Prehospital emergency care for trauma victims in Nepal: a mixed-methods study

Abstract

Background: The prehospital care system in Nepal is poorly developed, with multiple providers, limited co-ordination of services and no national coverage. There is little published evidence reporting the prehospital care of patients with trauma, data which are important to inform the development of the prehospital care system.

Objectives: In order to understand the challenges of providing prehospital care to trauma patients, the study aimed to explore the burden of trauma presenting to prehospital care providers and the experience of providing care to these patients.

Design: We used a mixed-method study that included secondary data analysis and qualitative semistructured interviews.

Setting: Nepal (Kathmandu Valley, Chitwan, Pokhara and Butwal).

Participants: Staff employed by the Nepal Ambulance Service including ambulance drivers, emergency medical technicians, dispatch officers and service managers.

Data sources: Data describing callouts by the Nepal Ambulance Service over 1 year. Callout data were anonymised and analysed descriptively. Semistructured interviews were audio-recorded, transcribed, translated and analysed using inductive thematic analysis.

Results: Of 1408 trauma calls received, 48.4% (n = 682) resulted in prehospital care being provided. The most common mechanism of injury was falls (35.8%), followed by road traffic crashes (19.1%) and the commonest types of injuries were fractures (33.1%) and spinal injuries (10.1%). Mean time from call to arrival at hospital was 48 minutes (range 20 minutes–6 hours). Seventeen staff described factors facilitating effective prehospital care, including having adequate resources, systems and training. Barriers to delivering prehospital care included the expectations and behaviour of patients’ relatives and bystanders, a lack of public awareness of the role and provision of prehospital care, and poor road and traffic conditions.

Limitations: For some data fields, data were missing, limiting the ability to precisely determine patient needs and response times. The qualitative data may have been subject to responder bias if participants felt uncomfortable reporting something that may have reflected badly on their employer.

Conclusions: Trauma is a major reason for requesting prehospital care, which can be delivered in less than an hour from receiving a call to arrival at the hospital. Multiple factors impede the effective delivery of care which could be addressed through further development across the prehospital care system.

Future work: Qualitative research to explore the perceptions and experiences of trauma victims, road users, emergency department staff, police officers, members of organisations involved in prehospital care, firefighters, and policy-makers would complement the findings from this study. Specific issues raised, such as the difficulties experienced when handing over patients between prehospital and hospital care providers, warrant further exploration.