Improvement in quality of trauma care at non-tertiary hospitals in Ghana during on-hours and off-hours with a trauma intake form: A stepped-wedge cluster randomized trial

Background We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at non-tertiary hospitals in Ghana during on-hours (8AM-5PM weekdays) compared to off-hours (nights, weekends, and holidays). We also sought to assess the effectiveness of a standardized trauma intake form (TIF) with built-in decision support prompts to improve care and to assess whether this effectiveness varied between on-hours and off-hours. Methods A stepped-wedge cluster randomized trial was performed with research assistants directly observing trauma care before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs and mortality were assessed using multivariable logistic regression and generalized linear mixed regression. Results Management of 4,077 patients was observed; 1,126 (28%) during on-hours and 2,951(72%) during off-hours. At baseline, four of 20 KPIs were performed significantly more often during off-hours. TIF improved care during both on- and off-hours. Seventeen KPIs improved during on-hours and 18 KPIs improved during off-hours. After TIF, six KPIs were performed more often during on-hours, but differences, though significant, were small (1%-5%). Examples of KPIs which were performed more often during on-hours after TIF included: airway assessment (99% for on-hours vs. 98% for off-hours), evaluation for intra-abdominal bleeding (91% vs. 87%), and spine immobilization for blunt trauma (90% vs. 85%) (all p<0.05). At baseline, mortality among seriously injured patients (Injury Severity Score >9) was higher during on-hours (27%) compared to off-hours (17%, p=0.047). TIF lowered mortality for seriously injured patients during both on-hours (27% before TIF, 8% after, p=0.027) and during off-hours (17% before, 7% after, p=0.004). After TIF, mortality among seriously injured patients was equal between on- and off-hours (8% vs. 7%, NS). Conclusions At baseline, KPIs of trauma care were slightly better during off-hours compared with on-hours, and mortality was lower among seriously injured patient during off-hours. A quality improvement initiative (the TIF) using built-in decision support prompts improved care strongly in both on- and off-hours and eliminated the mortality difference between on- and off-hours. Use of similar decision support prompts during initial trauma care should be promoted widely in other low- and middle-income countries.