Impact of rural trauma team development on prehospital time, referral decision to discharge interval, and outcomes of neurological and musculoskeletal injuries: a cluster randomized controlled trial

BackgroundWe assessed the impact of rural trauma team development course (RTTDC) on clinical processes and patient outcomes of motorcycle-accident-related neurological and/or musculoskeletal injuries in selected Ugandan hospitals. MethodsTrial design: Two-arm, parallel, multi-period, cluster-randomized controlled trial. Participants: Trauma care frontliners, and patients aged 2-80 years at three intervention and three control Ugandan hospitals (1:1 allocation). Randomization: Hospitals were randomly allocated to intervention or control using permuted block sequences. Blinding: Patient-participants and outcome assessors were blind to allocation. Intervention arm: 500 trauma care frontliners received RTTDC; patients received standard care. Control arm: Patients received standard care without RTTDC for staff. Primary outcomes: Time from accident to admission and from referral to discharge. Secondary outcomes: 90-day mortality and morbidity related to neurological and/or musculoskeletal injuries. We followed the CONSORT guidelines for cluster randomized trials. ResultsWe analyzed 1003 participants (501 intervention, 502 control). The intervention arm had a shorter median prehospital time (1hr; IQR=0{middle dot}50-2{middle dot}00) and referral to discharge interval (median 2hrs; IQR=1{middle dot}25-2{middle dot}75) vs. [(2hrs; IQR=1{middle dot}50-4{middle dot}00) mean difference 1{middle dot}13hrs, p<0{middle dot}0001 and (4hrs; IQR=2{middle dot}50-4{middle dot}10), mean difference 1{middle dot}39hrs, p<0{middle dot}0001 in the control], respectively. The 90-day mortality was more than halved in the intervention (5%, 24/457) vs. (13%, 58/430) in the control arm (p<0{middle dot}0001). Fewer participants in the intervention group had unfavorable Glasgow Outcome Scale scores (9%, 42/457) vs. (20%, 87/430), p<0{middle dot}0001. No difference was found in musculoskeletal injury morbidity outcomes (p=0{middle dot}567). InterpretationRural trauma team development training improved organizational time efficiency and clinical outcomes for neurological injuries without negatively impacting musculoskeletal injury morbidity outcomes. FundingUniversity of Turku Graduate School, Neurocenter-Turku University Hospital, Turku University Hospital Foundation, Center for Health Equity in Surgery and Anesthesia-University of California San Francisco. Ethical approvalUganda National Council for Science and Technology (Ref: SS 5082). Trial registrationPan African Clinical Trial Registry (PACTR202308851460352). Research in contextO_ST_ABSEvidence before this studyC_ST_ABSUnderstaffing and injury-related mortality are highest in low-and middle-income countries (LMICs) where trauma education and training opportunities are scarce. Observational studies in the US suggest that rural trauma team development training can improve clinician knowledge and reduce pre-hospital intervals. However, there are no prospective, randomized controlled trials that have assessed the translation of this knowledge and training into clinical practice affecting patient outcomes in LMICs. Added value of this studyIn a multi-center, cluster-randomized controlled trial, we investigated the impact of rural trauma team development, training and coordination on pre- and intra-hospital intervals, and outcomes for neurological and musculoskeletal injuries in an African low-resource setting. Results showed a reduction in prehospital time and all-cause mortality by more than half, without worsening patient-reported trauma morbidity. Implications of all the available evidencePrognostic level II evidence from this trial supports that locally contextualized, trainee-led rural trauma team development interventional programs are feasible and improve clinical processes and patient outcomes in LMICs.