Assessment of post-crash care system following road traffic accident in selected areas of Bangladesh

 

Bangladesh is currently undergoing an epidemic of Road Traffic Crashes (RTC) and hardly a day passes without a report of such an incident in the media. The annual road crash deaths per capita in Bangladesh are twice the average rate for high-income countries and between 1990 and 2017, the increase in the road crash fatality rate per capita was three times higher in Bangladesh than that across the South Asia region[1]. The levels of mortality and morbidity are quite high and the economic loss from RTC is estimated to be around 2 to 3% of the gross domestic product (GDP)[2]. Thus, the issue has become both a public health concern as well as a development challenge…

 

The achievements of Bangladesh in the UN road safety decade have been mixed and not to the expectation, mainly due to an unruly transport sector and lack of strategic investments and governance. A new Road Transport Act 2018 (approved in October 2018), replaced the Motor Vehicle Ordinance of 1983 after long deliberations. It also has a National Road Safety Strategic Action Plan that has recently been updated to 2020 with a vision of fulfilling the SDG target 3.6 of reducing the deaths and disabilities to around 50% by 2020. However, substantial gaps remain for improving vehicle safety, road user safety regulations, and post-crash response services…

The study assessed the current pre-hospital and hospital-based post-crash care services to get a holistic picture of the post-crash system existing in Bangladesh… A cross-sectional study design was applied, with a combination of approaches that included: a) Rapid review of literature on existing post-crash care in the country; b) pre-hospital and hospital-based trauma care assessment guided by WHO tools and on-site verification; c) qualitative studies [e.g., key informant (KIIs) and in-depth interviews (IDIs) with stakeholders, informal/focus group discussions (FGD), and observation] to elicit perceptions and experiences of the key stakeholders and have their insight regarding the opportunities and challenges of designing a state-of-the-art post-crash care system in the country…

 

The study population covered both supply and demand sides for pre-hospital and hospital-based trauma care assessment. In the demand-side, the study population included community people, RTC victims/ caregivers. In the supply-side, the study population included service providers, facility authorities’ and relevant key stakeholders from the local and national level. The study population also included public and private ambulance service providers in pre-selected areas.

 

Key findings

 

Pre-hospital care: by-stander/first responder care

·         the first responders were found mainly to be the bystanders who usually attend the RTC victims on a voluntary and humanitarian basis. However, there are no good Samaritan laws or rules in the country to indemnify the bystanders who give essential first aid to the RTC victims.

·         70% had inadequate knowledge on how to stop and call for help, and how to assess scene safety; 60% of the respondents had inadequate knowledge on how to establish the need for additional help but were aware of universal emergency number (60%).

·         majority of the respondents had no relevant knowledge and skills such as how to: evaluate breathing (80%), remove foreign bodies (70%), restore airway using manual manoeuvres (90%), restore airway using recovery position (90%), management of wound (70%), burns (60%), dressing (80%), basic immobilization (60%), using spinal precautions (90%),  evaluate external bleeding (50%) The majority (90%) were aware of how to control external haemorrhage using direct pressure but only 50% knew about how to evaluate the extent of external bleeding.

Pre-hospital care: ambulance services

 ·         there is no unified national ambulance system in the country; ambulances in the public sector are under MoHFW and FSCD/Mo Home Affairs while those in the private sector runs under the whims of the owners which may be a person or association or institution etc. None of these is under any central command and the regulatory regime for the ambulances is almost non-existent.

·         there is no provision for registering vehicles as ambulances with specific amenities, all are registered as is common for motor vehicles; in the private sector, the microbus is converted to makeshift ambulances with few amenities like an oxygen cylinder and a stretcher.

·         no GPS tracker or location identifier system or any app-based mechanism was available in the ambulances; not all ambulances were connected to the emergency call number 999 e.g., the UpHC ambulances. However, these and the private ambulances had their emergency contact number.

·         public sector ambulances were found to be used not for the transfer of victims from the accident spots to the nearest health facilities but the transport of referral patients, this task is mainly accomplished by the ambulances of the FSCD department with trained staff; and quite frequently the public sector ambulances were used for transport of staffs. People mainly used whatever transport is available at hand and private makeshift ambulances, if available, is too costly for poor patients. 

·         most of the ambulances, public or private have a single staff i.e., the driver who helps in moving the patient to the ambulance with the help of the bystanders or others. Only FSCD ambulances have staff in addition to the driver who is trained to resuscitate and provide first-aid care.

 

Hospital-based care

·         trauma care, in general, was found to be concentrated in the secondary and tertiary level public sector hospitals in the big cities only. In most cases, patients were referred to the district hospitals and in severe cases, ended up being referred to the tertiary level, sometimes super specialized, facilities. None of the hospitals had dedicated trauma care unit in the outdoor or in-door facilities neither any triage facility was available except DMCH.

·         none of the attending doctors/staff of the emergency rooms in the DH and UpHC is trained in RTC related trauma care/emergency care including no SOPs or uniform protocols; services were provided based upon their knowledge and skills depending on the availability of necessary equipment. DHs had orthopaedic and surgery consultants, however, no specific training/courses were received on RTC trauma care.

·         most emergency and lifesaving procedures are available in DMCH for post-crash victims at emergency and casualty department, OSEC (One Stop Emergency Center); triage and screening is performed at emergency and patients managed accordingly; not having training on RTC trauma care but followed ATLS (Advance Trauma Life Support) protocol based on their seniors’ instructions.

 

Communication and registration system

·         Around 30% of the bystanders were not aware of the national emergency contact number (999) and nearly half of the ambulances, including UpHC ambulances, were not linked to any emergency number.  At the UpHC & DH level, 22% of the facilities did not have a functional (land/mobile) contact number in the emergency room.

·         No system of registering the RTC cases in the health facilities was found. UpHCs usually did not have a separate logbook for RTC case record; it is recorded in the emergency case logbook along with all other emergency cases. At DHs, a separate logbook was maintained for all type of injury-related causalities including the RTCs. At the tertiary level, the private facility did not have RTC injury case records/ log of all RTA cases. The UpHCs, DHs and tertiary hospitals reported the case records along with other case records to DGHS on monthly basis.

RTCs from gender perspectives

·         Around 16 female respondents participated in the assessment and shared their experiences as by-stander/first responder, victim and care-giver to the victim. As bystander, female played similar role as the males while attending the victim on spot. However, for referring victim to the health facility, they needed support. They were not conformable to attend the victims when the incident happened at night due to safety reason. Female victims felt more vulnerable and experienced hesitance on from the bystanders/first responders to help them. Along with the victims, the female care-givers suffered mental and financial trauma while dealing with the consequences of the RTCs.

·         Some of the female victims stated that they didn’t get any attention from the local people. Rather, they felt, some people overlooked them and intentionally didn’t help them as they were female. Also, they were more vulnerable from the RTCs. As they were women with responsibilities for household chores, even if the injury was debilitating or prolonged they had to continue without complaint. There was no one else to assist them.

·         Most of the female victims went through a severe mental trauma. They said that most of the time they were stressed, anxious and worried about their family, health and financial support. Not only victims, but their female family members also suffered and became vulnerable as they had to support the family following the loss or disability of the male member.

 

Day vs night time emergency care services

·         During day time, emergencies in facilities were already overcrowded which caused delay in receiving services. Sometime victims other than the RTC cases visited the emergency room with severe conditions and service providers had to provide treatment to them first. In such conditions, the RTC victims had to wait prolonged hours.  After 2 pm, lab services were not available. Availability of emergency services on government holidays was a challenge most of the times.

·         Emergency services at mid-night were delayed and sometimes, victims had to wait for care until morning. Ambulance of the facility was not available to refer patient with critical condition and the relatives had to hire private transport at a higher fare. 

Conclusions

The findings of this assessment reveal that the current post-crash care system following RTCs is rudimentary, fragmented, and poorly resourced (regarding HRH and logistics and equipment) not fit for meeting the challenges of the twenty-first century and achieving the national goal of UHC by 2030. Phase-wise, the following conclusions are drawn:

·         The bystander/first responder care is almost non-existent; whatever exists is totally amateurish and arises from humanitarian concerns, not from any evidence-informed, professional system. There is also the absence of skilled and trained health staff for the ambulances who can provide emergency services on transit. To note: there is a well-managed system of ambulance services under the FSCD with formally trained staff and necessary equipment for resuscitation and first-aid care.

·         There are ambulances but do not function under any SOPs, either in the public or the public sectors and not under any central authority with uniform operation procedure; the majority are makeshift ambulances and are not properly equipped with necessary amenities for resuscitation and first-aid care; communication system is not well-developed and connected.

·         Staff trained professionally in first aid/resuscitation/life-saving care is largely unavailable for the ambulances; there is no separate organogram for ambulances in the public sector. Lack of trained HRH and allocation of resources are major barriers; the FSCD played a prime role in pre-hospital service

·         No dedicated emergency room and staff for treating the RTC victims, especially at the roadside health facilities; no universal SOPs/protocol manual to manage such victims. The ER staff are not formally trained in emergency care, including doctors.

·         The readiness of the hospitals to receive and treat trauma victims including RTC victims varies across levels and areas; shortage of basic equipment and medicines, trained and experienced staff and absence of dedicated trauma care unit in the facilities limit the kind and quality of services provided and make it costly., Most cased ended up being referred to tertiary level facilities in big cities that increased cost of care particularly in case of severe injuries which require long recovery time.

 

Specific recommendations based on findings:

Pre-hospital emergency care services

 

i)             By-stander/first responder care

 

·         Well organised, community-driven, by-stander/first responder development training programmes (following the Trauma Link and similar other models) should be scaled up under public-private partnership model including refresher training at regular intervals; highway police may also be trained in first responder care to assure on-the-spot management of victims.

·         Registration/certification/ recognition (monetary/non-monetary) of the first responders to enhance motivation for this voluntary works including the passing of good Samaritan legislature for indemnifying them while providing services.

 

ii)           Ambulance based care

 

·         Ensuring the availability of basic equipment and resources for resuscitation and first-aid care as basic criteria for registration of vehicle as an ambulance; vetting may be done by MoHFW or FSCD department to ensure a minimum standard for ambulances; enabling GPS tracker/location identifier in the ambulances

·         Dedicated line of management for the governance of the ambulance services in both public and private sectors, preferably under a unified system; The FSCD organogram can be used for this purpose.

·         Given their current role in transporting victims from accident spots to nearest health facilities with trained and skilled staff, the FSCD ambulance services in coordination with the MoHFW, can be developed as the lead focal agency exclusively for this task.

·         Train and develop staff (including drivers, if feasible) for providing emergency care services in the ambulances while on transit;

·         Develop SOPs for the ambulances both on-the-spot and during transit and until reaching the health facility; the private ambulances should be brought under regulatory control for quality and cost.

·         In the long run, ambulances in the public and private sectors should be integrated into an independent National Ambulance Service

 

Facility/hospital-based trauma care services

 

·         Dedicated trauma care unit with necessary equipment and resources (including medicines and human resources) in all hospitals from UpHC to district and above (secondary and tertiary care hospitals); SOPS and protocols for management of trauma cases including RTC cases.

·         Specific academic and practical training on emergency/trauma care services including specific care for the RTC victims for all staff of the emergency rooms at every level.

·         Emergency/contingency fund for RTC patients at the hospitals to reduce high OOP expenditure and catastrophic expenditure; allocation of resources in the national budget for developing the post-crash care/trauma care system in the country.

[ Excerpts from a forthcoming report on post-crash care system in Bangladesh]

 

---

[1] World Bank 2020. Delivering road safety in Bangladesh: Leadership Priorities and Initiatives to 2030.

[2] Rahman 2011. Road Traffic Injuries in Bangladesh: a neglected epidemic.