspects. per year) not only improve resource allocation but
The development of trauma systems in these also diminish morbidity and mortality even in highly
countries could lead to an improvement in neuro- complex cases (15% of the total trauma population).
trauma care with an optimal use of the resources. Some regional hospitals in Colombia receive
between 2000–10 000 trauma patients every year
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(similar to many other low- and middle-income

Trauma systems settings). The incidence of TBI ranges from 20–40%
of these admissions [11]. Improving the organization
A Trauma System is a global concept that involves and planning for trauma care services in these
not only medical, but legal, administrative and social facilities represents an affordable and sustainable
aspects. It is defined specifically as a comprehensive method to improve outcome. Some hospitals have
system of organized care for patients with traumatic reported successful experiences including pro-
injuries. It is structured within a geographic area and grammes for trauma audit and trauma registry
is integrated within the emergency medical system at management, with improvement in specific issues
local or regional levels. Its primary purpose is to such as decreasing time delays for surgery [12, 13].
improve the health of the community covered by the When comparing trauma systems from high-
system by delivering and triaging patients to the income countries to those in low- and middle-
appropriate and highest level of trauma care avail- income countries, however, one must consider
able. The system is multidisciplinary, with allocation that, in low income settings, there is a greater
of resources and expertise along the continuum of volume of patients at some centres resulting from
care and with the goal of maintaining continuity of inappropriate distribution due to lack of regionali-
care. The legal aspects are very important not only to zation. Even in many high income countries, there is
manage the system but also to regulate the social and a lack of regionalization and inappropriate co-
administrative issues. ordination of transport and delivery of patients
An appropriately organized system should not with severe injuries.
encourage the improvisation of unstructured trauma Patients with severe injuries arriving at centres that
care models [4, 5]. A solid structure of the system do not have enough resources diminish the possibil-
requires active participation from the medical scien- ity of survival. Furthermore, precious time is lost in
tific community (medical associations) as well as trying to relocate these patients to other centres (not
governmental representatives. For example, in far from the initial one) that probably could have
Colombia, a low–middle income country, recent provided a higher level of care. This is a complex and
documents such as Decree 1011 of 2006 (obligatory difficult process. Even in the US where regulation
health quality guarantee of the general social security concerning trauma regionalization was passed more
system) and Resolution 1043 of 2006 (conditions for than 30 years ago, only 50% of the country has
healthcare providers to qualify their services and to regionalized trauma care [4]. Trauma care is still
implement audit components for quality improve- often disjointed and lacking in co-ordination.
ment) are important tools that begin to lay the This last issue is more profound in low- and
 264 A. M. Rubiano et al.

Table I. Requirements to consider for a neurotrauma centre to offer optimal care of the patient [14].

Minimum requirements for a reference neurotrauma care centre

1. Computed Tomography available 24 hours a day.

2. Neurosurgeon available 24 hours a day (time of on call arrival less than 15 minutes).
3. Immediate availability of operating room.
4. Immediate availability of intensive care unit with an intensive care physician. *(Neuromonitoring is recommended)
5. Availability of other specialties for advanced care of trauma patient (general surgery, orthopaedic surgery, plastic surgery, etc.).

middle-income settings. For example, patients with Section of Neurotrauma and Critical Care and the
head or spinal cord injury (SCI) often arrive to Brain Trauma Foundation developed the Guidelines
facilities that do not fulfil the minimum recom- for the Management of Severe Traumatic Brain
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mended requirements for the care of these patients Injury and Paediatric Guidelines for the
(Table I) [14]. Management of Severe Traumatic Brain Injury
This often leads to a greater incidence of death or [14, 18].
severe disability with higher costs for the system, These documents are also clear examples of
family and society. In a recent study about the effect academic technical consensus acting as an instru-
of the hospital designation level in outcome, DuBose ment in the accreditation process of health institu-
et al. [15] analysed 16 037 patients with TBI in US tions. Also, these aforementioned associations have
trauma centres. Admission to a lower trauma actively participated advocacy for seatbelt and
designation level facility was an independent predic- motorcycle helmet laws [19]. Another important
tor of mortality (p < 0.001), complications example is the active participation of medical asso-
(p < 0.001) and progression of neurological insult ciations in broad collaborative meetings of the
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(p < 0.001). In a similar study, Macias et al. [16] WHO. The International Association for Trauma
analysed 4121 patients with SCI who were treated in Surgery and Intensive Care (IATSIC) and the
100 trauma centres and 601 non-trauma centres in International Society of Surgery have participated
the US. Paralysis was significantly lower at trauma in international meetings to develop standards for
centres (p < 0.001). Non-trauma centres with higher trauma care resources for countries at widely varying
admission caseload were associated with worse economic levels, including those of Africa, Asia,
outcome. Indeed, if these outcomes are coming Latin America, as well as high-income countries.
from reasonably well-established trauma systems These guidelines were aimed to eliminate
communities, it is likely that low- and middle- discrepancies in outcomes of trauma patients
income countries without trauma systems would globally [20, 21].
have even worse outcomes. For example, one study demonstrated that, for all
persons with injury severity scores (ISS) greater than
9, mortality was proportional to the economic
Role of the scientific associations resources of the environment. Mortality declined
from 63% in low income to 55% in middle-income
Scientific associations have begun to play a very to 35% in high-income settings. Looking specifically
important role in several aspects related to trauma at mid-range injury severity (ISS 15–24) the dis-
care. For example, these associations have developed crepancies become even more pronounced, with 6-
technical documents that can help governments in fold differences in mortality between low income and
evaluation and quality control processes. Many high-income countries [22]. These differences in
scientific associations are also very active in injury mortality have led to the development of recom-
prevention. These processes need to be conducted mendations for the elaboration of trauma care
according to international standards but also need to guidelines according to different models of care
take into account local issues. In North America, for based on local availability of resources.
example, for many years the Committee of Trauma Another role of medical associations is the active
of the American College of Surgeons (ACS) created participation in political and governmental processes
Resources for the Optimal Care of Injured Patients relating to the delivery of care. For example, in 2001,
[17]. This document is a model to evaluate trauma the AANS/CNS Section of Neurotrauma and
centres for accreditation, not only in the US, but also Critical Care helped to unify the recommendations
for international societies as well. In addition, the for hiring neurosurgeons that cover emergency
American Association of Neurological Surgeons rooms in trauma centers in the United States. The
(AANS)/Congress of Neurological Surgeons (CNS) main aim was to improve the labor conditions and
 Strengthening neurotrauma care 265

diminish the possibility of occupational risk arising amounts of data are those that annually arrive at
from the lack of institutional resources, benefiting the governmental organizations to determine adjust-
both the neurosurgeon and the patient [23]. ments in budgets and programmes of impact in
healthcare. Due to the lack of data, important but
unfortunately uneducated decisions may be made in
An appropriate data base: A basic element of a many low- and middle-income countries based on
trauma system data that do not represent an accurate assessment of
the healthcare offered by the system. The Pan
Death after trauma is evaluated in several papers and American Health Organization (PAHO) reviewed
is presented in bi-modal, tri-modal or tetra-modal injury data from their 35 member states, focusing
distribution, according to the maturity of the trauma on countries with a minimum population of 10
system [24–27]. As a common issue in all the million [35]. The research group obtained informa-
distribution models, 50% of trauma deaths occur tion of 11 countries (88% of the total population of
early in the first minutes of the event and are not the region) included in the WHO Statistical
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amenable to treatment, even with a greater amount Information System (WHOSIS). In the 11 countries
of resources available at the scene. Most of these examined, during 2000, the cumulative potential
early deaths are due to central nervous system inju- productive years of life lost (PPYLL) from injuries
ries in both civilian and military scenarios [24–29]. exceeded the burden of infectious diseases, diseases
Knowledge of such distributions of trauma deaths is of the circulatory system or malignant neoplasm
key to being able to allocate trauma care resources combined (Figure 1). However, the budgetary allo-
effectively. Thus, adequate databases about trauma- cation for infectious diseases in the 2006–2007
related deaths are a key tool in trauma systems. periods for the same region was USD$107 million
Without the existence of reliable databases, the and injury, violence and disabilities programmes
impact and the effectiveness of the system cannot received only USD$2 million.
be measured. Trauma centres in high income Resource allocation most of the time is based on
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countries have the opportunity to constantly analyse analysis of available data. Trauma systems can
their own databases and use this information to generate appropriate data to justify resource alloca-
obtain funding for specific trauma care areas as well tion and also developing of trauma quality improve-
as targeted prevention programmes [28–33]. This is ment programmes, providing information on public
a fundamental reason supporting the need to begin health, assessment and quality of care. These
building national trauma registries. programmes allow generating appropriate interven-
Availability of statistical information is vital to the tions based on real data such as reducing unneces-
process of applying for governmental and non- sary delays in the care processes [36]. This entire
governmental funds, be it for research or quality process helps to avoid audit errors minimizing time
improvement activities. The increase in survival in discussion with insurance companies (private and
rates, the impact of morbidity and mortality and governmental offices) and other resource allocation
the possibility of evaluation of prevention policies are issues.
some of the elements that one can test through such The National Trauma Data Bank of the American
databases. Unfortunately, in the worldwide evalua- College of Surgeons (ACS), the National Traumatic
tion of trauma care models and systems, one great Coma Data Bank of the AANS and the ‘Common
failure in low- and middle-income countries has Data Elements for TBI Project’ are examples of
been the deficiency of databases and the resultant databases that can rapidly provide detailed informa-
lack of information and true understanding of the tion for analysis of academic and administrative
basic details surrounding trauma in these regions. In processes [37–40]. This information can immedi-
a recent evaluation, the WHO demonstrated that ately benefit the affiliated institutions. These are also
appropriate health databases are used in only 29 of powerful tools in the evaluation of quality improve-
the 115 countries that are reporting data to the ment programmes, as well as the impact of the centre
organization. This represents real data from only on the regional or local public health. This informa-
13% of the global population. For example, some tion is useful to identify risk factors and high risk
countries report only 10% of the major health events groups in the community. As an example, a database
managed by their systems [34]. If nearly 90% of the allows clear identification of the severity of the
trauma victims are concentrated in low and middle- traumatic brain injuries in motorcycle riders for
income countries, it is easy to see that most countries certain regions where there is still not an implemen-
do not have adequate information sources with tation of obligatory helmet use [41]. This lack of
which to make informed decisions. This situation implementation is often due to a lack of knowledge
does not allow an appropriate analysis of the real of statistics among the general public and little
behaviour of the trauma system. These small involvement of health organizations and scientific
 266 A. M. Rubiano et al.
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Figure 1 Injuries are the main cause of potentially productive years of life lost in the American region including Canada, the US, Cuba,
Argentina, Brazil, Chile, Colombia, Mexico, Venezuela, Ecuador and Guatemala. This figure was originally published in Fraade-Blanar
et al. [35].

medical associations in aggressive campaigns of Advantages of trauma care health facilities

prevention. One aspect of this is highlighted,
Development of trauma care centres could lead to a
although the need for continued prospective
significant minimization of the number of prevent-
collection of data is not only to assess changes in
able deaths after trauma. Preventable deaths by
incidence or characteristics of trauma but also to
definition are deaths that could be avoided by an
make real improvements in prevention and care.
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appropriate management scheme according to the

available resources and the training of the care team.
These often arise due to a failure in the management
Characteristics of a trauma care health process (inappropriate use of the resources or
facility medical failures in the management). These situa-
tions usually involve patients with more than one
A trauma centre most often is developed in a hospital significant injury and, for this reason the manage-
of medium-to-high complexity level. Nearly 15% of ment process involves many resources and also
the general trauma patient population will benefit interdisciplinary participation of more than one
from acute care at this kind of centre [4, 5]. This specialty. A failure in the interdisciplinary trauma
centre must be a leader in the development of care team ‘harmony’ is often found in the quality
specialized care programmes, protocols and care evaluations of non-specialized health care
algorithms and must have an internal evaluation centres. Survival rates of patients with severe injuries
programme for quality improvement that measures (ISS > 24) are near 50% in specialized trauma
adherence to guidelines by members of the care centres [4, 5]. Mortality rates in severe TBI
teams. (head AIS > 3 or GCS < 9) in high-income
This also includes the availability of a certain level countries trauma centres range between 15–40%
of trauma care capability 24 hours a day, 365 days a [15, 30–32, 40]. Mortality rates higher than these
year. These centres also must promote continued values lead to specific questions about the appropri-
educational programmes for the multidisciplinary ate organization of a healthcare facility and its ability
team as well as prevention programmes within the to manage this kind of patient. Trauma centres
community. Lastly a trauma centre should have an usually have some minimum amount of errors in the
appropriate database to help research processes in management of a patient with multi-trauma and also
trauma care. Programmes for quality improvement a few failures in the monitoring process [24, 42].
in trauma care need to focus on monitoring all the Most studies have shown a 15–20% reduction in
levels of care. From the pre-hospital phase through- mortality for trauma centres vs non-specialized
out the evaluation and treatment and the rehabilita- healthcare centres [4, 5]. Celso et al. [43], in a
tion process, errors in process and quality must be systematic review comparing outcome of patients
identified and solutions created. This specialized with severe injuries treated in trauma centres fol-
care must be offered in a sequential manner, planned lowing the establishment of trauma systems, found
with a real connection between the guidelines and an overall 15% lower mortality following trauma
institutional protocols [4–6]. system implementation. Thus, the organization and
 Strengthening neurotrauma care 267

planning that go into establishing a trauma centre different world zones, recently the AANS/CNS
have been well demonstrated to improve patient Section of Neurotrauma and Critical Care published
outcome. a review of global statistics on this topic (Table II).
According to the worldwide directory of neurosur-
geons, there are 23 940 neurosurgeons for a total
The neurosurgeon’s role in the trauma care population of more than 6 billion people, 1 for
team each 230 000 inhabitants. Half (50%) of these
neurosurgeons are concentrated in countries of
One of the major differences between models of
high and medium-high income, covering 30–40%
trauma care in low, middle and high income
of the world’s population, whereas in the countries
countries is the presence and role of the neurosur-
of low and middle income, a much smaller percent-
geon in the trauma team. Because of the relatively
age of neurosurgeons cover 60–70% of the exposed
small number of neurosurgeons relative to popula-
population to trauma emergencies [44].
tion need, only a small proportion are available in
Esposito et al. [47, 48] and Valadka et al. [49], in
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some areas of the world, especially in low- and

middle-income countries [44]. In many of these the US, showed that nearly 20% of neurosurgeons
countries, the few neurosurgeons are concentrated in who are in charge of initial management of
main cities, without appropriate coverage in rural neurotrauma cases would prefer not to do it, due
zones and intermediate suburban cities that also to issues of financial reimbursement, medical liabil-
have a significant population nearby. Some ity and impact on elective practice. This tendency is
European countries and areas of North America increasing in several countries forced by multiple
currently have the same problem, although in situations such as medico-legal risks, differences in
smaller proportions. The true significance of this reimbursement between emergency vs elective neu-
paucity of neurosurgeons in low- and middle-income rosurgical procedures (oncology, vascular and spine
countries is uncertain, but it is likely a contributor to surgery) and the lack of appropriate processes of
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the higher rates of death from trauma in these institutional contracts. Some of these contract
countries [45, 46]. models do not provide any benefit or incentive to
Additionally, secondary transport to the trauma encourage neurosurgeons to choose a practice with
centres in health systems of high income countries is acute emergency care neurosurgery rather than a
generally by air and the total transport time is not more lucrative elective practice. These factors have a
more than 1 hour; after this transfer, a neurosurgeon direct impact on how patients are identified for long-
and a neuro ICU bed is almost always available for term follow-up. In some hospitals of low income
this patient [33, 47]. Ambulance ground transfers of areas, follow-up with a neurosurgeon is limited to
trauma patients (including severe TBI) in countries only those who underwent craniotomy; other
of low and middle income can take several hours patients with moderate and severe injuries that
without appropriate transport management, espe- were under medical management are lost to follow-
cially when they come from rural areas and finally up. Long-term care is sometimes assumed by other
when they arrive to receive appropriate definitive specialties without a multidisciplinary trauma team
care sometimes the neurosurgeon is not available approach [12]. Furthermore, the lack of participa-
and/or an ICU bed is not immediately available. tion of neurosurgeons is frequent and has led to the
In order to have an idea of the availability of training of other disciplines such as anaesthesiolo-
neurosurgeons and their distribution throughout gists, critical care physicians, trauma surgeons and

Table II. Global neurosurgeon’s distribution around the world [44].

Area population Population Number of neurosurgeons Neurosurgeons per inhabitant

World >6 Billion 23 940 1/230 000

Africa 700 Million 565 1/238 000
Subtropical Africa 600 Million 79 1/3 600 000
Latin America 305.7 Million 2489 1/123 000
Mexico 107 Million 280 1/377 000
Asia 3.253 Billion 9618 1/336 000
Japan 120 Million 7987 1/22 000
India 1.12 Billion 800 1/1 400 000
North America 370.8 Million 4583 1/81 000
European Union 799 Million 6594 1/121 000
Australia 21.1 Million 103 1/205 000
 268 A. M. Rubiano et al.

technicians to be able to undertake some of the developed the Guidelines for Essential Trauma Care
elements of neurotrauma care, including intra- [2, 54]. This defined 11 core essential trauma care
cranial pressure monitoring and medical aspects of services that every injured person in the world should
TBI management. In Europe, Latin America and realistically be able to receive. To assure the avail-
Australia, training programmes for non-neurosurgi- ability of these services, the Guidelines delineate 260
cal specialties have been put into place as a result of items of human resources (skills, training, staffing)
this crisis [48–51]. This problem is still more acute and physical resources (equipment, supplies) that
in the absence of the trauma centre. should be in place as a spectrum of healthcare
All other disciplines can be trained to perform facilities globally, as described in Tables III and IV.
monitoring placement and protocols. However, the For each cell within the matrix delineated above,
education of these individuals is not as well rounded the authors recommend those resources (vertical
nor does it cover the gamut of neurological/neuro- axis) that should be available at a specific level of the
surgical emergencies. Similarly not all patients who healthcare system (horizontal axis). In the develop-
suffer a TBI require the expertise of specialized team ment of national trauma plans, countries may very
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care. As an example, Huynh et al. [52] presented a appropriately decide to convert some of the items in
study of TBI patients with abnormal head computed the desirable category to essential.
tomography at emergency room arrival (43% with The priority of each item was given a designation
contusions, 38% with subarachnoid haemorrhage, according to the following criteria [2]:
14% with subdural lesions and 5% with epidural
. ‘Essential’ (E) resources: The designated item
lesions) [52]. Of these patients, only 16% showed
should be assured at the stated level of the
changes in the follow-up computed tomography
healthcare system in all cases. As this Essential
after 12 hours. Sixty per cent of these showed
Trauma Care Project covers the spectrum of
some improvement in the new image and 40%
facilities across the world, the E designation
showed deterioration. This last group would require
represents the ‘least common denominator’ of
definitive neuro-surgical intervention. In another
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trauma care common to all regions, including

study, Havill and Sleigh [53], in a review of 831
even those where access to resources is most
patients of TBI managed in a period of 10 years in a
severely restricted. It is felt that these services
Level II centre on a rural network of trauma care in
could and should be provided to patients with
New Zealand showed the following results: of the
injuries at the level of health facility concerned,
total number of patients, 547 (65%) had a severe
even in countries whose ministries of health have a
TBI. There were 191 deaths in the hospital before
total budget of only $3–4 per capita per year.
being referred (34% mortality). Of the remaining
patients, only 33 patients (9%) required neurosur- Essential items could be provided, primarily
gical management. This series was predominantly through improvements in organization and plan-
closed head injuries and the local trauma surgeons ning, with a minimal increase in expenditure.
performed burr holes before the reference to the . ‘Desirable’ (D) resources: The designated item
neurological surgery service 130 km from this hospi- represents a capability that increases the proba-
tal. These data suggest that, in specific areas with bility of a successful outcome of trauma care. It
organized trauma systems, TBI patients can be also adds cost. Such items are not likely to be
adequately triaged and managed by personnel with- cost-effective for all facilities of a given level in
out full neurosurgical expertise. These physicians environments with the poorest access to
appropriately oriented by neurosurgeons under resources. Hence, they are not listed as essential.
specific guidelines and protocols could work as part However, for countries with greater resource
of the neurotrauma system. In countries with high availability, such items may ultimately be desig-
incidence of penetrating severe TBI, the frequency nated essential in their own national plans.
of requirement of the neurosurgical resource is much Likewise, there are some services for which only
greater and in this case an appropriate process of low-cost physical resources would be required and
organization of the system is a real priority. for which training of healthcare personnel at the
level in question would be feasible. However, in
order for this training to be considered essential,
mechanisms would need to be in place to ensure
The essential trauma care project of the world
that it is provided for all health care workers at the
health organization: A tool for trauma and
level in question, within the time constraints of all
neurotrauma care system organization
else for which they must be trained. In cases
In order to promote improved organization and where it did not seem reasonable to assure such
planning for trauma systems worldwide, the World training nationwide, such services have been
Health Organization with other partners worldwide designated as desirable. Individual countries may
 Strengthening neurotrauma care 269

Table III. Guidelines for Essential Trauma Care. Resources Matrix for TBI management according to the different facility level [2].

General
Basic Physician Specialist Tertiary
Resources Facility Facility Facility Facility

Recognize altered consciousness; lateralizing signs, pupils E E E E

Full compliance with AANS guidelines for head injury I I D D
Maintain normotension and oxygenation to prevent secondary brain injury D E E E
Avoid over-hydratation in the presence of raised ICP (with normal BP) D E E E
Monitoring and treatment of raised ICP I I D D
CT Scans I D D D
Burr holes (skills plus drill or other suitable equipment) I PR D E
More advanced neurosurgical procedures I I PR D
Surgical treatment of open depress skull fractures I PR D E
Surgical treatment of closed depress skull fractures I I PR D
Maintenance of requirements for protein and calories I E E E
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AANS, American Association of Neurological Surgeons; ICP, Intracranial Pressure; CT, Computed tomography; BP, blood pressure;
MRI, Magnetic resonance image; E, essential; D, desirable; PR, possibly required; I, Irrelevant.
Full definitions of designations Essential, Desirable, Possibly Required and Irrelevant are given in the text under the section: ‘The Essential
Trauma Care Project of the World Health Organization: A tool for trauma and neurotrauma care system organization’.

Table IV. Guidelines for Essential Trauma Care. Resources Matrix for SCI management according to the different facility level [2].

Basic General Physician Specialist Tertiary

Resources Facility Facility Facility Facility

Assessment—recognition of presence of risk of spinal injury E E E E

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Immobilization: C-Collar, backboard D E E E

Monitoring of neurological function E E E E
Assessment by International classification system I I D E
Maintain normotension and oxygenation to prevent D E E E
secondary neurological injury
Holistic approach to prevention of complications, especially D E E E
pressure sores and urinary retention/infection
CT scan I D D D
MRI I I D D
Full compliance with AANS guidelines I I D D
Non-surgical management of spinal injury (as indicated) I PR E E
Surgical treatment of spinal injury I I PR E
Surgical treatment of neurological deterioration in the I I PR E
presence of spinal cord compression

AANS, American Association of Neurological Surgeons; ICP, Intracranial Pressure; CT, Computed tomography; BP, blood pressure;
MRI, Magnetic resonance image; E, essential; D, desirable; PR, possibly required; I, Irrelevant.
Full definitions of designations Essential, Desirable, Possibly Required and Irrelevant are given in the text under the section: ‘The Essential
Trauma Care Project of the World Health Organization: A tool for trauma and neurotrauma care system organization’.

wish to upgrade these to essential, either at all procedures that might otherwise be performed
such facilities or at a sub-set of those with high by more highly trained personnel. Hence, it is to
trauma volume. be emphasized that the ‘PR’ designation is
. ‘Possibly required’ (PR) resources: In environments different from the ‘desirable’ designation.
with poorer access to resources, some trauma PR represents a potential necessity to increase
treatment capabilities might need to be shifted to availability of trauma care services in environ-
lower levels of the healthcare system in order to ments with poorer access to resources. It is
increase their availability. Such services usually anticipated that the PR designation will apply
represent only minimal increased cost, relative to primarily to low income countries, but not to
the provision of such services only at higher levels middle-income.
of the healthcare system. Shifting to a lower level . ‘Irrelevant’ (I) resources: This implies that one
in the healthcare system would usually imply that would not ordinarily expect this capability at the
a provider with less advanced trauma-related given level of the healthcare system, even with full
training and skills would be performing availability of resources.
 270 A. M. Rubiano et al.

The World Health Assembly Resolution 60–21 on administrators that should reflect appropriate con-
Trauma and Emergency Care was released in March tracting models that specifically support and encour-
2007. Since then few countries have started a formal age participation in trauma care initiatives by
process for policy development in order to improve providing incentives and benefits for those being in
trauma and emergency care. This is an important charge of acute emergency care. Neurosurgeons are
document that all the medical specialties need to an important resource for the patient who is multiply
promote and take into account for build capacity in injured and particularly those with severe TBI.
countries without a formal trauma system [55]. A Neurosurgeons have a definitive role in these
brief comment of this resolution related to the care trauma teams and must be allocated appropriately.
of TBI patients is supported by the International
Brain Injury Association (IBIA) on their website Declaration of Interest: The authors report no
[56]. This is linked with the patient safety culture conflicts of interest. The authors alone are respon-
that has been promoted from WHO. A recent sible for the content and writing of the paper.
publication of Haynes et al. [57], of the WHO Safe
Brain Inj Downloaded from informahealthcare.com by Technische Universiteit Eindhoven on 11/14/14

Surgery Saves Lives Study Group, shows that

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