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Research review
Trauma system development in low- and middle-income countries: a review Tyler E. Callese,a,* Christopher T. Richards, MD,b,c Pamela Shaw, MS, MSLIS,d Steven J. Schuetz, MD,a Lorenzo Paladino, MD,e Nabil Issa, MD,a and Mamta Swaroop, MDa a
Division of Trauma and Critical Care Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois b Center for Healthcare Studies, Northwestern Feinberg School of Medicine, Chicago, Illinois c Department of Emergency Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois d Galter Health Sciences Library, Northwestern Feinberg School of Medicine, Chicago, Illinois e Department of Emergency Medicine, State University of New York-Downstate School of Medicine, New York, New York
article info
abstract
Article history:
Background: Trauma systems in resource-rich countries have decreased mortality for
Received 12 August 2014
trauma patients through centralizing resources and standardizing treatment. Rapid
Received in revised form
industrialization and urbanization have increased the demand for formalized emergency
12 August 2014
medical services and trauma services (EMS and TS) in low- and middle-income countries
Accepted 25 September 2014
(LMICs). This systematic review examines initiatives to develop EMS and TS systems in
Available online 2 October 2014
LMICs to inform the development of comprehensive prehospital care systems in resourcepoor settings.
Keywords:
Materials and methods: EMS and TS system development publications were identified using
Trauma
MEDLINE, PubMed, and Scopus databases. Articles addressing subspecialty skill sets, public
Resource-poor
policy, or physicians were excluded. Two independent reviewers assessed titles, abstracts,
LMIC
and full texts in a hierarchical manner.
Trauma system development
Results: A total of 12 publications met inclusion criteria, and 10 unique LMIC EMS and TS
Systematic review
programs were identified. Common initiatives included the integration of existing EMS and
Global surgery
TS services and provision of standardized training and formalized certification processes for prehospital care providers, as well as the construction of a conceptual framework for system development through the public health model. Conclusions: There is no single model of EMS and TS systems, and successful programs are heterogeneous across regions. Successful EMS and TS systems share common characteristics. A predevelopment needs assessment is critical in identifying existing EMS and TS resources as a foundation for further development. Implementation requires coordination of preexisting resources with cost-effective initiatives that involve local stakeholders. High-impact priority areas are identified to focus improvements. Financial stresses and mismatching of resources in LMICs are common and are more commonly encountered
* Corresponding author. Wake Forest School of Medicine, Wake Forest University Baptist Medical Center, WinstoneSalem, NC 27101. Tel.: þ1 (312) 695 4835; fax: þ1 (312) 695 3644. E-mail address:
[email protected] (T.E. Callese). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.09.040
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when implementing a high-income model EMS and TS in an LMIC. Preimplementation and postimplementation evaluations can determine the efficacy of initiatives to strengthen EMS and TS systems. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Rapid industrialization and urbanization in low- and middleincome countries (LMICs) have shifted the focus of the global burden of disease toward trauma [1]. In the 1990s, road traffic incidents were the ninth leading cause of disease worldwide but are predicted to be the third leading cause by 2020 [2]. An estimated 90% of all trauma-related deaths occur in LMICs with 80% occurring in the prehospital setting [3]. The design of trauma systems vary widely among LMICs because of regional geography and culture, but the implementation of trauma systems of care consistently have been shown to improve patient outcomes [3e15]. The shifting of disease epidemiology toward acute illness and trauma has made the development of emergency medical services and trauma service (EMS and TS) systems a national public health priority in several LMICs. However, implementing EMS and TS has the potential to be very resource-intensive, which may be viewed as a barrier to implementation, especially in resource-limited countries. Identifying common approaches used to develop EMS and TS in resource-poor areas can aid in the development of new EMS and TS in areas where none currently exist. This systematic literature review examines existing initiatives to improve or implement EMS and TS systems in LMICs to inform the design of comprehensive trauma systems in resource-limited settings.
2.
Methods
2.1.
Search strategy
The Population, Intervention, Comparison, and Outcome format was used to develop inclusion and exclusion criteria. Specifically, the populations included for analysis included studies that reported the development, implementation, and sustainability of EMS and TS systems in LMICs. Interventions included initiatives to improve existing EMS and TS systems or implement new systems in LMICs. Comparators were informal and unstructured approaches to prehospital emergency care in resource-limited settings. The outcome assessed was the successful improvement or implementation of EMS and TS systems in LMICs. PubMed and/or MEDLINE, and Scopus databases were queried to identify relevant peer-reviewed literature describing or evaluating efforts to improve or implement EMS and TS systems in LMICs from 1965eJanuary 2014. Search terms were “trauma center,” “trauma system,” “EMS,” “system development,” “system establishment,” and “program development” and were restricted to LMICs. Studies conducted in non-LMIC settings and non-English articles were excluded after title and abstract review. Only articles published in
English were included in this analysis. Additionally, bibliographies of reviewed publications were cross-checked for additional relevant studies.
2.2.
Eligibility criteria
Publications that described initiatives to improve existing EMS and TS systems or implement new systems in LMICs were included for review. One independent reviewer assessed titles and abstracts, and two independent reviewers assessed full texts in a hierarchal manner. Articles that met search criteria were obtained, and the full articles were reviewed for inclusion. Disagreements among reviewers were resolved through consensus. Exclusion criteria were applied in abstract and full article review. Publication types labeled as “comments” or “letters” were excluded to focus on formal evaluation of existing initiatives. Articles that reported current EMS and TS system capabilities without describing interventions were excluded. Publications that focused on health policy, mass casualty incident response, education of providers and laypersons, or were not specific for system development were also excluded.
2.3.
Thematic analysis
A thematic analysis was developed to identify important core concepts in the development of trauma systems that can be applied across the spectrum of LMICs. A qualitative thematic analysis with a 5-stage iterative process was used to analyze each eligible article (1) development of coding schedule, (2) coding of data, (3) description of main categories, (4) linking of categories to themes, (5) and development of explanations for relations among themes. Initial codes were created inductively from the articles. One author developed the coding schedule, and two independent reviewers applied thematic categories to each eligible article in an iterative manner. Disagreements were resolved by consensus. Major themes were identified from the categorized articles. Data were managed using Microsoft Excel (Microsoft Corporation, Seattle, WA).
3.
Results
3.1.
Included articles
Searches returned 212 unique results, and after limiting to articles specifically about LMIC, the number of potentially relevant results was reduced to 43. Twelve articles fulfilled the inclusion criteria (Figure).
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212 potentially relevant citations Excluded by review of abstracts (n=169) - Comments/Letters, psychological studies - Specific skill set in subpopulations - Non-English specific - Publication Date 43 potentially appropriate manuscripts
- Non-LMIC specific Excluded by review of full text (n=31) - Reports on current capabilities - Policy specific - Non-specific to system development - Mass-casualty incidents
12 manuscripts included in review
Figure e Flow chart of the selection process for studies included in the systematic review.
3.2.
Programs descriptions
In this section, the twelve identified initiatives will be briefly described (Table). In Guatemala, efforts were targeted at expanding prehospital training and certification through the establishment of a dedicated degree program in prehospital emergency care within medical schools and reorganizing their existing fragmented EMS system [8]. Lack of funding was identified as a significant barrier to the successful implementation of these initiatives. The authors describe limited collaboration and cooperation among competing ambulance services, which they hypothesize may be attenuated through the establishment of a centralized emergency dispatch system [8]. In Chennai, India, programs aimed at strengthening trauma care were developed after a comprehensive needs assessment [16]. Initiatives targeted education and infrastructure improvements, including the establishment of an integrated EMS dispatch service, stratification of trauma centers by level of care, and formalization of EMS and emergency physician training [16]. In Iran, the public health model was used to develop a theoretical framework for a decentralized trauma system after a needs assessment [17]. The implementation of this new system progressed through two phases: (a) the “exclusive phase” where administrative provinces within the country would each conduct their own needs assessment studies to establish regional injury epidemiology, integrate available local resources, and identify needs for additional resources essential to optimize system performance and (b) the “inclusive phase” where the proposed system is operationalized and performance is monitored for further development and improvements [17].
In Mexico, a cost-benefit analysis of different levels of EMS training was performed [6]. A prehospital trauma life support (PHTLS) course was compared with basic trauma life support and advanced cardiac life support. PHTLS was found to be more cost-effective than the advanced certifications in resource-limited settings [6]. In Armenia, efforts to implement formal trauma systems of care focused on improving and standardizing training for EMS providers, implementing a trauma registry, and integrating EMS systems with receiving hospitals to ensure system-wide coordination [18]. These initiatives were identified after the completion of a comprehensive needs assessment [18]. In Kuala Lumpur, Malaysia, a cost-benefit analysis of an EMS system based on a high-income model was performed [7]. The implemented EMS system costs USD $2.5 million per year to operate while saving seven lives, suggesting that highincome trauma system models may not be cost-effective for resource-limited settings [7]. There have been significant improvements in emergency care in Malaysia since the implementation of the ambulance service. Programs include the recognition of prehospital medicine as a subspecialty of emergency medicine, formalized training for EMS providers, improved dispatch capabilities, and the redesigning of ambulances to fit epidemiologic data [19]. In Pakistan, the efficacy of two newly implemented formal EMS systems was evaluated [4,12]. Rescue-15, in Islamabad, Pakistan, is an innovative privateepublic partnership between the police, private sector, and the community that has effectively improved prehospital care, increased medical access, and has shown to be sustainable [4]. The Islamabad police department initiated the development of Rescue-15 to increase public confidence in emergency services and increase
Table e Initiatives to strengthen EMS and TS systems in LMICs. Authors
Hess et al.
Setting
Date
Guatemala
2004
Initiatives
Integration and reorganization of EMS systems Formal training certifications for EMS providers
Ramanujam et al.
India
2007
Increased funding Improved EMS dispatch capabilities Designation of trauma centers (level 1/2/3) Standardization of ED physician trauma education
Tarighi et al.
Iran
2012
Formal training certifications for EMS providers Public health approach to EMS and TS development
Mexico
2004
Hojnoski et al.
Armenia
1998
Establishment of regional EMS training center Formal training certifications for EMS providers
Hauswald et al. Hisamuddin et al.
Malaysia Malaysia
1997 2007
Comprehensive needs assessment Integration of EMS and TS with receiving hospitals Establishment of trauma registry HIC model EMS system implemented in Kuala Lumpur Prehospital medicine recognized as a subspecialty of EM Formal training certifications for EMS providers Improved EMS dispatch capabilities
Ali et al.
Pakistan
2006
Waseem et al.
Pakistan
2011
Redesigning ambulances to fit epidemiological data Publiceprivate partnership EMS and TS ambulance service Establishment of trauma registry Involvement of key stakeholders EMS and TS ambulance service implemented Involvement of key stakeholders Formal training certifications for EMS providers
Limitations
Private and public ambulance services No system cooperation or collaboration
Postimplementation evaluation not included
Ambulance services for transportation only No prehospital care provided Inadequate ED physician training
Retrospective review of prehospital records that were not required to be reported
Private and public ambulance services No standardized training requirements
May not be appropriate for all countries
Private and public ambulance services No system cooperation or collaboration No standardized training requirements Ambulance services for transport only No system cooperation or collaboration
Data relied on self-reporting by EMS providers, no independent validation
Retrospective and prospective clinical trials are required to determine efficacy of system
Themes
123
12
1234
34
123
No preexisting EMS and TS capabilities Private and public ambulance services No standardized training requirements Inadequate EMS dispatch capabilities
Analysis specific to EMS response to cardiac arrests Postimplementation evaluation not included
4
Private and public ambulance services No standardized training requirements
Relied on interviews. EMS records were not required.
234
Private and public ambulance services No standardized training requirements No system cooperation or collaboration
Retrospective and prospective clinical trials are required to determine efficacy of system
234
13
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Arreola-Risa et al.
Development of lead EMS and TS agency to guide initiatives Comprehensive needs assessment Implementation of formal certifications
Existing EMS and TS systems
303
Development of lead EMS and TS agency to guide initiatives (continued)
304
1 Increased number of ambulances and personnel Formal training certifications for EMS providers 2005 Indonesia Pitt et al.
Increased auto and industrial regulations 2011 China Zong et al.
Themes: 1. Initial needs assessment; 2. System-wide coordination; 3. Targeted corrective action; and 4. HIC models in LMICs.
Postimplementation evaluation not included
1234 Literature review is limited to peer-reviewed publications and may not capture the true picture of trauma care in China
13 Retrospective and prospective clinical trials are required to determine efficacy of system
Ambulance services for transport only No standardized training requirements Private and public ambulance services No standardized training requirements No system cooperation or collaboration Public ambulance service No system cooperation or collaboration Development of lead EMS and TS agency to guide initiatives 2007 Lebanon Bayram
Authors
Table e (continued )
Setting
Date
Initiatives
Existing EMS and TS systems
Limitations
Themes
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community involvement. Unlike Rescue-15, Rescue-1122, in Punjab, Pakistan, is primarily government funded [12]. Rescue-1122 initially started as an ambulance service but has since expanded to provide fire, rescue, and disaster response as well as instituted community safety programs [12]. Both systems have successfully improved trauma care in Pakistan by involving key stakeholders, encouraging community ownership, and by strengthening weaknesses identified in a preimplementation needs assessment [4,12]. In Lebanon, the inefficient use of foreign aid intended for improving trauma care led the Ministry of Health to support the establishment of the Lebanese Society of Emergency Medicine and physician residency training programs in Emergency Medicine [20]. International aid has been used to fund several studies aimed at improving prehospital care in Lebanon, yet none of the recommendations from these studies had been implemented by the time of the authors’ report [20]. Lebanon has also received donated training supplies and equipment but has not yet developed a plan for its utilization [20]. In China, the national government has made efforts to improve trauma care in response to increased population and frequency of industrial- and automobile-related traumatic injuries; however, there is a lack of a comprehensive trauma system. Adopted initiatives included streamlining automobile traffic patterns and legislation promoting industrial safety, but no initiatives at the level of trauma systems of care were reported [13]. In Indonesia, a needs assessment of prehospital care identified an absence of ambulance and patient retrieval services and identified several challenges to improving trauma care, including the culture in which traumatic accidents are perceived as fate [11]. One ambulance system serving five urban centers in Indonesia was identified as a leader in the provision of emergency care; however, it suffers from lack of human and material resources [11].
3.3.
Thematic analysis
A qualitative thematic analysis was used to analyze each included article. Four themes were identified in this review: (1) a systems-based needs assessment involving relevant stakeholders is essential to the successful design of EMS and TS systems, (2) system-wide coordination is necessary to ensure that prehospital and hospital capabilities are complementary, (3) targeted corrective action should be used to improve system components, and (4) models and systems used in highincome countries (HICs) may not be applicable to LMICs dues to cost and resource limitations.
4.
Discussion
Traumatic injuries present a significant public health problem in LMICs. Rapid industrialization and population growth in resource-limited settings have outpaced infrastructure improvements leading to an epidemiologic shift in patterns of disease burden as trauma and chronic illnesses overtake infectious diseases as the main perpetuators of public health in LMICs [1]. The resulting increase in automobile- and industryrelated accidents negatively impacts productivity and
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economic growth and adds to the burden on communities in these developing nations. In response to increased traumatic injuries, strengthening trauma care is quickly becoming a priority in many LMICs. Four themes were identified in this review regarding interventions aimed at improving or implementing new EMS and TS systems in LMICs. These themes represent the core concepts that are applicable across the LMIC stratum. Actual EMS and TS systems are heterogeneous by country and region, socioeconomic level, culture, and government; however, four core concepts and strategies were identified through this review that are potentially applicable across all LMICs.
4.1.
Systems-based needs assessment
Well-designed and systems-based needs assessment studies that include all identified stakeholders, including those in the public sector, private institutions, political and legislative forces, and community based resources, will guarantee global buy-in for the design and implementation of effective EMS and TS systems. An effective needs assessment is a collaborative effort between local leaders and citizens that determines the ability of existing EMS and TS systems while identifying areas for improvement [11,13,16,18,20]. The needs assessment process should determine disease epidemiology and mechanisms of accessing EMS and TS to identify the burden of injury and access to emergency care. Identifying a need for improved trauma care and the target community’s openness to TSs is essential for successful implementation of sustainable interventions. Methods of executing needs assessment studies include literature reviews, community surveys, household surveys, and methodological documentation of cross-sectional observations [11,13,16,18,20]. There are three major components of an EMS and TS system that a needs assessment should address such as: prehospital care, hospital-based care, and system administration. Prehospital assessment should include the ability of the system to identify and manage traumatic injuries and to transport patients to receiving hospitals [11,13,16,18,20]. Formal training and education levels of prehospital care providers and treatment protocols should be identified and evaluated [11,13,16,18,20]. Hospital-based care should be assessed for the overall organization and the level of trauma care provided within the emergency department, the inpatient capabilities to manage trauma-related injuries, and the availability of rehabilitation facilities to decrease long-term trauma-related disability [13,20]. Establishing a functional and wellmaintained trauma database facilitates longitudinal system evaluation and directs further refinements to the system and informs political and legislative bodies on the most appropriate allocation of scarce resources [11,13,20].
4.2.
System-wide coordination
EMS and TS systems are a network of individual components working together as part of a wider reaching trauma care structure, and as such, it is important to develop interventions that strengthen and build on existing systems to ensure maximum utilization of these scarce and valuable resources [13]. Existing systems of administration, legislative
305
framework, human resources, organizational structure, and infrastructure must be considered when developing system initiatives [4,12]. Because of the financial and professional resource constraints that LMICs are subject to, coordination at the provincial level may be a more effective approach to systems implementation [11,13,17]. Nationwide initiatives can be difficult to implement, even in HICs. By focusing on initiatives at the provincial level, resources can be more easily integrated, stakeholder ownership improved, and systems innovations quickly identified and readily implemented [11,13,17]. Rescue-1122 ambulance service in Punjab, Pakistan, and Rescue-15 ambulance service Islamabad, Pakistan, provide two examples of the level of coordination required to implement a sustainable and effective system [4,12]. Coordination with political leaders to prioritize EMS and TS system policy [4,7,10,11,13], coordination with emergency medicine physicians and prehospital care experts to develop training curriculum and treatment protocols [4,12,13], and coordination with community leaders to define local leadership and infrastructure development [4,8,12,13,16,18] are considerations that must be made when developing system interventions. Initiatives should aim to not only improve trauma care but also to promote long-term sustainability and complementary services. That is, interventions should ensure that prehospital care capabilities are complementary to capabilities of the receiving hospital’s emergency department and vice versa. When existing systems are not considered in the planning stages of a new intervention, unconstructive competition can occur between competing groups that provide similar services. In Guatemala City, Guatemala, the bomberos voluntarios, bomberos municipales, Alerta Medica, and paramedic operate competing ambulance services with individual emergency telephone numbers and separate dispatch centers [8]. Guatemalan authorities suggest that competition between these services is beneficial in reducing response times and increasing patient care; however, a structured review of their EMS system suggests that a more integrated system of emergency services would be more efficient and would improve standards of care [8].
4.3.
Targeted corrective action
Targeted corrective action addresses system weaknesses through initiatives that maximize benefit while minimizing costs [21]. Weaknesses can be identified through quality improvement processes, such as needs assessments or specialized tools for systems analysis. Targeted corrective actions maximize cost-effectiveness by leveraging existing resources and integrating reforms in modest, low-cost interventions. Two high-yield targeted corrective actions for emergency health care services include context-appropriate ambulance services and formalizing training certifications and treatment protocols for care providers [4,6,8,12,19]. Ambulance services designed within the resource constraints of the target area improve patient care, increase access to EMS and TS, and decrease patient transport time; however, sustainable funding and integration with existing systems can be difficult [4,6,12]. Formalizing training certification and treatment
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protocols for care providers by mandating minimum levels of training, establishing treatment guidelines, and developing a trauma registry may improve standards of care and provide a baseline for the longitudinal evaluation of training curriculum. Legislative policy targeting trauma prevention through automobile, traffic, and industrial regulations may be a potential target, but success is largely dependent on law enforcement and public awareness [13].
4.4.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
Application of high-income models in LMICs
One potential pitfall in the improvement or implementation of EMS and TS systems in LMICs is to attempt to replicate systems that have been successful in HICs. Unlike HICs, LMICs suffer from severe constraints of available resources, including poor infrastructure, lack of sustainable funding to support the immense costs of operating HIC models, and inadequate human resources [4,12]. For example, when a HIC EMS system was replicated in Kuala Lumpur, the implementation was costly and with little outcome improvement attributable to the EMS system [7]. The authors hypothesize that the design of the HIC EMS system, which focused on cardiac arrest from ventricular fibrillation and ventricular tachycardia, may not have been adaptable to the mortality epidemiology in Kuala Lumpur, which has a higher mortality from trauma. Initiatives to improve or implement EMS and TS systems in LMICs should be developed within the context of the resource limitations of the target region to decrease financial stress and inefficient resource allocation. Locally developed and constructed ambulances and equipment decreased system costs by USD $25.58 million in Pakistan, substantially reducing the financial stress of implementing an EMS and TS system [12]. Developing training curricula and treatment guidelines with respect to local human and physical resources and disease epidemiology can decrease financial stress. Courses designed in collaboration with LMICs, such as the PHTLS course, are more cost-effective than Advanced Trauma Life Support or Advance Cardiac Life Support in resource-limited settings [6,7,22]. Successful EMS and TS implementation may draw on principles used in HIC systems but are ultimately adaptable to local factors [13,18].
5.
data collection. T.E.C., C.T.R., and M.S. analyzed the data. T.E.C. drafted the article. All authors contributed substantially to its revision.
Conclusions
There is no single model of EMS and TS systems appropriate for all LMICs. Successful programs are heterogeneous across regions, and although studies on the effectiveness of trauma systems are influenced by geography and culture, results show that trauma systems improve patient outcomes [3e15]. Four common themes were identified in this review that define successful EMS and TS in LMICs: preimplementation needs assessment, system-wide coordination, targeted corrective actions, and context-appropriate system models.
Acknowledgment Authors’ contributions: T.E.C., C.T.R., S.J.S., N.I., and M.S. conceived and designed the study. P.S. performed the initial
references
[1] Mathers CD, Lopez AD. Projections of global mortality and burden of disease 2002-2030. Plos: Med 2006;3:e442. [2] Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Published by the Harvard School of Public Health on Behalf of the World Health Organization and the World Bank; 1996. [3] Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90:523. [4] Ali M, Miyoshi C, Ushijima H. Emergency medical services in Islamabad, Pakistan: a public-private partnership. Public Health 2006;120:50. [5] Anthony DR. Promoting emergency medical care systems in the developing world: weighing the costs. Glob Public Health 2011;6:906. [6] Arreola-Risa C, Mock C, Herrera-Escamilla AJ, Contreras I, Vargas J. Cost-effectiveness and benefit of alternatives to improve training for prehospital trauma care in Mexico. Prehosp Disaster Med 2004;19:318. [7] Hauswald M, Yeoh E. Designing a prehospital system for a developing country: estimated cost and benefits. Am J Emerg Med 1997;15:600. [8] Hess A, Thomas T, Contreras R, Green GB. Development of emergency medical services in Guatemala. Prehosp Emerg Care 2004;8:308. [9] Mock C, Kobusingye O, Joshipura M, Nguyen S, ArreolaRisa C. Strengthening trauma and critical care globally. Curr Opin Crit Care 2005;11:568. [10] Morrison W, Wright JL, Paidas CN. Pediatric trauma systems. Crit Care Med 2002;30:S448. [11] Pitt E, Pusponegoro A. Prehospital care in Indonesia. Emerg Med J 2005;22:144. [12] Waseem H, Naseer R, Razzak JA. Establishing a successful prehospital emergency service in a developing country: experience from Rescue 1122 service in Pakistan. Emerg Med J 2011;28:513. [13] Zong ZW, Li N, Cheng TM, et al. Current state and future perspectives of trauma care system in mainland China. Injury 2011;42:874. [14] Davenport RA, Tai N, West A, et al. A major trauma center is a specialty hospital not a hospital of specialties. Br J Surg 2010;97:109. [15] Mashiko K. Trauma systems in Japan: history, present status, and future perspectives. J Nippon Med Sch 2005;72:194. [16] Ramanujam P, Aschkenasy M. Identifying the need for prehospital and emergency care in the developing world: a case study in Chennai, India. J Assoc Physicians India 2007; 55:491. [17] Tarighi P, Tabibi SJ, Motevalian SA, et al. Designing a model for trauma system management using public health approach: the case of Iran. Acta Med Iran 2012;50:9. [18] Hojnoski JA, Ciottone GR, Aghababian RV. International development of emergency medical systems: educational
j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 3 ( 2 0 1 5 ) 3 0 0 e3 0 7
techniques for the future. Eur J Emerg Med: Official J Eur Soc Emerg Med 1998;5:23. [19] Hisamuddin NA, Hamzah MS, Holliman CJ. Prehospital emergency medical services in Malaysia. J Emerg Med 2007; 32:415. [20] Bayram JD. Emergency medicine in Lebanon: overview and prospect. J Emerg Med 2007;32:217.
307
[21] Mock C, Cherian MN. The global burden of musculoskeletal injuries: challenges and solutions. Clin Orthop Relat Res 2008;466:2306. [22] Sethi D, Kwan I, Kelly AM, Roberts I, Bunn F. Advanced trauma life support training for ambulance crews. Cochrane Database Syst Rev 2001;2: CD003109.
