Hrev_master Abstract It is estimated that 1.35 million people die each year as a result of road traffic injuries worldwide, with Africa having the highest annual rate. Ethiopia has the highest fatality rate in road traffic accidents, at 79%. There is no well-established emergency medical system in Ethiopia to provide pre-hospital trauma care. A cross- sectional study was conducted at selected public hospitals in Addis Ababa. Purposive sampling was used to select the victims who arrived at the emergency department by ambulance. Data was gathered through structured questionnaires administered by an interviewer and a review of victims’ medical records. SPSS Version 25 was used to analyze the data. In this study, 262 victims took part, with a 94% response rate. Patient positioning (50.8%) was the most commonly provided service, followed by bleeding control (43.5%). Within the first 24 hours, 8.4% of the victims died. The first 24-hours of injury-related death were significantly associated with head/neck/spine injury and total pre-hospital time. Action should be taken to increase the availability of necessary equipment in ambulances and the number of paramedic personnel. Introduction It is estimated that 1.35 million people die and more than 50 million are injured in road traffic accidents worldwide each year.1 Road Traffic Injury (RTI) is the eighth leading cause of death, accounting for 2.46% of all deaths worldwide, according to the Global Burden of Disease Study report.2 RTIs have a significant social and economic impact due to the victims’ suffering, loss of life, and loss of productivity. RTI-related deaths are at least twice as common in low- and middle-income countries as in high-income countries. RTI mortal- ity rates have remained relatively stable globally since 2007, despite rising rates in many developing countries.3 Surprisingly, Africa has the highest annual rate of road fatalities in the world, with 27 deaths per 100,000 people.3 Ethiopia, one of the African countries with the highest rate of road traffic injury-related fatalities in the world, has a 79% road traffic injury-related fatality rate.4 Furthermore, global burden of disease study reports from 1990 to 2017 revealed that the inci- dence and mortality rate of road injuries are increasing at an alarm- ing rate, and this has become a growing national concern in Ethiopia.5 In the fiscal year 2014/15, there were 15,086 road traffic crashes,6 while the road traffic mortality rate per 100,000 popula- tion in Ethiopia was 26.7 in 2016.7 Emergency Care Journal 2022; volume 18:10745 Correspondence: Helina Bogale Abayneh, Department of Emergency and critical care Nursing, St Paul Hospital Millennium Medical College Addis Ababa, Ethiopia, P.O.Box: 1271. Tel.: +251912218245, Fax: +251112774787 E-mail: helinabogale2005@gmail.com Key words: Pre-hospital; ambulance; Ethiopia; Addis Ababa; emer- gency; emergency medicine. Acknowledgments: The authors would like to thank the study partici- pants, acting hospital heads and care provider staffs, for their coopera- tion throughout the data collection. Contributions: MBR and HBA carried out the study starting from con- ception, data collection, analysis and interpretation of the data, drafting, and reviewing of the manuscript. TGL and BAW participated in the study design, data analysis, interpretation and critical review of the manuscript. All authors read and approved the final draft of the manu- script. Conflict of interests: The authors declare no competing interests. Availability of data and materials: Data supporting the findings in this paper are available upon reasonable request. Ethics approval and consent to participate: This study was conducted by following the Declaration of Helsinki, and approval was obtained from institution review board of St. Paul’s hospital millennium medical col- lege and from Addis Ababa public health research review committee (protocol number PM23/547). Informed written consent was obtained from the participants before proceeding the data collection. Informed consent: Informed written consent was obtained from the par- ticipants before proceeding the data collection. Received for publication: 18 July 2022. Revision received: 15 September 2022. Accepted for publication: 19 September 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10745 doi:10.4081/ecj.2022.10745 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. [Emergency Care Journal 2022; 18:10745] [page 35] The role of pre-hospital ambulance care in the management of road traffic injuries in Addis Ababa (Ethiopia) Mulugeta Bonsa Regasa,1 Tesfaye Girma Legesse,2 Birhanu Asrat Wudineh,3 Helina Bogale Abayneh3 1Department of Adult Emergency, Butajira General Hospital, Butajira; 2Department of Nutrition, St Paul Hospital Millennium Medical College, Addis Ababa; 3Department of Emergency and critical care Nursing, St Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia Non -co mmerc ial us e o nly For the finding report of a high pre-hospital mortalities for road traffic crash injured individuals in Ethiopia, several studies recommended research investigation to provide appropriate cor- rective measures.8,9 Investing in and developing pre-hospital emergency care is one of the primary strategies for reducing the burden of injuries, partic- ularly those caused by RTIs.10 However, many developing coun- tries lack pre-hospital emergency medical service systems, and road traffic deaths occur due to a lack of timely post-crash respons- es and access to hospitals.11 Despite efforts to train emergency personnel, Ethiopia lacks a well-established emergency medical system to provide pre-hospi- tal trauma care.12 The only available emergency service is infre- quent ambulance transportation, which is insufficiently supported by healthcare professionals and supplies.13 According to reports, pre-hospital care services in Ethiopia have not been prioritized and are characterized by insufficient coordination among actors. In comparison, only 20.3% of patients in Addis Ababa, Ethiopia’s capital, were transported to hospitals by ambulance services, with the remainder handled by bystanders and public transportation services.14 As a result, it is timely and important to examine pre-hospital ambulance care for road traffic crash victims in order to improve informed management and gain a better understanding of how to improve the quality of pre-hospital care. As a result, the purpose of this study is to evaluate pre-hospital ambulance care and factors associated with the first 24 hours of injury outcome among road traffic accident victims visiting emergency departments of selected public hospitals in Addis Ababa, Ethiopia. Addis Ababa is the capital city of Ethiopia, with a current esti- mated population of 3,384,569. The city has a total of 48 hospitals; thirteen of them are public hospitals. Fire and emergency depart- ment, Red Cross association and Tebita private ambulance compa- ny are organizations providing pre-hospital care services in the city. Addis Ababa Burn, Emergency and Trauma (AaBET) hospi- tal, All Africa Leprosy, Tuberculosis, Rehabilitation and Training Center (ALERT) hospital, Tikur Anbessa Specialized Teaching Hospital (TASTH), Menilik II hospital, Yekatit 12 hospital, Zewditu Memorial Hospital, Ras Desta Hospital and Tirunesh Beijing hospital are currently providing emergency medical care to road traffic collision victims. AaBET hospital, Menilik II hospital, Yekatit 12 hospital, and Zewditu Memorial hospital were random- ly selected for this study. Based on each hospitals’ statistics report, the average number of RTI victims attended by an ambulance were 191, 50, 42, and 58 respectively. Materials and Methods Study design From December 25, 2021 to January 25, 2022, an institution- based cross-sectional study was designed and carried out in the emergency departments of selected public hospitals in Addis Ababa. The total study sample was allocated proportionally to the emergency departments of each selected hospital based on their monthly average number of RTI patients. The sample size was calculated using the single population proportion formula, assuming a 95% confidence interval, 5% mar- gin of error (d), taking the proportion ambulance utilization at Dessie referral hospital, Ethiopia, 21%,15 and adding a non- response rate of 10% yielded a total sample size of 279. A total of 279 participants, who were transported by ambulance, who agreed to participate, and who were live at the hospital presentation were included. Those with any form of memory (psychiatric) problems and with no relatives/bystander, patients transferred from other hospitals after initially treated, and unconscious victims with no relatives/bystander were excluded from the study. The number of study units to be sampled from each facility is determined using the proportional size allocation formula: n= nf×ni/ N Where: ni = number of RTI patients in each hospital; nf = final sample of the study; N = total number of RTI patients in all select- ed hospitals, yielded 129, 50, 41, 58 for AaBET hospital, Menilik II hospital, Yekatit 12 hospital, and Zewditu Memorial hospital respectively. Structured interviewer questions and a review of medical records at the ED were used to collect data. The questionnaire was pretested, adapted, and modified from previous studies,14-17 and includes questions about socio-demographic characteristics, injury characteristics, pre-hospital time, pre-hospital ambulance care, and injury outcomes after 24 hours. Following the arrival of the ambu- lance at the emergency department of each selected hospital, data were collected by trained BSc nurses after informed consent was obtained from each study participant (victims, relatives, bystanders, and pre-hospital ambulance accompanied health care provider). Data for the first 24-hours of injury outcomes were obtained from medical records/charts by tracing the patient’s med- ical record number. On a daily basis, the principal investigator and supervisors collected completed questionnaires and checked for missing values and completeness. Statistical analysis Data were cleaned, coded, and entered into Epidata 3.1 before being exported and analyzed in SPSS version 25. For continuous data, descriptive statistics such as mean, range, and standard devi- ations were computed, as well as percentage and frequency tables for categorical data. To summarize the data, descriptive statistics such as percent, pie chart, graphs, proportion, and ratio were used. To investigate the effect of independent variables on dependent variables, bivariate logistic and multiple logistic regression were used. The Crude Odds Ratio (COR) for each independent variable was initially calculated at 95% Confidence Intervals (CI). Variables with p-value <0.25 on bivariate logistic regression analy- sis were subjected to multiple logistic regression analysis. A p- value of less than 0.05 was regarded as significant. Result Socio-demographic characteristics of participants Two hundred and seventy-nine people were approached, and 262 of them agreed to participate in this study, with a 94% response rate. Males made up more than half of the injured victims, 162 (61.8%). The average age of the study participants was 31, with a standard deviation of 16 years, and 78 (29.8%) of the injured victims were between the ages of 31 and 44. The majority of the participants, 218 (83.2%), were from Addis Ababa; 55 (21.0%) were students, and 123 (46.9%) had completed primary school (Table 1). Characteristics of the road traffic injury victims The majority of the 182 (69.5%) road traffic injured victims studied sustained their injuries on the street. The victims with the highest proportion, 87 (33.2%), were pedestrians. On the other hand, more than half of the accidents, 150 (57.3%), occurred dur- Article [page 36] [Emergency Care Journal 2022; 18:10745] Non -co mmerc ial us e o nly ing the day. More than half of the victims, 142 (54.2%), had a sin- gle injury, with the extremity being the most common anatomic site of injury (138 (52.7%). More than half of the patients, 144 (55.0%), had open wounds, while 68 (26.0%) had open bone frac- ture injury (Table 2). The condition of the victims upon arrival at the emergency departments revealed that more than three-quarters, 206 (78.6%), were unstable, and more than half, 135 (51.1%), arrived at the health facility within an hour of injury. According to the victim’s triage category given at ED, the majority, 114(43.5%) were classified as red patients. More than half of the 262 injured patients studied were admit- ted for further treatment, with 168 (64.1%) admitted for further treatment, 72 (27.5%) treated and discharged to home, and approx- imately 22 (8.4%) dying within the first 24 hours (Table 3). Article Table 1. Socio-demographic characteristics of road traffic injury victims transported by ambulance from the scene to emergency depart- ment of selected public hospitals, Addis Ababa, Ethiopia, 2022 (n=262). Variable Alternatives Frequency Percent (%) Gender Male 162 61.8 Female 100 38.2 Age (in years) ≤15 63 24.0 16 – 30 64 24.4 31 – 44 78 29.8 ≥45 57 21.8 Mean age (SD) 31.3(16.3) Address Addis Ababa 218 83.2 Out of Adds Ababa 44 16.8 Educational status No formal education 33 12.6 Primary (1- 8) 123 46.9 Secondary (9-12) 51 19.5 College and above 55 21.0 Occupation Merchant 45 17.2 Student 55 21.0 Civil servant 44 16.8 Farmer 34 13.0 Driver 48 18.3 Others* 36 13.7 *daily laborers, driver assistance, housewife. Table 2. Characteristics of road traffic injury victims transported by ambulance from scene to emergency department of selected public hospitals, Addis Ababa, Ethiopia, 2022 (n=262). Variable Alternatives Frequency Percent (%) Site of injury Street 182 69.5 Othersa 80 30.6 Mode of injury Car driving 50 19.1 Motor cyclist 56 21.4 Pedestrian 87 33.2 Passenger 49 18.7 Driver assistant 10 3.8 Othersb 10 3.8 Time of incident Morning to mid-day 83 31.7 Afternoon 67 25.6 Mid-night 83 31.7 Mid-night to morning 29 11.1 Number of injuries Single injury 142 54.2 Multiple injuries 120 45.8 Injured body part Head /Neck/Spine 69 26.3 Chest/Abdomen/Pelvis 55 21.0 Extremities 138 52.7 Open bone fracture Yes 68 26.0 No 194 74.0 Open wound Yes 144 55.0 No 118 45.0 arural roads, workplace, public gathering places. broad janitor, street boys, shoeshine boy. [Emergency Care Journal 2022; 18:10745] [page 37] Non -co mmerc ial us e o nly Pre-hospital care provided for road traffic injury victims From the road traffic injury victims included in this study, 81(30.9%) were trapped in the wreck and only 9 (11.1%) were removed from the wreck by health professionals, while more than half 45 (55.6%) were removed from the wreck by people around them or bystanders. Finding on type of pre-hospital care provider showed that Nurses 121 (46.2%) were the most frequent care provider (Table 4). Patient positioning was the most frequently provided type of pre-hospital ambulance care (133.8%), followed by bleeding control, splinting/immobilizing 56 (21.4%), analgesics 39 (14.9%), fluid resuscitation 36 (13.7%), and suctioning 15 (5.7%). According to the Kampala Trauma Score-II results, the major- ity of patients (143 (54.6%) who presented to the emergency department had severe injury, 69 (26.3%) had moderate injury, and 50 (19%) had mild injury. 17 (11.9%) of the severely injured patients died. The standard deviation of the Kampala Trauma Score-II of the road traffic accident victims was 2.5 (Table 5). Factors associated with the first 24-hours of road traf- fic injury outcomes Bivariate logistic regression was used to determine which vari- ables should be included in the final multiple regression model, with injury to the head/neck/spine, injury to the chest/abdomen/pelvic, bleeding control, and total pre-hospital arrival time having p-values of 0.25 and being considered for mul- tiple logistic regression. The final multiple regression model dis- covered that head/neck/spine injury and total pre-hospital arrival time were significantly associated with first-day road traffic injury mortality. Victims with head/neck/spine injuries were four times more likely to die from a road traffic injury within 24 hours than their peers [AOR= 3.76; 95% CI (1.29, 10.96)]. Similarly, total pre-hos- pital arrival time greater than sixty minutes increases the odds of death within the first 24 hours by four times when compared to total pre-hospital arrival time less than or equal to sixty minutes [AOR= 4.31; 95% CI (1.39, 13.36); Table 6]. Discussion According to this study, 8.4% (95% CI: 5.0%, 11.8%) of vic- tims died within the first 24 hours of sustaining a road traffic injury. This finding is higher than studies conducted in Japan,18 India,19 and Addis Ababa, Ethiopia,17 which reported 5.1%, 6%, and 4.9% of road traffic injury victims died within the first 24 hours, respectively. However, this finding was lower than studies conducted in Wolaita Sodo, Ethiopia,20 which found that 14.1% of road traffic injury victims died within the first 24 hours, and Gondar 22.5% died within the first 24 hours. The difference in the prevalence of survival of road traffic injury victims could be attrib- uted to differences in socio-demographic characteristics, testing methods, the Emergency Medical Service (EMS) system, the qual- ity of pre-hospital and in-hospital care provided, and the types of Article [page 38] [Emergency Care Journal 2022; 18:10745] Table 3. Characteristics of road traffic injury victims transported by ambulance from scene to emergency department of selected public hospitals, Addis Ababa, Ethiopia, 2022 (n=262). Variable Alternatives Frequency Percent (%) Condition of the victim on the arrival to the ED Stable 56 21.4 Unstable 206 78.6 Response time (min) <16 min 13 5.0 16 - 30 min 70 26.7 >30 min 179 68.3 Total pre-hospital time (min) <60 min 127 48.5 ≥60 min 135 51.5 Victim’s triage category at ED Green 29 11.1 Yellow 45 17.2 Orange 74 28.2 Red 114 43.5 The first 24 hrs. injury outcome Died 22 8.4 Survived 240 91.6 Table 4. Pre-hospital Ambulance care provided for road traffic injury victims transported by Ambulance from scene to emergency department of selected public hospitals, Addis Ababa, Ethiopia, 2022 (n=262). Variable Alternatives Frequency Percent (%) The victim in wreck or entrapped Yes 81 30.9 No 181 69.1 The victim removed from wreck or extricated by (n=81) Health professionals 9 11.1 Police 18 22.2 Bystanders 45 55.6 Relatives/Friends 9 11.1 Pre-hospital care provider Nurse 121 46.2 EMT 27 10.3 First responder 106 40.5 Other health prof * 8 3.1 *Other health prof= Health officer, midwife, pharmacist. Non -co mmerc ial us e o nly affected anatomic body parts during the injury. According to the study, 43.5% of victims received pre-hospital bleeding control. This is higher than the 33.9% found in a previous Addis Ababa21 study. This finding, however, is lower than that of a study conducted in western Ethiopia,22 which reported 67.8%. This disparity may be due to differences in the nature of the injury and the service provider. In this study, head/neck/spine injury and total pre-hospital time were found to be significantly associated with first-day mortality. Victims with head/neck/spine injuries were four times more likely to die within the first 24 hours of a road traffic accident than vic- tims with other types of injuries. This finding was consistent with a study conducted in Spain23 and China,24 which revealed that vic- tims with head/neck/spine injuries had a higher chance of dying within the first 24 hours when compared to survivors. This could be due to the severity and characteristics of a head/neck/spine injury, which could result in a serious complication with no way to intervene. Furthermore, compared to total pre-hospital time less than or equal to sixty minutes, total pre-hospital time greater than sixty minutes increases the odds of death within the first 24 hours by four times. This finding is consistent with research from Peru,25 China,24 and Gondar.26 A delay in hospital arrival after an injury may increase the risk of complication and death, which is related to heavy blood loss and major organ damage. Conclusions In conclusion, only one-tenth of road traffic injuries and trapped in wreck victims were removed from the wreck by health professionals. The victims’ most common pre-hospital ambulance care was bleeding control. During pre-hospital trauma care, nearly half of the victims received pre-hospital ambulance care from first responders. More than half of the victims arrived at the hospital after golden hour. 8.4% of the victims studied died within the first 24 hours. The first 24 hours of road traffic injury death were sig- nificantly associated with head/neck/spine injury and total pre-hos- pital time. The establishment and strengthening of advanced pre- Article Table 5. Description of Kampala Trauma Score II (KTSII) and road traffic accident injury severity of victims on arrival to emergency room in Addis Ababa, Ethiopia, 2022. Variable Label Description /Score Frequency Percent (%) Systolic BP >89 mmHg (2) 163 62.2 50 – 89 mmHg (1) 80 30.5 ≤49 mmHg (0) 19 7.3 Respiration rate 10 – 29/ min (2) 151 57.6 ≥30/min (1) 73 27.9 ≤9/min (0) 38 14.5 Neurological status Alert (3) 49 18.7 Responds to verbal stimuli (2) 70 26.7 Responds to painful stimuli (1) 88 33.6 Unresponsive (0) 55 21.0 Serious injuries None (2) 61 23.3 One injury (1) 55 21.0 More than one injury (0) 146 55.7 Age (in year) 5 – 55 (1) 238 90.8 <5 or >55 (0) 24 9.2 Total Kampala Trauma Score Mean (SD) 6(2.5) Kampala Trauma Score Category Mild (9 –10) 50 19.1 Moderate (7 – 8) 69 26.3 Severe/fatal (≤6) 143 54.6 Table 6. Stepwise logistic regression, assessing factors associated with road traffic injury first 24-hour mortality among victims trans- ported by Ambulance to emergency department of selected public hospitals, Addis Ababa, 2022. Variables 24hrs Mortality COR (95%CI) AOR (95%CI) P value Yes No Sites of injury Head/Neck/Spine 10 58 4.55 (1.49, 13.90)* 3.76 (1.29, 10.96)** 0.015 Chest/Abdomen/Pelvic 7 50 3.69 (1.12, 12.18)* 4.31(0.52, 6.48) Extremities 5 132 1 1 Bleeding control Yes 5 109 0.35 (0.12, 0.98)* 0.36 (0.13, 1.05) 0.062 No 17 131 1 1 Total pre-hospital time (minute) ≤ 60 4 123 1 1 >60 18 117 4.73 (1.55, 14.39)* 4.31 (1.39, 13.36)** 0.011 Abbreviations: COR, crude odds ratio; AOR, adjusted odds ratio; CI, confidence interval. NB. 1: reference, *Remained significant at p-value <0.25, **Remained significant at p-value <0.05. [Emergency Care Journal 2022; 18:10745] [page 39] Non -co mmerc ial us e o nly hospital ambulance care, as well as the reduction of pre-hospital trauma time, should be prioritized. 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