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Table of Contents 2 Acknowledgments 3 Acronyms Executive Summary 4 SECTION I Introduction 7 SECTION II Background 10 SECTION III Trauma Registry Data 14 Collection Process SECTION IV Analysis of the 17 Trauma Registry Data SECTION V Challenges and Actions for 25 Successful Trauma Registry Implementation SECTION VI EMS Pilot, Challenges 31 and Lessons Learned SECTION VII Discussion, Policy Relevance 36 and Recommendations References 40 Appendix 1: Additional Figures and Tables 42 Appendix 2: Trauma Registry Questions 49 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 1 Acknowledgements T he principal investigators (PIs) for this research are Sveta Milusheva, Development Impact Evaluation Group (DIME), World Bank; Saahil Karpe, DIME; Kevin Croke, Harvard School of Public Health; Linda Chokotho, Department of Surgery, College of Medicine, University of Malawi; and Wakisa Mulwafu, Department of Surgery, College of Medicine, University of Malawi. This report was written by the PIs together with Jonna Bertfelt, DIME and Meyhar Mohammed, DIME, World Bank. We would like to thank the Government of Malawi (GoM) and especially the Ministry of Health (MoH). We wish to thank the team that has been working tirelessly on the implementation of the Malawi Emergency Response (EMS) Pilot, whom we have collaborated closely with during the set up and running of the Malawi Trauma Registry. This includes, but is not limited to, Dr. Jones Kaponda Masiye, Deputy Director Clinical Services (NCDIs and Mental Health), Dr. Yankho M Luwe, EMS Pilot Project Coordinator, Mr. Henderson Lomosi, EMS Call Center Manager, Mr. Jairos Chirwa, EMS Capacity Building Manager, Mr. Noel Kasomekera, Technical Advisor, and Mr. Sammx Phiri, IT Specialist. We are also grateful to the Malawi Roads Authority, the Directorate of Road Traffic and Safety Services, and the Malawi National Police Service for their collaboration on this research. Furthermore, we would also like to thank the Malawi Country Management Unit, Hugh Riddell, Malawi Country Manager, Chris De Serio, Senior Transport Specialist, Chikondi Clara Nsusa- Chilipa, Transport Specialist, Virginia Maria Henriquez Fernandez, Transport Specialist, and Dominic S. Haazen, Lead Health Policy Specialist, for implementation support of the Trauma Registry and the EMS Pilot more broadly. Valuable and important input to this report has also come from Peter Okwero, Senior Health Specialist, Suresh Kunhi Mohammed, Senior Health Specialist, and Inaam Ul Haq, Program Leader, The World Bank. A big thanks also goes to the data collection teams, Trauma Registry (TR) Coordinators and District Health officers who contributed to the TR data collection and offered feedback on the trauma registry design and implementation, as well as the data collection support team Foster Mbomuwa, Edith Khayzah and Temwa Mayuni-Mhone. Funding Funding was provided by the DIME Impact Evaluation to Development Impact ieConnect program, which has been funded with UK aid from the UK government. Additional funding was provided by the Global Road Safety Facility (GRSF), the AO Alliance, and by the Research Support Budget in the Development Economics Vice-Presidency of the World Bank. Ethics Approval Ethical approval for this study was granted by the Malawi National Health Sciences Research Committee (NHSRC), protocol 18-05-2030. 2 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Acronyms  AVPU Alert, Voice, Pain, Unresponsive scale ER Emergency Room EMT Emergency Medical Technicians DHO District Health Officer DRTSS Directorate of Road Traffic and Safety Services KCH Kamuzu Central Hospital GSC Glasgow Coma Score HMIS Health Management Information System LMIC Low or Middle Income Country MACRA Malawi Communications Regulatory Authority MOH Ministry of Health MOTPW Ministry of Transport and Public Works MRA Malawi Roads Authority NHRSC National Health Sciences Research Committee QECH Queen Elizabeth Central Hospital RTC Road Traffic Crash SSA Sub-Saharan Africa TR Trauma Registry TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 3 Executive Summary G lobally, Road Traffic Crashes (RTC) account for around 1.35 million deaths annually, with this burden falling heavily on low- and middle-income countries. This is especially true for Sub-Saharan Africa and countries like Malawi, which is in the top 20 countries in terms of fatalities from RTCs (WHO, 2018). Further, deaths occur mostly in the economically active age-groups of the population, leading to important economic consequences for these countries (WHO, 2018). Sustainable Development Goal (SDG) 3.6, calls for a halving of the number of global deaths and injuries from road traffic crashes. While preventive measures can decrease the number of RTCs, it is also important to invest in post-crash care to save more lives (Soro and Wayoro, 2017). Yet, in Sub-Saharan Africa (SSA), where the problem is most acute, very few countries have developed 4 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI systematic and sustainable Emergency Medical Services (EMS) The TR data was collected with several objectives in mind, systems at scale (World Bank, 2021). 1 including 1) providing an understanding of the trauma burden in Malawi, 2) acting as a baseline for the EMS pilot project in Malawi is a prime example of this precarious road safety order for the team to conduct a rigorous impact evaluation, and situation, showing both high numbers of annual RTCs (WHO, 3) supporting the improved functioning of the EMS system in 2018) and having a weak emergency response system, the longer term through insights on the trauma burden, care including pre-hospital care (Mulwafu, 2017). To address this and outcomes. challenge and in an attempt to decrease victims of RTCs in Malawi, the Government of Malawi developed an Emergency The EMS pilot is still ongoing; consequently, the impact Response Pilot (the EMS Pilot), to be implemented along the evaluation has not been completed since it will require the pilot busiest stretch of Malawi’s largest road, the M1, between to be fully implemented and operational for a period of time Lilongwe and Blantyre. This pilot is funded by the World Bank in order to evaluate the impacts. Therefore, the goal of this through the Southern Africa Trade and Transport Facilitation report is 1) to provide insights into the current situation and Program – Phase 2 (SATTFP2), and it is being implemented overall burden of trauma and RTCs in Malawi, 2) to share by the Ministry of Health (MoH). The EMS Pilot is being what we have learned about how to effectively run a implemented in two Central and four District Hospitals digital trauma registry in a low-resource setting, and 3) to and it includes the provision of 12 ambulances, a central highlight lessons learned from the implementation of the dispatch center, capacity building of medical personnel EMS pilot. These insights can provide valuable information to in trauma care as well as a Trauma Registry (TR), to collect data improve our understanding of trauma and road traffic injuries in on trauma cases, care and outcomes. the country as well as the practicalities around rigorous data collection and setting up of an EMS system, which can help in Given the importance of understanding the implementation and the framing and targeting of future policy in the sector. This report impacts of this pilot project, as well as the burden of trauma provides a few key findings and recommendations: more broadly, in order to inform potential scale-up to the rest of the country, the Development Impact Evaluation Group (DIME) at the World Bank partnered with the MoH to conduct an impact evaluation of the EMS pilot project. As part of this work and Burden of Trauma in collaboration with the MoH and local researchers from the 1. Like data from other TRs in the region, the Malawi College of Medicine, University of Malawi, the DIME team TR shows marked gender and age patterns in the supported in setting up and expanding high quality trauma data incidence of trauma, with overrepresentation of collection, in the form of a Trauma Registry, in five of the six pilot males and younger adults. health facilities and five comparable health facilities along the 2. RTCs make up almost half of admitted trauma cases M1 road that were not part of the pilot.2 The process of setting recorded (48%). While falls make up 46% of all trauma up the TR also provides crucial learning and may help inform cases recorded, they are only 22% of hospital admissions. trauma registry implementation endeavors for policy makers in 3. Almost half (49%) of RTC victims are non-motorized similar contexts. road users such as pedestrians and cyclists. This report shares data insights and makes recommendations 4. 84 % of patients who were passengers of motor vehicles based on the findings from the TR data. The Malawi TR such as cars, buses, and trucks report not having worn was operational in 10 district and central hospitals in Malawi a seatbelt. And 52% of patients who were drivers or for 35 months (August 2018–June 2021) and collected data on passengers of motorbikes report not wearing a helmet. 118,013 patients. It provides detailed data on patient demographics, 5. Patients report major delays between the time of injury trauma causes, care, medical outcomes, and road traffic injuries. and the time they reach the hospitals as well as delays in care after arrival in hospital. Focusing on cases where the patient arrived within 24 hours of the trauma, RTC 1 The report defines EMS as prehospital care that is formalized and provided by cases have around 1.4  hours between the time of emergency care professionals, whereby there is an established entity, agency or trauma and the time of arrival. All serious trauma cases system facilitating the coordinated, timely, and safe provision of emergency care and transportation to the most appropriate healthcare facility. (including RTCs) arriving within 24 hours of the trauma 2 One of the pilot facilities, Kamuzu Central Hospital, already had a high-quality trauma have a median time to arrival of 2 hours, but non-RTC registry in place, and therefore additional data collection was not implemented as part of this work. serious cases have a median time to arrival of 4 hours. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 5 6. For admitted cases, 29% arrive by private vehicle, 21% of resources and personnel requirements for call center use commercial vehicles such as taxis, 16% come using management and EMS pre-hospital care considerations, public modes such as minibuses, and only 6% use an towards elevating EMS as part of critical care planning ambulance. and budgeting. 15. More effective public communications campaigns are vital to increase local awareness on the proper use Implementation of Trauma Registries of the new emergency number (*118), the relevance of 7. Digital Data collection is feasible in this setting. The formal post-crash care for road trauma, and to reduce upfront costs might be slightly higher, but the data the misuse of the toll-free number. quality is better. Initial skepticism from counterparts disappeared as the TR was set up and functioned well for almost three years. Recommendations 8. Stakeholder engagement and coordination at both 1. The data demonstrate the burden of road traffic crashes the centralized level and individual facility level is critical for health facilities and the need to implement additional for effective and complete data collection. policies that can decrease RTCs, which will help to alleviate 9. Pre-testing, piloting, training, frequent data quality resource needs within health facilities. checks and feedback to data collection teams are 2. There is a need to target policies and infrastructure to critical components for high-quality data collection. improve road safety for the most vulnerable users — 10. TR coordinators and hospital management found the TR pedestrians and cyclists. data useful for reporting and planning purposes. 3. The data collected shows the scope for increased seat belt 11. TR data analysis demonstrates the potential of trauma and helmet use to reduce RTC-related trauma in Malawi, registries to inform both preventive policies and through both increased enforcement of related road laws clinical care. and public safety advocacy. 4. Investment in a comprehensive communications campaign and use of existing data to help guide and Process of EMS Pilot Implementation evaluate the effectiveness of the campaign will be 12. The implementation of the EMS call center and ambulance important. dispatch could have benefitted from greater focus on 5. There should be increased use of all the different data change management within the implementing agency, that are collected by the EMS systems and within health to emphasize efforts at building an overall understanding facilities in order to help guide operations and lead to of how core elements of an EMS system are unique and higher effectiveness. different from previous use of ambulance services in 6. A continuation and a refinement of the TR, including Malawi. greater detail on care delivered and patient outcomes, 13. Recognition was needed at an earlier stage of the need for could contribute to the evidence base regarding trauma an active and engaged ICT specialist to support throughout care in Malawi. Streamlining of the variables collected (by the process of systems engineering and planning for the identifying the most important ones) and integration into technology, communications and related protocols existing data collection practices in health facilities can needed to enable a core part of the EMS system, the help support sustainability. dispatching of ambulances. This could have increased 7. Increased investment in digital data collection in health efficiency, effectiveness and speed of system rollout. facilities could help to improve the quantity and quality of 14. An in-depth analysis of operational and financial data data collected and increase the usefulness of the data for collected during the pilot can usefully inform the level policy planning and health facility operations. 6 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI SECTION I Introduction R oad traffic crashes are the eighth leading cause of death globally, with approximately 1.35 million people dying annually (WHO, 2018). Low- and middle-income countries (LMICs) carry the majority of the burden, accounting for 93% of these fatalities, and vulnerable road users (pedestrians, cyclists, motorcyclists) make up a high share of deaths, especially in these countries (WHO, 2020; World Bank, 2021). There are also important economic consequences of RTCs, given that they especially impact the prime working-age groups, and RTCs are the leading cause of death worldwide among those aged 15–29 years (Boniface et al., 2016; WHO, 2020). In addition to the large mortality burden, approximately 50 million people per year sustain injuries resulting in long term disability due to RTCs. Yet investments in road safety interventions and emergency medical care are non-existent or inadequate (World Bank, 2021). In particular, Sub-Saharan Africa represents the largest group of countries (by population) with no effective pre-hospital emergency care systems in place. More data-driven regional evidence to improve mortality and morbidity TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 7 is needed in this area to support both reductions in RTCs and income countries and low-and middle-income countries directly improvements in outcomes from RTCs (World Bank, 2021). relate to the level of post-crash and pre-hospital care received immediately at the accident scene, and subsequently in a health- care facility. Post-Crash Care The Global Plan for the Decade of Action for Road Safety 2011–2020, initiated by the United Nations, identified improved Impact of RTCs and Post-Crash Care “post-crash response” as one of the five pillars within the overall in Malawi framework for its activities. While the main goal to be pursued by Fatalities and injuries from road traffic crashes represent a policymakers should be to prevent road traffic injuries, the reality significant and growing economic and social cost in Africa, is that road crashes will continue to occur. Therefore, it is also particularly along major trade corridors. Africa has one of the important to look at policies that can mitigate the consequences highest road traffic death rates in the world, with 26.6 deaths of crashes and improve the quality of life for those people that are per 100,000 people (WHO, 2018). This rate far exceeds the injured, in conjunction with policies to decrease the number of global rate of 18.2 traffic deaths per 100,000, with the best crashes. In this light, as described by the WHO, “the aim of post- performing countries at rates below 3 per 100,000. In Malawi, crash care is to avoid preventable death and disability, limit the the death rate from RTCs is estimated to be 31 per 100,000, and severity of the injury and the suffering caused by it, and ensure in 2016 alone there were an estimated 5,601 deaths in Malawi the crash survivor’s best possible recovery and reintegration due to RTCs (WHO, 2018). into society” (WHO, 2006). The relatively high mortality rate due to RTCs in LMICs points towards weaker health care and trauma Even though around half of all road traffic deaths occur almost care systems in these countries, that are especially in need of immediately at the scene of the crash, the outcome for the investments in emergency care (Reynolds et al., 2017). Yet, many survivors at the crash site could be affected by the quality of the developing countries lack adequate emergency medical response medical care that they receive. However, the ability to provide systems and the disparities in injury outcomes between high- rapid emergency medical care for serious trauma in developing 8 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI countries is often limited. An assessment of the capacity of rates of non-communicable disease as well as injuries, which are trauma care and emergency medical assistance to respond increasingly burdening these health systems. However, very few to motor vehicle crashes conducted in Malawi in 2014 found of the SSA countries have found a model for their Emergency very little pre-hospital care, lack of a coordinated emergency Medical Service (EMS) system that is operationally and financially response system, and poor capacity in hospitals to provide sound and sustainable (World Bank, 2021). adequate trauma care (Malwafu et al. 2017). Further, in-hospital care was found to be especially sub-optimal in district hospitals, This report shares the results of a research project that set out mainly due to scarce human resources, unavailability of basic to help fill this knowledge gap, through an impact evaluation of and necessary equipment and lack of training in trauma care a new EMS pilot in Malawi. At this point in time, the EMS pilot (Malwafu et al. 2017). As of 2017, there was also no national has not yet reached its full capacity and we cannot assess and emergency access telephone number in Malawi, an important share the impact of this new system. However, the data that component of a successful post-crash response. has been collected, through this project, can shed light on the epidemiology of trauma in Malawi, lessons learned regarding Road safety will only continue to grow as a problem if it is not trauma data collection and experiences and insights of starting addressed. As more resources are channeled towards improving a public EMS system in a low-resource setting. road infrastructure, these upgrades often lead to higher road speeds, which can increase the number of injuries and deaths Section II of this report provides background on the operational from RTCs (Job and Sakashita, 2016). At the same time, rigorous project and an overview of the impact evaluation that was evidence on effective interventions is lacking for all aspects of originally designed. Section III covers the trauma registry set the road safety agenda, and it is paramount to both study and up and data collection process. Section IV provides quantitative implement a broad range of policies and interventions, from analysis based on data collected using the trauma registry. preventive measures that reduce the frequency and severity of Section V provides limitations related to the data collection, crashes, to improved post-crash strategies that can decrease including details on data collection during COVID-19, and mortality and morbidity through post-crash response and identifies the challenges, successes and lessons learned with medical treatment. a focus on implementation logistics, stakeholder engagement strategies and data monitoring and quality assurance. Section VI There are particularly large gaps in the evidence base with respect shares insights on the process of implementing the EMS pilot in to post-crash trauma care and emergency care, in Malawi like Malawi by bringing together data and experiences from the TR, in the majority of SSA countries. Many SSA countries have, in the EMS monthly reporting, the call center data collection and the recent past, started to pay more attention to and build out close collaboration with the EMS management team. Section VII emergency health care services, to respond to higher prevalence concludes with a discussion and a focus on policy implications. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 9 SECTION II Background T he DIME ieConnect Health Impacts of Emergency Response and Post-Crash Medical Care, Malawi, impact evaluation (IE) project was designed to support and evaluate a new Emergency Medical Services (EMS) pilot in Malawi, which was planned and being implemented under the Southern Africa Trade and Transport Facilitation Program (SATTFP). The goal of this IE was to evaluate the impact of the EMS pilot on trauma cases in general and RTC victims in particular. To evaluate and support the new EMS pilot a digital multi-site Trauma Registry (TR) was set up to collect data on trauma cases and outcomes from ten district and central hospitals across the country. This report provides insights from analysis done on data collected through this TR, which ran for almost three consecutive years and collected data on over 118,000 trauma patients. It also shares insights and learnings on the process of the implementation of the TR and the EMS pilot. 10 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Malawi Health Care System Health services in Malawi are delivered to the public through different providers including, public, private for profit and private not for profit organizations. The public sector includes all facilities run by the MOH, which is the largest provider of health care services in the country. The publicly run health care system includes 4 central hospitals and 26 district hospitals. Among the smaller facilities, there are 360 health centers and 98 dispensaries, clinics and health posts. The Christian Health Association of Malawi (CHAM) is the second largest provider of health care and provides approximately 29% of all health services in Malawi through their 170 different level health facilities. Health care services are organized in three different levels: primary, secondary and tertiary care. Tertiary health care facilities are the central hospitals, which are meant to provide specialist health services and referral services for difficult and emergency cases from the lower levels of care within the region. The Health Sector Strategic Plan II (HSSP II) identifies some of the greatest challenges in the health system to be 1) only 76% the same year. The project initially had an end date of 31st of the population lives within an 8 km radius of a health facility; December 2021, but with approved additional financing from the 2) there is a regular shortage of essential medical products and World Bank, the timeline has been extended by two years until technologies; and (3) overall, there is a 45% vacancy rate for 31st December 2023. medical personnel (MOH, 2017). Improvements in the corridor are expected to lead to higher HSSP II also states that, prior to the new EMS pilot, EMS services speeds and reductions in travel time, and without accompanying in the country were weak and uncoordinated, and mostly attention to road safety, such interventions can result in increases focused on emergency referrals rather than pre-hospital care in crashes and fatalities from RTCs. To forestall this potentiality, and emergency transportation to a health facility. Furthermore, several road safety components are integrated into large transport prior to the EMS pilot, Emergency Medical Technicians (EMT) programs like this one. In this case, among other efforts, a post- training for paramedics was not available in the country, and crash intervention was developed — The Malawi EMS Pilot. there was no national emergency number dedicated to medical This program sub-component is focused on improving health emergencies. The third Health Sector Strategic Plan is currently services and emergency medical response. The pilot project is being developed, and this HSSP is set to include a section being implemented along 310km of the major highway in Malawi dedicated to Emergency Care. (the M1) between Lilongwe and Blantyre and includes six health facilities: Kamuzu Central Hospital, Dedza District Hospital, Ntcheu District Hospital, Lisungwi Community Hospital, Balaka Southern Africa Trade and Transport District Hospital and Queen Elizabeth Central Hospital. The pilot involves the following components: Facilitation Project — EMS Pilot In Malawi, and Tanzania, the World Bank is financing the Southern ◾ Creation of a central call and ambulance dispatch center, and Africa Trade and Transport Facilitation Program – Phases 1 & 2 activation of an emergency access telephone number; (SATTFP), with the objective of facilitating the movement of ◾ Training of 500 community first responders from village health goods and people along a North-South Trade Corridor, while committees in communities adjacent to the EMS pilot area; supporting improvements in road safety and health services ◾ Training of paramedics and ambulance drivers; along the corridor. The objectives of the SATTFP shall be ◾ Procurement and management of 12 ambulances and other realized through a sequential improvement in the physical, EMS equipment; institutional and social infrastructure and the strengthening of ◾ Design and roll out of an information campaign announcing the management of the corridor. The project in Malawi (Phase 2) the new emergency number and educating the public in how was approved in April 2015 and began implementation in May to use it; TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 11 ◾ Renovation and improvement of the Trauma Care Centers in the year, the Malawi emergency number, *118, was created and a six hospitals that are part of the EMS Pilot, this includes: call and dispatch center was set up. Dispatchers were trained ⦁ Procurement of equipment, consumables and laboratory in answering and handling emergency calls as well as in how to equipment for each of the hospitals; dispatch ambulances, using a dispatching software. The TR also ⦁ Increasing capacity with refresher training on Advanced started operating in 5 out of 6 EMS hospitals. Trauma Life support. A live trial of the EMS pilot began in May 2019. In order to get ◾ Collecting data on trauma cases, care and outcomes, through the system running well and address any operational challenges, the set-up of a multi-site Trauma Registry (TR); the EMS pilot started operating with 6 of the 12 new ambulances. In Malawi, there are gaps in the trauma care system, but also in The goal of this limited roll-out was to test the new system and the data infrastructure which would allow policymakers to better work on improving its management until it was ready to operate understand the scope of these problems. Previous attempts to at full scale with all 12 ambulances. establish trauma registries in Malawi have been largely based In early 2020, one ambulance was used to travel around Blantyre at referral hospitals (e.g., Queen Elizabeth Central Hospital and and meet with the public and share information about the EMS Kamuzu Central Hospital) with several more limited registries services. This public-facing communication activity (known as in single district hospitals over a limited period. Hence, broader a “roadshow”) showed some success locally in educating the trends with respect to trauma in Malawi, especially outside of public about the new EMS system and emergency number. the larger cities of Lilongwe and Blantyre, have not previously However, the roll-out of a large-scale communication campaign to been comprehensively measured. This has limited the ability of the public is still needed. Renovation of the Trauma Care Centers policymakers to quantify the size of Malawi’s trauma problem, at the six EMS hospitals is expected by late 2022. and hampered their efforts to develop, target, and evaluate policy interventions in this area. Therefore, a new multi-site trauma registry was included as an element in the EMS pilot, with the objective to collect more and better data on trauma in Malawi. Emergency Medical Services Pilot Impact Evaluation The implementation of the EMS pilot started in May 2015. The While program components similar to those in the Malawi EMS first step was to appoint a Project Steering Committee, with pilot have been implemented in other contexts before, there is the responsibility to provide oversight, strategic leadership and limited evidence on the effectiveness of the implementation conduct performance monitoring of the EMS pilot implementation of this specific combination of EMS services in low income, progress. A project implementation plan was also developed, and high RTC incidence settings such as Malawi. Therefore, an IE finalized, in October 2016. was developed to generate evidence related to EMS services Implementation of activities started with training of ambulance in this context. The planned IE meant to evaluate the impact of drivers, first responders and EMS providers in 2017. Twelve the EMS pilot on intermediate outcomes such as health status mini-van ambulances and related medical equipment were bought of trauma patients at the arrival to hospital and timeliness of and delivered to Malawi in the second half of 2018. In the same treatment of trauma patients as well as outcomes such as treatment and next-day condition (if admitted). The broad, long term, objective of the IE was to evaluate the impact of the program on health outcomes of trauma patients and to enable policy makers to calculate the cost effectiveness of an EMS system. Additionally, evidence was meant to inform decisions of expansion of the system, or, alternatively, provide information on whether other strategies might be more effective to reduce the burden of road traffic injuries. Finally, given the limited evidence on trauma broadly, another goal was to produce high-quality data on trauma that could help provide insights on trauma causes and care in Malawi. The main strategy for this study was to collect detailed data on trauma cases coming into the six health facilities that are part of the EMS pilot using the TR that was planned as an integral part of the EMS pilot project. 12 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI To note, since one of the EMS health facilities, Kamuzu Central all the project components is still ongoing, an impact evaluation Hospital, already had a well-functioning trauma registry in place, of the EMS pilot is not possible at this time. Once all components we focused on the remaining five facilities where there was are fully functional for a period of time, additional data collection no data on trauma being collected. The TR was started prior to could allow for evaluation of the pilot. Nevertheless, there are the intervention in order to have a comparison period before several important and policy-relevant learnings and insights the intervention to study how outcome variables changed coming out of these data. These include insights on setting up after the intervention was implemented. Additionally, in order high-quality trauma registries that could support better data to set up a rigorous research project, and knowing that other collection in the future, as well as analyses that provide information factors affecting trauma outcomes could occur at the same on the current status of trauma in Malawi. Additionally, the study time, we also selected five control units. In other words, we allowed a more in-depth look at the process of implementing this include an additional five health facilities in the TR as ‘comparison type of EMS project, and some of the learnings from this can facilities.’ These facilities are also located along the M1 highway be applicable more broadly to these types of projects. Some of but are not part of the EMS pilot. Including both intervention these have been discussed in specialized academic publications, and control units, the TR was set up in a total of ten central and and this report helps to bring together the learning from these district hospitals in Malawi. This strategy allowed for a difference- publications and the study into one report. in-differences design for the impact evaluation. In addition, by collecting detailed trauma registry data in major facilities This report shares the results from the analysis of the all along the main highway in the country, we could provide a epidemiology of trauma in adults, including trauma care, more comprehensive analysis of trauma and road traffic crashes trauma outcomes and trauma related to RTCs, in Malawi. in Malawi. It also covers insights about how to effectively run a digital trauma registry in a low-resource setting, including During the course of 35 months (August 2018–June 2021) the TR challenges and lessons learned. Lastly, the report also shares collected a total of 118,013 observations. Since implementation of learning insights from the implementation of the EMS pilot. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 13 SECTION III Trauma Registry Data Collection Process F or the IE designed to evaluate the impact of the EMS pilot, a digital, multi-site trauma registry was planned as the main data source. A trauma registry is a systematic collection of data on trauma cases, including their cause, management, treatment, and outcome. In high resource settings, TRs are considered an essential element of a well-functioning trauma care system, as they can feed into quality improvement processes, improved clinical management and care, injury prevention initiatives and policy development (Nwomeh et al. 2006). In collaboration with the Ministry of Health (MoH), this TR was set up in ten central and district hospitals. The TR planning began in February 2018, different stages of piloting were conducted in June–August 2018, full-scale data collection began September 2018 and concluded at the end of June 2021 (Table 1). The aim of the TR was to collect detailed data on every trauma patient arriving to the health facility in order to understand the circumstances and outcomes of their trauma. This included demographics, information on the trauma, health data collected from the patient, and outcome data from the trauma. 14 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Table 1. Trauma Registry Implementation and Activity Timeline Malawi Trauma Registry Timeline Year Month Activity 2018 January Planning of TR started. Workshop with stakeholders; MOH, DHOs, DMOs, other district and central hospital representatives, external researchers, MRA, DRTSS and Malawi Police February–May Development and programming of Trauma Registry (TR). Field visits to all hospitals June Field testing of TR at Dedza District Hospital with two data clerks July Stakeholder Meeting to discuss the drafted TR and plans for implementation August Training of data collection teams, over a two-week period. Classroom training and ‘on the job training’/shadowing. Two weeks of piloting of data collection September Trauma Registry Launch November High Frequency Checks on the incoming data started about current best practices and desired data collection practices Data Validation 1. Validating one week of data against from stakeholders that would collect and use the data in order HMIS data to ensure ownership, and to explore feasible ways of setting 2019 June Data Validation 2. Validating one week of data against HMIS data up the trauma registry based on the context and best practices discussed and other relevant feedback from stakeholders. July Re-training 1. ‘On the job training’ A second meeting, with the same stakeholders, was held in July December Data Dissemination event to Stakeholders 2018 to discuss the logistics of the implementation of the TR. 2020 February Data Validation 3. Validating one week of data against HMIS data Over the course of 35 months (August 2018–June 2021) the TR April COVID safety protocols were implemented collected detailed data on trauma, trauma care and outcomes April Data Validation. Validating two days of data against HMIS from 118,013 patients. All hospitals in the TR were located along data to assess the impact of COVID-19 on the TR data the main national road in Malawi, the M1, running from north to collection south across almost the entire country. The EMS pilot is being July Publishing of paper: Implementation of a multi-center implemented in six hospitals located on the southern segment digital trauma registry: Experience in district and central of the M1, between Lilongwe (the capital city) and Blantyre (the hospitals in Malawi, in The International Journal of Health Planning and Management commercial hub). The TR was implemented in five out of those 2021 June TR stopped operating six, as one hospital already had a well-functioning trauma registry. Another five hospitals were chosen for the IE to be part of the September Dissemination Event to Stakeholders , meaning they were similar to TR, in order to act as “controls” the EMS pilot intervention facilities but did not receive the The World Bank DIME research team, MOH and other government intervention. They were also located along the M1, but north of agencies worked in close collaboration in the development, Lilongwe. These five facilities shared certain key features with the implementation and maintenance of the TR. To commence the five facilities that are part of the EMS pilot. These features include: project, a one-day workshop was held in Lilongwe, Malawi in location within 20 km distance from the M1 and a high volume January 2018, including the following stakeholders: MOH staff, of trauma patients from RTCs on the M1. The hospitals included District Health Officers (DHOs) and District Medical Officers in the TR were (from north to south): Rumphi District Hospital, (DMOs), other district and central hospital representatives, Mzuzu Central Hospital, Mzimba District Hospital, Kasungu external researchers, as well as the Malawi Roads Authority District Hospital, Dowa District Hospital, Dedza District Hospital, (MRA), the Directorate of RoadTraffic and Safety Services (DRTSS) Ntcheu District Hospital, Lisungwi Community Hospital, Balaka and the Malawi Police. The main objectives of the workshop 3 District Hospital, and Queen Elizabeth Central Hospital (Figure 1). were to ascertain the status of data related to road traffic crash trauma and trauma more broadly from the stakeholders, to learn 3 At this point in time the EMS Management Team had not yet been formed. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 15 Main Health Facilities in Malawi Based on consultations during the initial stakeholder meetings, it was agreed that the DHOs would select trauma coordinators for their respective hospitals, typically clinical officers or medical doctors in the participating health facilities, who would lead the TR teams. They were responsible for making sure that all trauma cases that arrived at the hospital were registered (including during nights and weekends); developing rosters for the trauma registry team; sending the data to the central server once a week; serving as the contact person and reporting any issues with the trauma registry; and serving as an expert on the trauma registry (which also required that they personally enter at least 5 cases per week). The responsibilities of the rest of the team members, including clinicians, data clerks and hospital attendants, were to collect data in collaboration with clinicians and nurses, to keep the tablets safe and secure, and to collect data on all trauma cases that arrived at the hospital. The TR teams, at each of the ten facilities, were composed of two clinicians and three data clerks. Trauma patients were defined as those who had sustained one or multiple injuries to any body region or regions, irrespective of severity. Data was collected on all trauma cases that present at the hospital, excluding cases in which the injury occurred more than 30 days ago. Only those injured patients who came to the hospital for the first time since the injury happened were entered into the registry, i.e., follow-up visits were excluded. The TR collected data on patient demographics, mode of transport to hospital, geographic location of trauma, time of trauma, time of hospital arrival and time attended, setting, intent and cause of trauma, vital signs, AVPU (Alert, Voice, Pain, Unresponsive) scale, Glasgow Coma Score (GCS), Kampala Trauma Score, and details on up to three injuries. Legend Responses were based on self-reporting from the patient to the Health Center, Treatment data clerk, for all parts of the TR except medical data (including M1 Highway vital signs), which were entered after a clinical staff member’s Main Roads assessment. Data collection was initiated by the data clerk when patients were waiting to be seen by the clinical staff. Central Hospital, Control Demographic information, time, location and type of trauma Central Hospital, Treatment was entered at this point; vital signs, AVPU scale and GCS score District Hospital, Control could also be entered if they were taken by the a trained data District Hospital, Excluded clerk or the nurse registering the patient’s arrival at the hospital. District Hospital, Treatment The medical information that was filled in after the patient had been attended to by clinical staff included information about the Figure 1.  Health Facilities Included in the TR injury, outcome on day one, vital signs, AVPU and GCS scores, Note: The above map shows all the health facilities that are included in the trauma if not yet recorded. If the patient was admitted overnight, the registry. The purple line represents the M1 highway segment. The green lines represent other roads in Malawi. clerk visited the patient the next day to collect information about vital signs, AVPU, GCS score, treatment received and outcome for day two. All data was collected and immediately entered into the TR using an Android tablet, while on or offline. The data was submitted weekly to the research team by connecting the tablet to the internet and sending the data to a secure server. 16 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI SECTION IV Analysis of the trauma registry data T he objective of this quantitative analysis of the TR data was to learn more about the epidemiological patterns and care of injuries in Malawi, with a specific focus on causes of serious trauma and RTCs. In this section we share the results from this analysis. In total, 118,013 trauma cases were recorded in the TR over 35  months. Figure  2 shows the distribution of cases by hospital, where each bar represents a hospital, in all cases but one. Queen Elizabeth Central Hospital (QECH) has two distinctly different entrances for trauma cases, AETC, for adults (15 years and above) and A&E for children below 15 years of age. These two departments are shown as two different bars in the graph. In all other hospitals included in the TR, adult and pediatric trauma were seen in the same department at the hospital. Appendix 1 includes the breakdown of cases per facility per month. We present the rest of the analysis focusing on specifically the data collected from September 2018– March 2020. We exclude the first month of data collection because it was a live-pilot phase of TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 17 20000 (15.7%) 18507 (13.2%) (12.6%) (12.7%) 15000 15550 14878 14971 (10.2%) (9.9%) 12079 11676 10000 (7.8%) (7.3%) 9248 (6.2%) 8664 7335 5000 (2.5%) (1.8%) 2980 2125 0 A&E QEH Balaka Dedza Dowa Kasungu Lisungwi Mzimba Mzuzu Ntcheu Queen Elizabeth Rumphi District District District District Community District Central District Central District Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Figure 2.  Number of Trauma Registry Cases by Facility data collection. We also do not include data since April 2020 for Therefore, once we remove the 15 months of data post-COVID-19 this analysis, when the COVID-19 pandemic began to affect and the data on cases below age 15, the total number of cases health system utilization and data collection (see section V for a in the analysis is 49,241 (see Figure 4 for caseload by month discussion on data collection during COVID-19). for this limited sample of adult cases). The results presented summarize the findings that have been included in the academic The analysis focuses on patients above the age of 15. The main paper “Epidemiology of adult trauma injuries in Malawi: Results reason for this is that pediatric patients experience a very different from a multi-site trauma registry” (Chokotho et al. 2021). epidemiology of trauma, with an overwhelming percent of cases being dominated by falls, and only a very small percent of cases due to RTCs (Figure 3). Given the different epidemiology, adult and pediatric trauma is generally analyzed separately (Sawe 4.72 et al. 2021b). The analysis therefore focuses on adults given the Road Traffic 5.25 Crash (RTC) particular interest of this project in road traffic crash victims. 8.04 Additionally, data was collected in QECH A&E for children under 72.35 age 15 for a much shorter period of time, and we did not want Fall 73.56 this limitation in data availability to affect the analysis.4 69.51 9.89 Stab/blunt 4 Data collection in QECH A&E began later, due to additional time needed to meet 10.44 trauma all bureaucratic requirements and ensure full buy-in from all stakeholders. Data 12.72 collection ended in April 2020 due to COVID-19. When the pandemic first started, the team discussed with each facility if they wanted to continue data collection and 10.87 determined that it posed no additional risk as compared to their typical work in the Bite/burn 9.63 health facility. QECH A&E was the only one that expressed a desire to cease data collection at this time, and therefore the data collection was stopped. 8.45 2.17 Other 1.12 1.27 0 10 20 30 40 50 60 70 80 Percent of cause 0−5 years 6−10 years 11−15 years Other includes: Drowning, foreign object, lightning, blast, gunshot, unknown Figure 3.  Cause of Trauma for Pediatric Patients 18 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 2830 Demographic Information March-2020 Februrary-2020 2566 Figure  5a shows the demographic correlates of trauma cases in the sample. Injuries are most common for younger adults. January-2020 3003 Two-thirds of trauma patients are male, with greater gender December-2019 3158 differences at younger ages. The most common occupations November-2019 3165 observed in the trauma registry are farmers (26%), students October-2019 3147 (16%), manual laborers (14%), small businessmen (12%), and September-2019 2899 housewives (12%). Most trauma cases occur among patients August-2019 3237 with primary education (47%), followed by secondary education (40%) and no education (5%). July-2019 3204 June-2019 3006 May-2019 2901 Injury Details April-2019 2576 The analysis examines mechanism of injury, type of injury, March-2019 2631 disposition, injury severity and timeliness of care for non-admitted February-2019 2028 and admitted trauma cases, using hospital admission as a January-2019 1986 proxy for severity. December-2018 2050 The most common mechanisms of injury are falls (45.8%), November-2018 1774 followed by RTCs (19.5%), blunt trauma (15.5%), stabs and cuts October-2018 1562 (10.7%) and bites (5.8%) (Figure 6). The most common diagnosis September-2018 1518 across all trauma cases are soft tissue injuries (42%), followed by 0 500 1000 1500 2000 2500 3000 3500 fractures (27%), lacerations (12%), bite/stab/abrasion/burn (10%), Monthly trauma cases contusion (4%), dislocations (2%), and head/spine/internal (1%). Figure 4.  Monthly Caseload in Trauma Registry For admitted trauma cases (which are also some of the more Note: This figure shows the total number of adult trauma cases above age 15 reported severe cases, demonstrated by the need to remain at the health (shown on the horizontal axis) each month of the study (as shown on the vertical axis). facility), the most common mechanism of injury was RTCs (48%), falls (22%), blunt trauma (12%) and penetrating wounds (11%). The most common type of injuries for admitted patients 5a: All Adult Trauma Patients 5b: Adult Road Traffic Crash Patients 15−20 years 17.07 15−20 years 10.29 20−25 years 18.00 20−25 years 17.45 25−30 years 14.55 25−30 years 16.29 30−35 years 12.63 30−35 years 14.96 35−40 years 11.06 35−40 years 13.82 40−45 years 7.58 40−45 years 9.23 45−50 years 5.69 45−50 years 6.16 50−55 years 4.00 50−55 years 3.97 55−60 years 2.96 55−60 years 3.02 60−65 years 2.29 60−65 years 1.73 ≥ 65 years 4.13 ≥ 65 years 3.08 0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18 Percent of trauma cases Percent of trauma cases Male Female Male Female Figure 5.  Age and Gender of Trauma Patients Note: The above graphs show the age groups on the vertical axis and the percent of trauma cases from each age group on the horizontal axis. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 19 6a: Share of Cause in Total Trauma 6b: Share of Cause for Hospital Admissions Burn 2% Bite 1.5% Road Traffic Crash (RTC) 19.49 Stab/cut Other 2.8% (penetrating Fall 45.80 wound) 11% Blunt trauma 15.45 Stab/cut (penetrating wound) 10.67 Blunt trauma Road Traffic Burn 1.28 12% Crash (RTC) 48% Bite 5.80 Fall 22% Other 1.51 0 10 20 30 40 50 60 70 80 90 100 Percent of trauma cases Discharged Admitted Figure 6.  Share of Trauma Causes were fractures (35%), followed by soft tissue injuries (20%), and 28 districts in Malawi. The districts in the map refer to the district lacerations (13%). 71% of injuries were to the extremities, while where the trauma occurred (Figure 7). For 24,523 trauma cases 7.14% were to head and neck, and 8.33% to the face, 3.19% to (50% of total trauma), the setting of the trauma was the patient’s the thorax, 1.54% to the abdomen, and 7.01% external. home, for these cases, the district of the patient’s home was used as the trauma district. It is important to note that the geographic concentration of trauma cases is largely driven by the location of Geographic Location of Trauma the ten health facilities where data was collected. The map in the In the trauma registry, data is recorded on the location of where center shows the number of road traffic crashes for each district. the trauma occurred. The trauma registry recorded cases from all Darker color represents the district with a higher number of RTCs. 7a: Total Trauma Cases by District 7b: Total RTC Cases by District 7c: Total RTC Cases by TA Health facilities Health facilities Health facilities Total trauma cases Total road traffic crashes Total road traffic crashes by district by district by TA 10000 2000 750 7500 1500 500 5000 1000 2500 250 500 Figure 7.  Geographic Information on Trauma in Malawi Note: The above panel shows total number of trauma cases by district (a) with 48,747 trauma cases (1% cases were missing information on district); the total number of RTC cases by district (b) for 9,489 RTC cases (1% cases were missing information on district); and the total number of RTC by TA (c) for 8,565 RTC cases (7% of RTC cases were missing or had incomplete information on TA in the trauma registry.) 20 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI The districts with the highest number of trauma cases are: Separately, we examined timeliness of treatment for the subset of Mzimba 10,954 (22%), Blantyre 9,832 (20%), Ntcheu 5,544 (11%), severe trauma cases that represent urgent need for care based Dedza 4,696 (9%), Kasungu 4,599 (9%), Balaka 4,114 (8%) and on four serious characteristics (patients who were admitted Rumphi 3,855 (8%). For each of these districts, RTCs make up to hospital, patients with AVPU < 4, patients with GCS < 8, on average 18.4% of their case load, with Dedza as low as 10% and patients whose self-reported pain level was severe or and Kasungu as high as 28%. We can further break down the extreme). We again focus on those that arrive within 24 hours geographic location of RTCs by “traditional authorities” (TA), of the trauma. Figure  8 shows the arrival times across all which are smaller geographic areas (Figure 7c). This is available trauma, RTCs, and severe trauma, focusing on cases arriving for 93% of RTC cases. Again, the geographic concentration is within 24  hours of trauma. Severely injured patients arrive largely driven by the location of the health facilities where data after a median time of 2 hours, and RTC patients arrive after is collected. Nevertheless, we see an important concentration a median time of 1  hour 40  minutes. If we only look at the of crashes in the north of the country on the M1. non-RTC severe cases, though, the median time to arrival is 4 hours. Figure 8 also shows the time to receive care post-arrival. For Time to Hospital Care RTCs, patients are seen by a clinician within a median 35 minutes Median time elapsed between occurrence of trauma and patient after arrival. For minor trauma, patients are seen approximately arrival at hospital is 8  hours 59  minutes (Interquartile Range, an hour after their arrival. Severely injured patients are seen IQR, 1 hour 50 minutes, 23 hours 50 minutes). Yet, around one within 10 minutes of their arrival. quarter of the patients come to the facility more than 24 hours after the trauma, signaling that this timing is not only a reflection For admitted trauma cases, the most common modes of transport of transport needs for accessing care but also behavioral trends to hospitals are private (29%) and commercial vehicles such in delays to seek care. When we limit the analysis to those as taxis (21%), public modes such as minibuses (16%), and patients arriving within 24 hours after the trauma, the median ambulances (6%). In contrast, ambulances are the most-used time to arrival is three hours. mode of transport for referral cases between facilities (39%). 8a: Time Taken to Arrive to Facility Since Trauma Occurred 8b: Time Taken to Get Care After Arrival in the Facility (only cases that arrive within 24 hours) All trauma All trauma (49 minutes) (3 hours) RTC (35 minutes) RTC (1.4 hours) Severe trauma Severe trauma (2 hours) (10 minutes) 0 2 4 6 8 10 12 14 16 18 20 22 24 0 25 50 75 100 125 150 175 200 225 250 275 300 Duration in hours Duration in minutes Figure 8. Time Elapsed from Occurrence of Trauma to Hospital Arrival and Care Note: The left panel shows the distribution of duration of arrival to the facility since trauma only for cases that arrived in the facility on the same day as the trauma occurred (i.e., within 24 hours). The vertical axis represents the distribution of arrival for all trauma, road traffic crashes and all severe trauma arrived in the facility within 24 hours of the trauma. The panel on the right shows the duration to get care since arrival to hospital. The vertical axis represents the distribution of arrival for all trauma, road traffic crashes and all severe trauma. In both figures the horizontal axis represents the duration time. The line inside each box represents the median duration of time, from trauma to arrival, and to care. All referred trauma cases are excluded. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 21 Disposition Out of 3,325 patients who were admitted to a ward, admitted to operating theatre, or taken to the ICU, 1,636 (49%) were still There are three separate measures that help in assessing the in the hospital 24 hours later. Of those no longer in the hospital, severity of a case. These include the GCS score, the AVPU scale 842 patients were discharged (79%), 119 transferred to another and the pain score provided by the patient. The large majority of hospital (11%), 29 (2.9%) died, 17 (1.5%) ran away and 54 (5%) cases coming to the health facilities are not severe, with a GCS was unknown. The next day status was missing for 628 (18%) score of 12 or above, a measure of “Alert” (4) on the AVPU scale, of the patients who were admitted to ward, ICU or operating and a pain score of none to moderate (Figure 9). theatre. Out of the patients who stayed overnight and were The trauma registry also records the final outcome of the trauma still in the hospital 24 hours later, 89% (1,459/1,629) reported case in the casualty department on the day they visit the hospital. being in moderate or severe pain on day 1, which went down 92% (45,374) of all trauma were treated and sent home the to 70% (1,156/1,629) as reported on day 2. This demonstrates same day, 6.5% (3,232) of cases were admitted to another improvements in the condition of over 20% of patients reporting ward, 0.14% (74) were taken to the operating theatre, 0.04% moderate or severe pain.5 (19) were taken to the ICU, 0.09% (42) of patients died in the casualty department, 0.49% (242) were referred to another 5 The pain level data was not available for seven of the patients who were admitted facility, 0.4% (177) were dead on arrival. to the hospital and were found 24 hours later. 9a: GCS Score Level 9b: AVPU Scale Level 9c: Subjective Pain Level Alert 95.89 None 0.28 GCS above 12 93.13 Responds Mild 39.41 2.33 GCS between to voice 8 and 11 3.52 Moderate 54.17 Responds 1.60 to pain Severe 5.83 GCS below 7 3.35 Unresponsive 0.18 Extreme 0.31 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 Percent of cases Percent of cases Percent of cases Figure 9.  Different Measures of Severity 22 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Trauma Due to Road Traffic Crashes Pain Relief (Diclofenac, 88 Panado, Paracetamol) Since RTCs represent almost half of all trauma cases requiring hospital admission, they are examined in more detail here. The Antibiotics 32 percent of trauma cases that are RTCs in each facility varies from 11% to 28%, with Kasungu, Lisungwi and Mzuzu seeing the POP cast/backslab 24 highest percent of RTCs (Figure  11). Table A1 in Appendix 1 shows the detailed breakdown of the number of trauma cases, Resuscitation (Given blood, 21 IV fluids, Oxygen) RTCs and admission by hospital. The demographic distribution Suturing/Laceration of RTC patients is similar to the distribution for all trauma 18 Repair patients, though it is much more concentrated in the ages of Fracture/Dislocation 20–40 (Figure 5b). Given these are the prime working ages, 7 reduction this demonstrates the large economic opportunity cost that RTCs represent. RTCs are also even more highly concentrated Traction 5 in men, compared to all trauma. 0 20 40 60 80 The analysis shows that 1.3% (133/9,595) of RTC patients were Percent of treatment dead on arrival at the facility and 18% required admission to Figure 10. Top Seven Treatments Given to Incoming Trauma Patients. hospital. Soft tissue injuries are observed in 45% of RTC patients followed by fractures (20%), contusions (11%) and lacerations Note: The above figure shows the different treatments (shown on the vertical axis) and the percentage share of trauma cases that the treatment was given. It is (11%) (Figure12). Importantly, head, spine and internal injuries important to note here that multiple treatments could be given to one patient so make up a much larger percent of RTC cases as compared to all this will not sum up to 100%. cases, and these are some of the most serious injuriesthat require significant care. The treatment provided was collected for 1,636 patients who We find that non-motorized users (pedestrians and cyclists) make stayed in the health facility overnight. The trauma registry recorded up approximately half of all RTC trauma patients (49%) (Figure 13). all types of treatment that were given to the patient. Pain relief was given in most of the admitted trauma cases, and antibiotics For motorized RTCs, we find limited adherence to safety were given in just over a third of cases (Figure 10). practices, where 84% of patients who were passengers of Balaka District Hospital 20 Soft tissue injury 45.62 Dedza District Hospital 11 Fracture 20.97 Dowa District Hospital 20 Contusion 11.65 Kasungu District Hospital 28 Lisungwi Community Hospital 26 Laceration 11.53 Mzimba District Hospital 19 Head/spine/internal 4.12 Mzuzu Central Hospital 28 Bite/stab/abrasion/burn 2.90 Ntcheu District Hospital 16 Dislocation 2.31 Queen Elizabeth Central Hospital 19 Rumphi District Hospital 16 Other 0.90 0 10 20 30 0 10 20 30 40 50 Percent share of RTC cases out of total trauma Percent of injury for RTC cases Figure 11.  Percent of Road Traffic Crash Patients by Facility Figure 12. Type of Injuries for RTCs TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 23 Hospital (17%) and Kasungu District Hospital (16%) each have Passenger: Car/truck/bus 26.25 more than 15% of the RTC caseload involving pedestrians (see Cyclist 23.39 Appendix 1 for total number of RTC for each hospital). There is Pedestrian 21.30 a clear need for a focus on pedestrian interventions in Blantyre where almost half of RTC victims coming to QECH are pedestrians. Driver: Motorcycle 11.62 Driver: Car/truck/bus 7.07 Figure  14 shows the peak hours of road traffic crashes as recorded in the trauma registry. There are two peaks of RTCs Passenger: Motorcycle 4.98 consistent across all the road users coinciding with morning Passenger: Bicycle 3.32 and evening rush hours, one between 6:00–10:00, and a second Other 2.06 peak between 16:00–20:00. Non-motorized users (pedestrians and cyclists) have a higher share of RTCs happen during those 0 5 10 15 20 25 Percent of RTC peaks and almost none in the night hours. By contrast, cars, Discharged Admitted trucks, and buses have a higher share of crashes happening between 22:00–6:00, possibly due to lower visibility, fatigue, or Figure 13.  Role on the Road for RTC Injuries speeding. Presence of alcohol was confirmed in 6.7% (45/678) Note: The above figure represents the types of road users on the vertical axis and of all drivers of cars, trucks, buses and suspected for an additional their percentage share in the trauma registry’s road traffic crashes on the horizontal axis. The light grey region represents share of road users that were discharged 2% (15/678). the same day, the dark grey region represents share of road users that required hospital admission after the injury. 0.10 motor vehicles such as cars, buses, and trucks report not having worn a seat belt, and 52% of patients who were drivers or 0.08 passengers of motorbikes report not wearing a helmet. 0.06 Share of RTCs Among admitted road traffic crash patients, passengers of car/ 0.04 bus/trucks make up a third (32%) of the road users in RTC cases, followed by pedestrians (20%) and cyclists (16%). Overall, 50% 0.02 of admitted pedestrians were struck by private vehicles or trucks, 23% by public transit vehicles, 17% by motorcycles and 4% by 0 bicycles. 0 2 4 6 8 10 12 14 16 18 20 22 24 Hour We present geographic variation in pedestrian crashes in Pedestrian Bicycle the regions surrounding the facilities by looking at the share Driver/passenger of car/truck/bus Motorcycle of RTCs involving pedestrians out of the total RTCs recorded Figure 14.  Distribution of RTC by Road Users and Time of Day in each facility from the 10 hospitals. Queen Elizabeth Central Note: In the above figure, each line represents a road user type recorded in the Hospital (45%), Dedza District Hospital (20%), Balaka District trauma registry. The figure represents the share of road traffic crashes recorded in Hospital (18%), Ntcheu District Hospital (17%), Mzuzu Central each hour of a 24-hour day (on the horizontal axis) for each road user type 24 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI SECTION V Challenges and Actions for Successful Trauma Registry Implementation Actions for Successful Implementation Like other trauma registries in similar contexts, key challenges for the TR implementation and data collection were institutional support, implementation logistics and data quality. ◾ Institutional Support: Data will only be useful if used and, data will only be collected if it fits naturally into the daily work routines. However, challenges in this process included busy schedules and many competing priorities in the health care system, and it was therefore not always easy to reach consensus. ◾ Implementation Logistics: Each hospital functions differently from the next, and they all run on very limited resources and staff. In addition, in several instances the institutional environment was complex, such as at referral hospitals, with multiple entry points for trauma patients, multiple ongoing research projects, and high patient volumes. Therefore, it was important to 25 develop a TR that was flexible enough to be able to function in crucial step in deciding what data to collect and how to execute any hospital, and easy to learn how to operate and implement the data collection. The MOH, the World Bank DIME research into the daily routines. team and other government agencies worked in collaboration ◾ Data Quality: An important aspect in working with trauma on the development, implementation and maintenance of data is ensuring the quality of the data, which is an ongoing the TR. To commence the project, a one-day workshop was process. Often trauma registries, especially in low-resource held in Lilongwe, Malawi in January 2018, bringing together settings, can suffer from quality issues including missing all relevant stakeholders. A second meeting, with the same variables or a large number of cases that are not entered at stakeholders, was held in July 2018 to discuss the logistics of all, as well as issues with incorrect information entered. the implementation of the TR. These engagements were critical in achieving consensus and ensuring that the data collected in Actions taken by the team to address these challenges can be the TR would be relevant for policymakers. divided into 3 categories: 1) Planning & stakeholder involvement, 2) Implementation support, and 3) Data quality assurance activities The initial and ongoing consultation and collaboration through (Table 2). the workshops, field visits, frequent communication and several rounds of receiving feedback and incorporating it into both the registry tool itself and into registry processes were important for Planning and Stakeholder Involvement establishing support and engagement. These forms of ongoing The team worked closely with end-users of the data at all levels, engagement were especially important when there was a need including clinicians, DMOs, DHOs and MOH, as well as the to iteratively test and adapt different approaches to solve data staff tasked to collect the data. Ultimately, this process was a collection or data quality challenges. Table 2.  Principles for Successful Trauma Registry Implementation Principles for success Actions taken Detailed explanation Trauma Registry Key stakeholder meeting and Several events (stakeholder consultations) and consistent communication and feedback throughout the Planning and Stakeholder communication process of planning, developing and implementing the TR involvement Develop a TR fit for context Study of the context and current best practices for data collections through discussions and feedback from stakeholders (on all levels) and field visits Make data available useful Key stakeholders to feedback on the draft tool and data feedback loops, continuously Trauma registry Pre-testing TR Drafted TR tool was pre-tested in one central and one district hospital, with trained HMIS data clerks implementation Piloting TR Pilot testing of TR tool, data management process and data feedback loops, in one central and one district support activities hospital Data collection team One TR coordinator (clinician), one ER clinician and three data clerks from each hospital, selected by the DHO Training Two days: One-day classroom training (including role play) & one day ‘on the job training’/shadowing Refresher training After 11 months; informed by the data collection and data quality seen during that period. With two main objectives: 1) to improve data quality in key variables like vital signs, cause and intent of trauma and 2) to train new data clerks that had been added or replaced Data quality Ongoing support and Each TR Coordinator had a main point of contact within the Trauma Registry Monitoring team, who aimed to assurance activities communication respond to any request within 24 hours by phone or WhatsApp Field visits Two supervisory visits to all hospitals in the first six months, and then as needed Digital Data Collection The digital data collection reduced data entry errors and increased data completeness. It allowed for hard-coded controls, automated skip patterns and immediate quality checking of the data, including feedback to the data collections teams Dashboard on Dropbox paper Weekly sharing of descriptive statistics at the facility level Weekly High frequency checks High frequency checks flagging potential issues and mistakes in the data, including checks on missing data, notable outliers and logically inconsistent answers Three data validation exercises Comparison of TR data with regular HMIS data Source: Croke et al 2020. 26 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Implementation Support To overcome the challenges generated by heterogeneity across health facilities, several visits were made to all ten hospitals, to see the infrastructure and to discuss with DHOs, medical and HMIS staff. As the TR was developed, pre-testing and piloting of the TR was extensive and allowed feedback to change the TR as needed. Testing was done in both a central hospital and a district hospital, acknowledging that the way these different levels of facilities work is different and therefore piloting should be done at both levels to ensure success. As change is constant, the research team continued to make support visits, respond to requests from data collection teams and make necessary changes to the TR throughout the entire data collection. High Frequency Checks Data Quality Assurance Activities The research team conducted weekly high frequency checks on With the help of several different strategies, the quality of the the incoming data to flag potential issues, including outliers and data in the TR improved over time. Improvements in data quality errors in the data entry. These issues were then reported back included an increase in monthly capture rates, completeness to all trauma coordinators and the data clerk who had made of important variables and improvements in correctness of the mistake. The high frequency checks included checks on data, in terms of outliers and inconsistencies. Data quality was missing data in important variables, such as vital signs, or notable ensured through frequent in-person and digital communication outliers and logically inconsistent answers, such as when the with trauma data collection teams, weekly updates and sharing diagnosis indicated that a patient was very badly injured but the of an online data dashboard showing results from ongoing ”6 There were recorded outcome was “treated and sent home. data analysis, and through the activities of the team, which 15 different checks and the research team conducted all of them conducted ongoing visits and refresher trainings. Even as data once a week. quality constantly improved, ongoing supervision was key in both improving and maintaining data quality over time. Three Looking at the monthly number of entries in the TR over all months additional activities were extremely important for quality the TR was running, there were lower numbers of entries during assurance: 1) the digital nature of the data collection, 2) high the first 6 months of the TR, which later increased and stabilized frequency checks, and 3) data validation. at a higher level (Figure 15). This increase is believed to be due to improvements in the TR operations, TR clerks’ understanding of the TR itself and how to operate it, and the consistent high Digital Data Collection frequency checks and weekly check-ins with the clerks. A digital data collection tool had many advantages. First, it reduced data entry errors, i.e. when entering data collected Data Validation on paper into a digital database. Second, it enabled hard-coded controls on what input is allowed, which also limited data entry In addition to high frequency checks for outliers and inconsistent mistakes. Third, it helped to ensure completeness of data as responses, the research team also conducted three data fields can be made mandatory to ensure data clerks or clinicians validation exercises to examine the completeness of the data. enter data for all of them. Fourth, it helped the data collector In government health facilities in Malawi, paper registers are used with skip patterns, making sure that only the questions valid to register patients. These are part of the Health Management for the situation at hand were being answered, which led to Information System (HMIS) in the country, and they capture less contradictions in the data. Fifth, it allowed for immediate basic demographic and medical information. The HMIS data is management and initial basic analysis of data, which could serve to improve the tool itself and facilitate learning of data collectors 6 Note that this type of inconsistency does not always indicate a mistake, since there might be a specific reason for someone that was indicated as badly injured and thereby continuously improve the trauma registry, the tool to be sent home. The flags were meant to indicate data points that should be itself and the data it collected. double checked and corrected if a mistake could be confirmed. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 27 15a: Impacts of COVID-19 on Monthly Cases Collected in Trauma Registry 15b: Trauma Cases by Month Excluding Facilities with Limited Data Aug’18 1515 Aug’18 1394 Sep’18 2517 Sep’18 2200 Oct’18 2581 Oct’18 2298 Nov’18 2899 Nov’18 2569 Dec’18 3205 Dec’18 2756 Jan’19 3283 Jan’19 2798 Feb’19 3215 Feb’19 2527 Mar’19 3849 Mar’19 2994 Apr’19 3732 Apr’19 2888 May’19 4092 May’19 3082 Jun’19 4161 Jun’19 3108 Jul’19 4517 Jul’19 3362 Aug’19 4681 Aug’19 3416 Sep’19 4364 Sep’19 3206 Oct’19 5096 Oct’19 3713 Nov’19 5142 Nov’19 3598 Dec’19 5051 Dec’19 3766 Jan’20 4616 Jan’20 3334 Feb’20 3933 Feb’20 3031 Mar’20 4362 Mar’20 3298 Apr’20 2692 Apr’20 2524 May’20 3187 May’20 2867 Jun’20 3133 Jun’20 2981 Jul’20 2785 Jul’20 2771 Aug’20 2756 Aug’20 2605 Sep’20 2901 Sep’20 2742 Oct’20 3032 Oct’20 2963 Nov’20 3289 Nov’20 3133 Dec’20 3167 Dec’20 3042 Jan’21 2398 Jan’21 2308 Feb’21 2135 Feb’21 2055 Mar’21 2552 Mar’21 2468 Apr’21 2585 Apr’21 2502 May’21 2431 May’21 2336 Jun’21 2142 Jun’21 2037 Monthly trauma cases Monthly trauma cases This excludes Room 8 and A&E pediatrics unit from Queen Elizabeth Central Hospital and Dedza District Hospital from the sample Figure 15. Trauma Cases by Month then aggregated in each hospital and fed into the national HMIS 2020, showing the cases in the HMIS data, the trauma registry data system. In the national HMIS data system, information and the percent coverage.7 about trauma cases is entered as code 47a (“Trauma”) or 47b (“Road Traffic Accident”). The research team used this HMIS data to compare and validate the TR data. The number of entries Additional Challenges in the TR was validated by comparing to the number of entries The shortage of health care staff in Malawi posed a challenge in these paper registers in all participating facilities. While there for the Trauma Registry data collection as it became clear that, were challenges with comprehensiveness of this HMIS data, when a staff member is absent there is seldom anyone available to the comparison provided a good indication of the coverage of the trauma registries. Data validation exercises took place on 7 Note that in some health facilities, the number of cases captured in the trauma registry exceeded the number of cases in the HMIS data. For a number of reasons, three occasions, November 2018, June 2019 and February 2020. there can be cases where not all patients coming into a facility are registered in the Table 3 provides the outcome of the last validation in February paper record and therefore the HMIS data can be an undercount of patients. 28 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Table 3.  Data Validation February 2020 spent elsewhere given the unreliable nature of the data coming from this facility (see Appendix 1 for monthly cases recorded in the Total Total TR at Dedza District Hospital). Before stopping the TR, the research trauma trauma Registry Date Dates of cases, cases, coverage team tried several different interventions in order to help the Hospital collected data* HMIS registry (%) situation, such as liaising with the Dedza DHO and the hospital’s TR QECH 16.07.19 24–30 June 282 251 89% coordinator, changing the TR coordinator, giving additional training for the data collection team in this facility as well as frequent site Balaka 17.07.19 24–30 June 61 114 187% visits. Despite the shorter period of data collection in this facility, it Ntcheu 18.07.19 1–7 July 166 94 57% was still a valuable learning experience in terms of the challenges Dedza 24.07.19 15–21 July 22 94 427% that can arise with data collection. In particular, we learned that Lisungwi 18.07.19 24–30 June 19 17 89% when the data collection is not an established routine task, the Dowa 05.07.19 24–30 June 40 56 140% TR data trends were often more erratic. This required additional follow-ups, check-ins and support to the coordinator, to keep the Kasungu 04.07.19 24–30 June 52 88 169% TR data collection performing well. Nevertheless, the two years Mzuzu 10.06.19 13–19 May 86 72 84% of data collected in the facility can still provide useful information. Mzimba 03.07.19 24–30 June 116 132 114% Rumphi 02.07.19 24–30 June 84 45 54% Total 928 963 104% Impact of COVID-19 on Trauma *Represents the range of dates within which the number of trauma cases from the Trauma Registry and HMIS was collected for comparison Registry Data Collection The first COVID-19 case in Malawi was confirmed on the 2nd of April 2020 after which the country had a relatively small first cover for this person. An example of this became apparent during wave between June and September 2020. The first wave was the February 2020 data validation (Table 3) when Rumphi District followed by two larger waves in December 2020–March 2021 Hospital, which generally performed well in the TR data collection, and June–August 2021.8 The Government of Malawi (GoM) showed a capture rate of only 54% for the incoming trauma implemented restrictions to decrease the spread of the virus, cases. After further investigation, it became clear the clinician working in the Orthopedic hospital entrance, which is one of two 8 https://covid19.health.gov.mw/ entrances for trauma cases at Rumphi District Hospital, had been absent during the dates used for data validation. This resulted in cases being missed during that time. It was not uncommon for us to find this to be the case when we observed a lower number of entries than expected at a specific facility. Further, while regular HMIS data should be collected at every department in all facilities, we do find that this is not always the case, i.e. the routine for data entering is not always established. This was for example the case at one of the trauma entries at Dedza District Hospital (Table  3), which we believe is the reason for 400% more trauma cases being reported through the TR than the regular HMIS data. While all hospitals had some challenges with the data collection at times, the teams worked through them and continued the data collection, which generally improved over time. However, in the case of Dedza District Hospital, the research team and the Dedza DHO agreed to stop data collection after two years, due to poor data quality. A number of factors, including the large volume of patients at the hospital, affected the quality of data collected in Dedza, and it was decided that data collection funds could be more effectively TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 29 such as closing schools, but a full lock-down has never been ⦁ An updated version of the TR included a question asking “Is implemented in the country. While this report does not cover the patient showing signs or symptoms of being infected a comprehensive analysis of the impact of COVID-19 on the TR by COVID-19? Based on the clinician’s assessment”. data collection (or on the epidemiology of trauma in Malawi), it ▪ If yes, then the TR is shortened to only ask questions is evident that the data collection was affected by the onset of about the following: hospital, mode of transport, the COVID-19 pandemic in Malawi, which will be described in demographics (shortened), time of arrival & time of this section. trauma, cause of trauma, VS and outcome day 1. In order not to contribute to any further spread of COVID-19 Due to the COVID-19 safety protocols that were implemented through the running of the TR, the data collection team in April 2020 (as above) the completion rate of some variables in contemplated stopping the registry. However, after a discussion the TR is lower after April 2020. with stakeholders and TR coordinators in April 2020, it was Additionally, while the TR continued in facilities, from the onset of decided that the TR should continue. Since the majority of the the pandemic in Malawi, in early April 2020, the number of monthly data collectors working on the TR were already health facility entries declined. The majority of the decline in cases in the TR is staff, working in the facilities seeing patients or collecting driven by the removal of full-time TR staff for COVID safety reasons standard data, continuation of the TR did not increase exposure as well as the stop of data collection in Dedza and QECH A&E (see risk. In two cases, external staff helped to collect TR data, one at comparison of Figure 15a and 15b). Nevertheless, there are still QECH in what is known as “Room 8” and one at Mzuzu Central some declines in cases during this period even after removing the Hospital. These two data clerks did stop working on the TR data facilities/units where data collection was stopped (Figure 15b). collection, in late April 2020 in order to ensure their safety. This Our analysis on the reasons for the decline in number of cases in led to significant reductions in the number of cases collected at the TR is only observational and includes the following: these two facilities, as seen in Appendix 1. Furthermore, safety protocols were implemented to ensure any risks associated with ◾ Trauma Cases might have been missed by the TR. With the TR were minimized. additional burden on the clinicians to enter more of the data, Trauma Registry COVID-19 safety protocol: due to the new COVID-19 protocols, some cases may have been missed during busy periods. ◾ Everyone working on the TR should wash hands with soap ◾ Lack of staff due to illness. Some hospitals were more and water — often! affected by COVID-19 than others and at times data collection ⦁ Always wash hands before and after start using the TR had to stop or was minimal. However, data was always picked tablet back up again when staff had recovered from illness and ◾ Wipe the TR tablets with spirit, regularly returned to work. ◾ The patients should be seen by a clinician first and then the ◾ Less trauma cases at the hospitals. Less trauma cases data clerk — this way if the patient is showing any signs of presenting at hospitals as it is considered a risky environment; COVID-19 the clerks should not interact with the patient at all. therefore, people may choose to not come in for what they ◾ Clerks should stop taking Vital Signs, for all patients — this view as less severe trauma. shall be done by clinicians. ◾ Lower trauma incident rates during COVID-19. Due ◾ If the patient is showing signs of COVID-19 the TR will be to government-implemented restrictions people might shortened to only include a few questions, to be filled in by have moved around less, leading to a drop in the trauma the clinician, not the clerk. incidence rate. 30 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI SECTION VI EMS Pilot, Challenges and Lessons Learned Status of EMS Pilot Implementation of the EMS pilot, with the oversight of the Project Steering Committee, started after the EMS Pilot Project Development Plan was finalized by MOH in late 2016. As of November 2021, many of the components in the plan have been undertaken and implemented, while others are still underway. Training of ambulance drivers, EMT staff, first responders and EMS providers was conducted in 2017. Procurement of 12 mini-van ambulances and related medical equipment was completed, and they were delivered to Malawi late 2018. In the same year, the Malawi emergency number, *118, was created and a call center was set up. Dispatchers were trained in answering and handling emergency calls as well as in how to dispatch ambulances, using an online dispatching software. In 2019, shortly before the launch of the EMS pilot in May 2019, an Operations Manager and a Call Center Manager were appointed. Around TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 31 the same time an Operations Manual was also developed. Lessons Learned based on Challenges Since May 2019 the EMS pilot has been operational as a ‘Live Trial’ with 6 ambulances, out of 12 that were procured. The Faced by the EMS Pilot goal of the live trial is to test the system, identify bottlenecks As part of the process of implementing the impact evaluation and solve remaining system challenges, with the intention to and collecting data on trauma, the team also collected qualitative eventually deliver more effective emergency medical services information on the EMS pilot rollout to be able to tie activities once the full-scale system starts operating. In early 2020, and events to the quantitative data as well as provide insights a ‘roadshow’ with one of the ambulances, in and around Blantyre, from a process perspective. Insights from the process evaluation showed some success in educating the public about the new data can be useful for the potential expansion of EMS delivery EMS system, and emergency number. However, apart from this, in Malawi, as well as to provide helpful information for other communication campaigns to the public regarding the availability health sector professionals that are considering similar approaches and proper use of the new EMS system have been limited, to implementation of post-crash care capacity in resource with a large-scale awareness campaign yet to be undertaken. constrained contexts. We focus below on five of the main It is therefore likely that the public is not yet aware of the EMS lessons learned. services, the emergency number or when and how it should be used. Further, renovation of the Trauma Care Centers at the six Change Management within the EMS hospitals is expected to be complete by late-2022. Implementing Agency Currently, while the TR data indicates that the burden of road crash Firstly, a government-run EMS system with a central dispatch and other trauma is substantial, only about ten ambulances per is new in Malawi, and the design requirements for this type of month are being dispatched through the EMS.9 The dispatch service system were not well understood and adopted from center is receiving 11,000–16,000 calls/ month, the majority the outset within some parts of the implementing agency. This of which are either prank calls, dropped calls where the caller might have been inhibited by initial resistance to a new model hangs up prior to a dispatcher responding, non-urgent calls, of pre-hospital care and ambulance operations. or calls that remain unattended due to high call volumes or insufficient call center staffing. This high number of non- Secondly, the goal of the EMS pilot was “to build a single emergency calls places an operational and financial strain on functional system, with central coordination”, that “operates the the EMS pilot system and remains a risk factor to its long-term ” However, many of the EMS same way in all EMS districts. sustainability. Further, an analysis of the incoming calls to the components have been treated as free-standing activities, rather EMS call center shows that less than 1% of the incoming calls than planned and integrated as part of a wider system where are true emergency calls (Figure 16). the activities are interdependent with clear linkages between call intake technologies, communication platforms, and patient care data management. This mindset and disconnect hampered Prank 56.27 the progress and success of the EMS pilot. Dropped 40.34 Weak signal 1.79 Thirdly, as the EMS system potentially leads to the need for a new cadre in the health system to fulfil EMS staffing requirements, in Learn about EMS/medical advice 1.11 this scenario it is important that respective roles are well defined. Emergency call outside EMS area 0.14 This should include details on the overall management structure, Emergency call inside EMS area 0.14 key personnel, their responsibilities and mandate, remuneration and other financial and non-financial incentives, as well as roster Information about COVID-19 0.20 guidelines and templates. For example, an observed challenge Transfer 0.02 was that staff who were trained to work in the EMS pilot already 0 10 20 30 40 50 60 held positions in the government run health care system. In Percent of calls addition, the role of an EMS Operations Manager in practice Figure 16. Type of Calls to Dispatch Center begins at a very early stage, during the preparatory work leading up to the system launch, yet this position was among one of the last ones to be filled. Instead, the preparatory work of the EMS pilot weighed heavily on the MOH staff assigned to oversee the 9 This is according to the monthly reporting on the EMS pilot, with data generated through the dispatch system. EMS project, among his many other duties and responsibilities. 32 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Starting out with defining the role of this critical position of liaising with MACRA (The Malawi Communications Regulatory Operations Manager and filling this position at the early stages Authority) and telecom providers in setting up a toll-free of designing the system could then ensure that the duties and emergency number, and later assuring that there is reliable position details of all other personnel can be designed early on and back-up internet connection for the Call Center. It would as a main responsibility of that Manager. also have included a more thorough market scanning to identify available technologies, system software configuration and testing Finally, as the EMS pilot offered a completely new framework to manage incoming emergency calls and ambulance dispatch, (in Malawi) for ambulance use, an Operations Manual was in order to validate that the system can receive emergency calls, developed, taking into consideration all practical and HR related capture emergency incident information, and communicate the aspects, and remains an essential guiding document. Such a same with the EMS responders. Though the call center and manual needs to cover all aspects of everyday work in sufficient dispatch platform are capably equipped for this purpose, the detail, including logistics, operations, equipment and HR, as major constraint of the computer-aided dispatch system was well as medical treatment guidelines, and it is ideally designed the compatibility and cost to access cloud-based systems and for ease of reference in EMS staff operations. However, Voice-Over-Internet Protocol within Malawi. a document like this can only be of help if the full EMS team feels ownership over the manual and everyone working within the For any EMS model or systems, an active and engaged ICT system has access to a copy, so that they can consult accordingly specialist support is required from the initial stages of an on all procedures and record-keeping. The Malawi EMS pilot could EMS project to help with scoping of all possible models for have benefited from the development of such a manual at an delivering effective EMS services, evaluating the technical earlier stage to help guide the system, and dissemination of the requirements and feasibility for each model within the specific Manual across the wider EMS team is still not complete. country context, providing guidance during the process of choosing a model based on the evaluation conducted, and Anytime that a new system is being implemented, supporting the process of implementation. irrespective of the specific type of system, having 1) a guiding document to outline the system in detail; 2) dedicated management early on that can help define Collection and Use of Performance Data the roles of all actors in the system based on the guiding Given the fact that the EMS is a pilot project, where an assessment document; and 3) building clear understanding of and buy- and decision shall be made on its continuation, expansion, or in for how the new system differs from and improves on closure, capturing and monitoring relevant metrics on both business as usual across all stakeholders are critical to operations and costs is crucial. The Malawi EMS pilot collects ensuring its successful implementation. a wealth of data and has improved the monthly monitoring of call center and ambulance operations, as well as financial Call Center/Centralized Dispatch Challenges resources necessary to maintain services, through systematic monthly reporting that summarizes key performance statistics. One of the key features that makes the Malawi EMS pilot different from the district management approach to ambulance services Nevertheless, the data-informed feedback-loops for adjusting (i.e. business as usual) is the centralized *118 call center and service delivery are still weak, and the day-to-day use of data dispatch system. During early stages of the pilot, the set-up of this to track EMS response could support optimizing operations. crucial component of the EMS system was not prioritized with Further, there is an abundance of data that is available but as yet the attention that was required. This likely arises from a lack of not fully analyzed or used (e.g. ambulance GPS data, details on 1) knowledge or expertise within MOH on the technology solutions the types of emergency calls received at the call center, EMS considered in communication platforms, 2)  coordination with response and patient delivery timelines, and the effectiveness of the telecommunications industry, and 3) establishing the right information and awareness campaigns on the EMS in reaching level of resources to make a call center available (24–7, year- the public), which will be further analyzed in a forthcoming EMS round). pilot assessment. The EMS pilot would have benefitted from having a dedicated ICT When piloting a new system, generating comprehensive specialist to assist MOH from the beginning of its implementation, data on operations and costs and analyzing it in a timely to work through setting up all the technical requirements for a manner is important for the development of an effective functional, complex system. This includes, among other things, and optimized system. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 33 EMS Pilot Launch ◾ Communication platform/channels. ⦁ Can the dispatchers reach the community first responders, The development and roll-out of a new system like the EMS an ambulance, paramedics and the receiving hospital pilot, where friction-free operations are essential, would have where the patient shall be taken? benefitted from more detailed schematics for data management ⦁ Can EMS staff receive and send all necessary information fully in place rather than pressure to meet a set launch date. to attend, respond and report on an incident, from dispatch The roll-out plan leading up to and following the launch should to drop off? clarify and guide as many operational details as possible, such as ◾ Human Resources. Are all call center and paramedic positions whether all activities shall be launched on the same day or one at filled with staff suitably trained for respective positions? a time, or whether roll-out should be staggered geographically. Further, the launch plans could have benefitted from testing the ◾ Resources and Equipment. Does the EMS staff have access to all the equipment and resources needed to respond to an different component functions individually and as a system. This type of testing might help narrow down and troubleshoot parts incident in their catchment area, using the EMS system? of the system that require fine tuning for effective operation. ⦁ Are ambulances available on the ground? The following functions would be useful to test before an EMS ⦁ Do ambulances have fuel? service following a similar model to the pilot system in Malawi ⦁ Do ambulances have medical equipment and consumables goes live. and is there a plan for restocking when supplies run low? ◾ Call Center. Is the call center functioning? Effective testing of each component of a new EMS system, ⦁ Are calls to the emergency number forwarded from all as well as testing of the entire system prior to a broad telecom providers to the dispatch center where they are launch can help to quickly identify and resolve challenges answered by a trained dispatcher that knows when and and could lead to significant improvements in the efficiency how to dispatch an ambulance? of the launch and the system at large. 34 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Communications Strategy and Campaign Road show with ambulance 72 To date the communication campaigns to the public regarding Radio 235 the intention and proper use of the new EMS system have been TV 6 limited, with a large-scale awareness campaign yet to be undertaken. It is therefore likely that the general public is not yet Newspaper 4 well informed of the *118 emergency number or when and how Friends/people in the community 917 it should be used. An EMS communication campaign strategy, At the clinic/hospital 25 which includes a range of different activities, was developed in 2019. However, different unforeseen events, including the onset Saw the ambulance 143 of the COVID-19 pandemic, have delayed the roll-out of the Other 164 campaign. The lack of communication to the public has likely 0 200 400 600 800 1,000 hampered the success of the EMS pilot, seen from the low Total number of emergencies reported and attended to as well as the high numbers of prank calls, both of which have become threats Figure 17.  EMS Awareness Source to the sustainability and further roll-out of the EMS. Note: These data have only been collected from persons calling the *118 emergency number for one of following reasons: 1) to learn about EMS/ medical advice or 2) called from outside EMS coverage area For the communication campaign to be successful and cost- effective it is recommended that an evaluation is done in conjunction with its implementation, to identify the most spread quickest. Initial analysis shows that most callers have effective communication channels. The DIME team worked learned about the emergency number from other community together with the EMS team to set up data collection in the members, demonstrating the potential effectiveness of this Call Center to collect data from some callers on how they channel (Figure 17). Continued collection and analysis of these learned about the emergency number. These data have only data as the communications campaign is rolled out can provide been collected from persons calling the *118 emergency guidance in real-time in terms of how well the campaign is number for one of following reasons: 1) to learn about EMS/ working, and could potentially help the EMS pilot team quickly medical advice or 2) called from outside EMS coverage area, pivot to allocate resources towards those channels that prove since for these calls an ambulance is not sent, while for any to be more effective. emergency calls within the coverage area, the dispatcher must focus on getting an ambulance dispatched and it is therefore Given the important role of the public in any EMS system to not possible to collect additional information. While these 10 contact the system in case of an emergency and thus start data are somewhat limited since they only ask a subset of the chain of steps for the provision of EMS services, effective callers how they heard about the EMS, they are still useful communication to the public regarding the system, how it to give a sense of how information about the EMS seems to works and when it should be used is critical. Data collection to understand how the public is interacting with the system can also be invaluable for improving the communication 10 For prank, dropped or weak signal calls it is not possible to obtain information from the caller. process and thus the functionality of the system. TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 35 SECTION VII Discussion, Policy Relevance, and Recommmendations T hrough the three-part analysis presented in the report, consisting of 1) the process of setting up and running the trauma registry; 2) epidemiology of trauma in Malawi; and 3) insights from the implementation process of the EMS pilot, we aim to give a comprehensive picture of both current and remaining challenges as well as opportunities, for decreasing trauma incidence and improving trauma care and trauma outcomes in Malawi. The Trauma Registry Despite some initial skepticism from counterparts, the work of setting up and running a digital TR showed that tablets are a feasible data collection tool in this setting. While initial implementation can be more costly when using digital tools, in terms of training time and upfront cost of tablets, in the long run there are several key advantages to collecting data digitally. For example, the data 36 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI can be immediately available for analysis, to inform operations, of trauma, with overrepresentation of males and younger policy development and decision making. Digital data also adults. (Chichom-Mefire et  al. 2017; Botchey et  al. 2017; increases completion rates and improves data quality. Further, Samuel et al. 2009; Banza et al. 2016). However, the share of the programmed TR has instant automated checks on the data, injuries stemming from RTCs (19.6%) is lower than several to help prevent data entry errors. The checks include constraints other comparable countries. For example, the corresponding on input values and automatic skip patterns. As efforts to digitize RTC rates in other settings were 55% in Cameroon (Chichom- medical records in Malawi are already under way, it is suggested Mefire et al. 2017); 36% in Kenya (Botchey et al. 2017); and 50% to integrate the TR into such an electronic EMR system, for long in Uganda (Kobusingye et al. 2002). A much smaller study of term sustainability. The analysis of the TR implementation also only one facility in Malawi for only 5 months in 2008 found 43% shows that it is possible to collect good quality data on trauma in of cases were RTCs, but the scope was quite limited, and the Malawi, if there is effort put into the planning and maintenance data collection exercise was more than a decade ago (Samuel of the same. et al. 2009). These trauma registries were largely implemented in tertiary or other urban referral facilities. By contrast, in this Insights from the data that were collected through the TR registry, which includes more district hospitals located outside were shared with facilities on a weekly basis and many of the of urban areas, the most common mechanism of injury is TR coordinators and hospital management teams found this falls. However, RTCs make up almost half of admitted information important and useful for reporting and planning trauma cases (48%). Furthermore, the nature of the RTCs purposes. This type of data-informed operations can be highlighted in this setting is distinctive. In several other settings, major as a good example within the MOH. The analysis demonstrates causes of RTCs were motorcycle-related crashes (Sawe et al. the potential of trauma registries to inform both preventive policies 2021a), while in the Malawi TR, roughly half (49%) of RTC (e.g. when and where road traffic trauma occurs) and clinical care victims are non-motorized road users such as pedestrians (e.g. training needed based on the types of injuries requiring care). and cyclists. These findings are consistent with those of A continuation and a refinement of the TR, including greater detail Banza et al (2016), who also found a heavy burden of injury on care delivered and patient outcomes, could contribute to the from RTCs on pedestrians and cyclists in a trauma registry at evidence base regarding trauma care in Malawi. Kamuzu Central Hospital in Malawi. This suggests the need While the data can give a picture of the volume and causes for targeted policies and infrastructure that aim to improve of trauma, the demographics of patients, and the modalities the built environment to recognize safety features that through which trauma victims access care, the registry is limited protect vulnerable road users. in its ability to capture population level data. This is because the TR Further, the analysis of the data also shows limited adherence to was only implemented in ten facilities in the country that were safety practices for motorized RTCs. Malawi law requires drivers not chosen to be representative of the population (instead they and front seat passengers to wear seatbelts (WHO, 2018), yet are chosen based on the EMS pilot project). Additionally, it does the TR data shows that 84% of patients who were passengers not capture detailed information on quality of care for hospitalized of motor vehicles such as cars, buses, and trucks report patients due to the complexity of capturing such information not having worn a seat belt. Similarly, helmets are required systematically. Future TR efforts might address these points for for both drivers and passengers of motorbikes, yet 52% of more comprehensive data on trauma in Malawi. patients who were drivers or passengers of motorbikes report not wearing a helmet. These findings are similar to those of Sundet et  al. (2021) who find limited seat belt use Trauma in Malawi among RTC patients in Lilongwe. This highlights the scope It is widely understood that trauma is a growing problem in for increased seat belt and helmet use to reduce RTC-related many sub-Saharan African countries, including Malawi. The TR trauma in Malawi. sought to fill the knowledge gap about trauma in Malawi with a large-scale data collection effort from both central and district Another concerning finding, which related directly to the work hospitals. The analysis of the data shows both similarities with with the EMS pilot, is the major delays observed in time data from trauma registries in other African settings as well as to reach hospitals and treatment, which can be analyzed key areas of divergence. using the “three delays” framework (delays in the decision to seek care, delay from injury to hospital, and delay from arrival Like data from other TRs in the region, the Malawi TR to being seen) (Calvello et al. 2015). Patients in this registry shows marked gender and age patterns in the incidence report long delays between the time of their injury and the TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 37 hospitals, with half of patients coming using a private or commercial vehicle. In Malawi ambulance transport is used more often for referral across facilities than for emergency transport from trauma sites to hospitals. EMS Pilot Firstly, there needs to be a greater emphasis and understanding on how an EMS system is unique and different from previous ambulance use in Malawi. Information on the EMS System, its overall goals, and the related timelines and sub-objectives should be communicated to all staff working on the EMS pilot or in close collaboration with the EMS pilot. Further, new ways of operating and delivering services need to be coupled with clear communication. This should include not only how the EMS system will operate, but also what positive outcomes are expected in implementing the EMS. It is also important to directly link these outcomes to the specific components of the EMS Pilot and how they improve the existing system. This is important both for the EMS staff and non-EMS staff in the pilot hospitals, to build confidence and buy-in in the new system and generate more awareness for the public that is the direct user. Deciding on a launch date should be determined by deployment readiness. The EMS pilot launch date was changed multiple times, which led to challenges in planning and allocating necessary resources for the EMS pilot. Relatedly, as the emphasis of an time they reach the hospital. In terms of seeking care, around emergency care system lies in its rapid response, testing of one quarter of cases seek care more than 24 hours after the different functions separately and in relation to each o ther, as trauma, including some severe cases.11 This signals the need well as a live test of the entire system, is crucial. Prior testing and for additional research to understand barriers to choosing to confirmation of system conformance would have been advisable seek care sooner. Focusing on those cases that arrive within in connection with the launch. 24 hours of the trauma, for RTCs, median time to arrival at the hospital is 1.4 hours. Several other registries in the region There are large amounts of data generated and collected as have recorded much shorter pre-hospital delays (Chichom-Mefire part of the EMS operations, specifically, the computer-aided et al; Kobusginye et al). These long delays however are consistent call center and dispatch software platforms used in this pilot. with findings from the Kamuzu Central Hospital registry in It must be emphasized that a fundamental premise of digital Malawi (Samuels et al. 2009). Notably, being close to the road technology in this instance is its automatic collection and storage is more closely linked to timely care than injury severity. RTCs of data available for analysis. As the data collected through the (both serious and non-serious), which happen on the road where above-mentioned systems will be useful in deciding how EMS transport options are present, have a median time to arrival of operation and financial resources needs can be optimized when 1.4  hours, but all serious non-RTC cases have a median time moving forward, it is suggested that additional effort is put into to arrival of 4 hours. This comparison highlights major barriers synthesizing the data that are already available. to transport for non-RTC serious trauma cases. Furthermore, With regards to the EMS Communication Campaign, a timely only 6% of admitted trauma cases use ambulances to reach and successful communication campaign about the MOH’s intentions of the EMS, proper use of *118 and ambulance dispatch availability is important. There is still a need to educate the public on how and when an emergency number should Unfortunately, it is not possible to distinguish directly between the time taken to 11 decide to seek care and the transport time to hospital. be contacted. 38 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Recommendations facilities in order to help guide operations and lead to higher effectiveness. Based on our findings we would like to make the following 6. A continuation and a refinement of the TR, including recommendations: greater detail on care delivered and patient outcomes, could contribute to the evidence base regarding trauma 1. The data demonstrate the burden of road traffic crashes care in Malawi. Streamlining of the variables collected for health facilities and the need to implement additional (by identifying the most important ones) and integration policies that can decrease RTCs, which will help to alleviate into existing data collection practices in health facilities resource needs within health facilities. can help support sustainability. 2. There is a need to target policies and infrastructure to 7. Increased investment in digital data collection in health improve road safety for the most vulnerable users — facilities could help to improve the quantity and quality of pedestrians and cyclists. data collected and increase the usefulness of the data for 3. The data collected shows the scope for targeting greater policy planning and health facility operations. seat belt and helmet use to reduce RTC-related trauma in Malawi, through both increased enforcement of related While the EMS pilot has seen some implementation challenges, road laws and public safety advocacy. it has come a long way and certainly improved its operations 4. Investment in a comprehensive communications campaign over time. It has helped to facilitate the collection of rich data, and use of existing data to help guide and evaluate the both within facilities as well as through the dispatch center, and effectiveness of the campaign will be important. as these data are further leveraged, they can help to inform more 5. There should be increased use of all the different data effective policymaking and decisions intended to reduce trauma that are collected by the EMS systems and within health and improve health outcomes. 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TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 41 APPENDIX 1 Additional Figures and Tables A&E QEH Nov’18 1 Jan’19 6 May’19 2 Jun’19 8 Jul’19 171 Aug’19 270 Sep’19 288 Oct’19 253 Nov’19 304 Dec’19 270 Jan’20 103 Feb’20 111 Mar’20 189 Apr’20 37 May’20 78 Jun’20 34 Total number of cases per month Balaka District Hospital Aug’18 259 Sep’18 441 Oct’18 455 Nov’18 504 Dec’18 423 Jan’19 404 Feb’19 465 Mar’19 483 Apr’19 400 May’19 513 Jun’19 423 Jul’19 513 Aug’19 536 Sep’19 514 Oct’19 591 Nov’19 568 Dec’19 488 Jan’20 486 Feb’20 443 Mar’20 456 Apr’20 375 May’20 458 Jun’20 478 Jul’20 376 Aug’20 171 Sep’20 342 Oct’20 480 Nov’20 520 Dec’20 423 Jan’21 295 Feb’21 271 Mar’21 376 Apr’21 359 May’21 325 Jun’21 264 Total number of cases per month Figure A1.  Monthly Trauma Cases by Facility TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 43 Dedza District Hospital Aug’18 121 Sep’18 317 Oct’18 283 Nov’18 240 Dec’18 191 Jan’19 230 Feb’19 444 Mar’19 599 Apr’19 474 May’19 467 Jun’19 431 Jul’19 318 Aug’19 367 Sep’19 224 Oct’19 367 Nov’19 584 Dec’19 292 Jan’20 459 Feb’20 178 Mar’20 255 Apr’20 131 May’20 230 Jun’20 117 Jul’20 14 Total number of cases per month Dowa District Hospital Aug’18 121 Sep’18 150 Oct’18 233 Nov’18 189 Dec’18 222 Jan’19 220 Feb’19 217 Mar’19 230 Apr’19 181 May’19 257 Jun’19 248 Jul’19 220 Aug’19 259 Sep’19 256 Oct’19 337 Nov’19 246 Dec’19 313 Jan’20 283 Feb’20 281 Mar’20 354 Apr’20 249 May’20 305 Jun’20 264 Jul’20 277 Aug’20 316 Sep’20 284 Oct’20 261 Nov’20 251 Dec’20 258 Jan’21 208 Feb’21 205 Mar’21 308 Apr’21 257 May’21 202 Jun’21 202 Total number of cases per month Figure A1.  Monthly Trauma Cases by Facility (continued ) 44 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Kasungu District Hospital Aug’18 100 Sep’18 164 Oct’18 188 Nov’18 192 Dec’18 299 Jan’19 482 Feb’19 302 Mar’19 391 Apr’19 424 May’19 362 Jun’19 352 Jul’19 420 Aug’19 349 Sep’19 365 Oct’19 555 Nov’19 543 Dec’19 563 Jan’20 358 Feb’20 293 Mar’20 306 Apr’20 254 May’20 311 Jun’20 298 Jul’20 380 Aug’20 296 Sep’20 399 Oct’20 340 Nov’20 414 Dec’20 373 Jan’21 249 Feb’21 310 Mar’21 297 Apr’21 323 May’21 256 Jun’21 168 Total number of cases per month Lisungwi Community Hospital Aug’18 59 Sep’18 133 Oct’18 116 Nov’18 91 Dec’18 114 Jan’19 106 Feb’19 98 Mar’19 121 Apr’19 94 May’19 100 Jun’19 73 Jul’19 94 Aug’19 133 Sep’19 117 Oct’19 111 Nov’19 107 Dec’19 124 Jan’20 99 Feb’20 59 Mar’20 66 Apr’20 72 May’20 90 Jun’20 68 Jul’20 70 Aug’20 70 Sep’20 70 Oct’20 60 Nov’20 54 Dec’20 62 Jan’21 71 Feb’21 51 Mar’21 57 Apr’21 58 May’21 58 Jun’21 54 Total number of cases per month Figure A1.  Monthly Trauma Cases by Facility (continued ) TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 45 Mzimba District Hospital Aug’18 229 Sep’18 416 Oct’18 423 Nov’18 517 Dec’18 564 Jan’19 603 Feb’19 491 Mar’19 514 Apr’19 550 May’19 579 Jun’19 601 Jul’19 545 Aug’19 629 Sep’19 581 Oct’19 663 Nov’19 644 Dec’19 601 Jan’20 627 Feb’20 592 Mar’20 581 Apr’20 452 May’20 546 Jun’20 589 Jul’20 454 Aug’20 478 Sep’20 502 Oct’20 570 Nov’20 594 Dec’20 564 Jan’21 481 Feb’21 400 Mar’21 462 Apr’21 507 May’21 471 Jun’21 487 Total number of cases per month Mzuzu Central Hospital Aug’18 104 Sep’18 158 Oct’18 179 Nov’18 315 Dec’18 255 Jan’19 259 Feb’19 278 Mar’19 300 Apr’19 274 May’19 305 Jun’19 300 Jul’19 393 Aug’19 428 Sep’19 352 Oct’19 381 Nov’19 393 Dec’19 497 Jan’20 356 Feb’20 377 Mar’20 313 Apr’20 241 May’20 228 Jun’20 251 Jul’20 262 Aug’20 292 Sep’20 194 Oct’20 236 Nov’20 193 Dec’20 289 Jan’21 140 Feb’21 162 Mar’21 198 Apr’21 130 May’21 145 Jun’21 70 Total number of cases per month Figure A1.  Monthly Trauma Cases by Facility (continued ) 46 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Ntcheu District Hospital Aug’18 167 Sep’18 303 Oct’18 226 Nov’18 227 Dec’18 294 Jan’19 274 Feb’19 280 Mar’19 337 Apr’19 382 May’19 377 Jun’19 387 Jul’19 429 Aug’19 463 Sep’19 323 Oct’19 383 Nov’19 397 Dec’19 380 Jan’20 364 Feb’20 384 Mar’20 539 Apr’20 357 May’20 257 Jun’20 368 Jul’20 383 Aug’20 403 Sep’20 364 Oct’20 424 Nov’20 481 Dec’20 437 Jan’21 357 Feb’21 229 Mar’21 204 Apr’21 335 May’21 313 Jun’21 236 Total number of cases per month Queen Elizabeth Central Hospital Aug’18 167 Sept’18 140 Oct’18 166 Nov’18 271 Dec’18 483 Jan’19 339 Feb’19 301 Mar’19 472 Apr’19 579 May’19 738 Jun’19 948 Jul’19 980 Aug’19 818 Sep’19 883 Oct’19 978 Nov’19 875 Dec’19 998 Jan’20 913 Feb’20 745 Mar’20 840 Apr’20 116 May’20 189 Jun’20 190 Jul’20 116 Aug’20 277 Sep’20 272 Oct’20 155 Nov’20 256 Dec’20 253 Jan’21 174 Feb’21 143 Mar’21 163 Apr’21 162 May’21 187 Jun’21 263 Total number of cases per month Figure A1.  Monthly Trauma Cases by Facility (continued ) TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 47 Rumphi District Hospital August’18 188 Sept’18 295 Oct’18 312 Nov’18 352 Dec’18 360 Jan’19 360 Feb’19 339 Mar’19 402 Apr’19 374 May’19 392 Jun’19 390 Jul’19 434 Aug’19 429 Sep’19 461 Oct’19 477 Nov’19 481 Dec’19 525 Jan’20 568 Feb’20 470 Mar’20 463 Apr’20 408 May’20 495 June’20 476 July’20 453 Aug’20 453 Sep’20 474 Oct’20 506 Nov’20 526 Dec’20 508 Jan’21 423 Feb’21 364 Mar’21 487 Apr’21 454 May’21 474 Jun’21 398 Total number of cases per month Figure A1.  Monthly Trauma Cases by Facility (continued ) Table A1. Trauma Cases by Facility Hospital name Total incoming trauma cases Total incoming RTC Total hospital admission Balaka District Hospital 5335 1077 437 Dedza District Hospital 5178 554 139 Dowa District Hospital 2754 550 311 Kasungu District Hospital 4659 1302 227 Lisungwi Community Hospital 1344 351 196 Mzimba District Hospital 6332 1221 982 EVIzuz u Central Hospital 4001 1129 489 Ntcheu District Hospital 4375 702 219 Queen Elizabeth Central Hospital 10308 1916 336 Rumphi District Hospital 4955 793 273 Total 49241 9595 3609 48 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI APPENDIX 2 Trauma Registry Questions The trauma ID assigned to this person is SMYCP665 Please record this trauma ID in the patient’s health passport. Who is filling in this trauma registry? Which hospital is this? Was the patient transferred here from other facility? From which facility was the patient referred? What was the patient’s mode of transport to hospital? What date and time did the patient arrive at the hospital? What is the first name of the patient? What is the last name of the patient? How old is the patient? This patient is less than 1 year. Please enter the patient’s age in months. 0-12 months What is the patients gender? What is the highest level of education for this patient? What is the patients occupation? In what region does the patient reside? In what district does the patient reside? In what TA does the patient reside? In what village does the patient reside? Do you have a mobile phone? Please enter a phone number to the patient. Who is the owner of this phone number? What is the name of the person who owns the phone? Can you provide a phone number to someone who is close to you, to for example a family member or friend? Please enter the secondary phone number. Who is the owner of this phone number? What is the name of the person who owns the phone? What date and time did the trauma happen? In what setting did the accident happen? In what district did the trauma happen? In which TA did the trauma happen? In which village/location did the trauma happen? Was the patient under influence of alcohol or other drugs? What was the patient’s mode of transport from crash site to first health care facility? How can the area where the accident happened best be described? What was the patients role on the road? What type of vehicle was the patient in at the time of the accident? What did the patient collide with, at the time of the accident? What was the pedestrian hit by? What was the cyclist hit by/hit? What was the motorcyclist hit by/hit? (continues on next page) 50 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI What was the oxcart driver or passenger hit by/hit? Was the patient wearing a helmet at the time of the accident? Was the patient wearing a seatbelt at the time of the accident? Heart rate (beats/ minute) Body temperature C Blood Pressure (systolic) Respiratory Rate (breathes/minute) What is the patient’s neurological status? Best eye response Best moto response What is the total GCS Score Date and time patient was attended to by doctor or other medical professional, for care? Please record the most serious injury that patient has. What type of injury is this? Is this an open or closed fracture? Where is the injury located? Is this a serious injury? Please record the second most serious injury that patient has. What type of injury is this? Is this an open or closed fracture? Where is the injury located? Is this a serious injury? Please record the third most serious injury that patient has. What type of injury is this? Is this an open or closed fracture? Where is the injury located? Is this a serious injury? On a scale from no pain to severe pain, how much pain are you in right now? Is it none, mild, moderate or severe? What was the patients outcome at casualty department? On the day of arrival. Which hospital was the patient referred to? (continues on next page) TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI 51 DAY 2 FOLLOW UP Is the patient still in the hospital? Where is the patient? What is the patient’s (trauma) id? Heart rate (beats/minute) Body temperature C Blood Pressure (systolic) Respiratory Rate (breathes/minute) What is the patient’s neurological status? Best eye response Best verbal response Best moto response What is the total GCS Score On a scale from no pain to severe pain, how much pain are you in right now? Is it none, mild, moderate or severe? What treatment has the patient received, since arriving at the hospital? What is the patients outcome, today? Which hospital was the patient referred to? Which body part was treated? 52 TRAUMA INCIDENCE AND EMERGENCY MEDICAL SERVICES IN MALAWI Photo Credits Cover: © Jason Colston/Global Environment Facility, “Malawi” March 27, 2015 via Flickr, Creative Commons CC BY-NC-SA 2.0. Page 4: © Sveta Milusheva. Page 7: © Jonna Bertfelt. Page 8: © Direct Relief, “Malawi Queen Elizabeth Central Hospital and UNFPA October 2013” October 23, 2013 via Flickr, Creative Commons CC BY-NC-ND 2.0. Page 10: © Sveta Milusheva. Page 11: © Jonna Bertfelt. Page 12: © Jonna Bertfelt. Page 14: © Kevin Croke, Harvard School of Public Health. Page 15: © Jaosn Friesen, TrekMedics. Page 17: © Ken Opprann/Norad, “Kamuzu Central Hospital i Malawi” September 26, 2017 via Flickr, Creative Commons CC BY-NC-ND 2.0. Page 18: © Jonna Bertfelt. Page 22: © Rachel Palmer/Sightsavers, “Safety is the responsibility of all staff, no matter how junior or senior they are. MALAWI”September 17, 2014 via Flickr, Creative Commons CC BY-NC 2.0. Page 25: © Hansueli Krapf, “Downtown Lilongwe” via Wikimedia Commons, Creative Commons CC BY-SA 3.0. Page 27: © Noel Kasomekera, Partners in Health, Malawi. Page 29: © Direct Relief, “Malawi Mangochi District October 2013” October 25, 2013 via Flickr, Creative Commons CC BY-NC-ND 2.0. Page 31: © Jonna Bertfelt. Page 34: © Jonna Bertfelt. Page 36: © Hansueli Krapf, via Wikimedia Commons, Creative Commons CC BY-SA 3.0. Page 38: © Direct Relief, “Malawi Mangochi District October 2013” October 24, 2013 via Flickr, Creative Commons CC BY-NC-ND 2.0. Page 40: © Jonna Bertfelt. Page 42: © Timon Zingg, via Wikimedia Commons, Creative Commons CC BY-SA 3.0. Page 49: © IFPRI, “Firewood Bicyclist” February 23, 2016 via Flickr, Creative Commons CC BY-NC- ND 2.0