الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Summary and conclusion
Injury is a leading cause of death and disability worldwide. According to the World Health Organization (WHO), a human life is lost due to an injury every five seconds (WHO, 2010). Traumatic injuries account for a significant proportion of the global burden of diseases. Despite the overall impact, the burden and pattern of injuries in developing countries are not well known, there have been a limited number of studies addressing this issue and the accurate data from many of the LMICs is usually difficult to find. Because of the lack of data from some of the most impacted countries, the actual number of injuries and its resultant morbidity and mortality is thought to be much higher than the currently available estimates (Bellouni and Ouni, 2019).
Traumatic injuries causing 9% of all deaths worldwide, more than 15,000 people die as a result of injuries every day and about 5.8 million people die from injuries every year. More than 90% of deaths that result from Road traffic injuries (RTI) occur in Low and Middle Income countries (LMICs). It is estimated that about 16% of all disabilities are attributable to injuries. Road Traffic Injuries (RTIs) are the leading cause of injury related deaths among young people aged 15–29 years (Dindi et al., 2019).
The effectiveness of trauma care systems in decreasing injury related morbidity and mortality has been documented and proved over and over again. The first documented evidence dating back to the 1950s during the Korean War, and the 1970s during the Vietnam War, where the time of transportation of injured patients dropped from 4.5 hours to 85 minutes, a corresponding reduction in mortality from 4.5% in World War II to 1.9% in the Vietnam War was recorded (Nathens et al., 2004).
In an effort to address the problem, the WHO started the Global Initiative for Emergency and Essential Surgical Care (GIEESC) in 2005. Measuring gaps in surgical capacities in LMICs has been a priority of the GIEESC. To facilitate this, the WHO has developed a standardized situation analysis tool, which has been used for situation analysis in more than 32 countries and studied and validated by third party institutions (Kushner et al., 2010).
The purpose of this study is to understand the impediments to establishing an acute care center meeting the WHO’s guidelines for essential trauma care in Egypt, as an example of a middle income country, To highlight on the pre-hospital emergency services and the emergency services introduced by the emergency department of Beni-Suef hospital to the injured patients, their prognosis and their satisfaction towards the emergency services. Also, to identify to what extent the blood banks fulfill the international standards put by the WHO.
Study type:
A cross-sectional analytical study was conducted to assess the emergency health services in the hospitals and the blood banks of Beni-Suef governorate. Quantitative and qualitative study methods were applied.
Study Settings:
A-The study was planned to be carried out in all hospitals in Beni-Suef governorate as following:
1- The governmental hospitals that belong to the ministry of health.
• General Hospital
• Six District Hospitals: El-Wasta Central Hospital, Naser Central Hospital, Beba Central Hospital, Somosta Central Hospital, Ehmnasia Central Hospital and El-Fashn Central Hospital
2- Health Insurance hospital (HIO) is located in Beni-Suef city; they are tertiary care hospitals and pooling nearly all areas of the governorate.
3- Beni-Suef University Hospital :It belongs to the Ministry of Higher Education; it is located in Beni-Suef city and is considered tertiary care hospital.
4- Four hospitals from eight private hospitals were selected randomly from all Beni-Suef district private hospitals that are working under the supervision of the ministry of health. They included: El-Gazeera Private Hospital, Saint Traiz Private Hospital, El-Salam Private Hospital and El-Da’wa Private Hospital
B-There are two blood banks in Beni-Suef governorate. The regional blood bank and university hospital blood bank both were included in the study for assessment of blood safety and transfusion services.
The target population was classified into two groups as follows:
1- The health workers in the studied hospitals in Beni-Suef governorate to fulfill the WHO guidelines questionnaire.
2-The attendants of the emergency department in the Beni-Suef university hospital. The study subjects were withdrawn from the attendants of the emergency departments. The average number of all attendants of the emergency department is 500 patients /day. While the average number of injured patients is 26 patients/ day. The emergency department of Beni-Suef university hospital during the study was working two days per week. So the total number of the studied injured patients was (n=632). They were attending the emergency department in the period from January to March 2018. All the assigned subjects (or their relatives) of the study were interviewed to fulfill the questionnaire.
Study results:
I-Regarding the assessment of the emergency and essential surgical care services in Beni-Suef Governorate’s hospitals on WHO guidelines (WHO Integrated Management for Emergency & Essential Surgical Care (IMEESC)), it was summarized that:
• The university hospital is the main sector for the total number of admissions followed by the general hospital. The outpatients of the university hospital receive the highest number of patients followed by the general hospital. The main health care caterpillars in Beni-Suef governorate are the university and the general hospitals.
• The running water and the electric source are available in all the studied hospitals all the time (100%). The studied hospitals have no complete medical records or data collection system. Regarding the availability of an emergency care unit, postoperative care unit, they are found in all the studied hospitals (100%). Unfortunately, there are no management guidelines available for emergency care in all the studied hospitals. Only the university and the general hospitals (15.4%) have anesthesia and pain relief guidelines. All the studied hospitals have laboratory and radiological facilities for urine, hemoglobin and functioning pulse oxymeter all the time.
• There are limited availability of specialized surgeons, Anesthesiologists and Obstetricians/Gynecologists in the university (30 qualified surgeons) and the general hospitals (28 qualified surgeons) but there is shortage in the HIO and district hospitals (mean 5 qualified surgeons). The private hospitals can bring any specialists at any time as they can afford for the cost of the service on expense of the patients. There are no non-specialized physicians can provide surgical or anesthesia in any of the studied hospitals.
• All major and minor surgical interventions could be done in the general (7.7%), the university (7.7%), the HIO hospital (7.7%) and the private hospitals (30.7%). Regarding the district hospitals depends more on the referral to the university hospital or the higher care levels that belongs to the health insurance system, almost outside Beni-Suef governorate.
• All district hospitals and HIO (53.9%) of the sample do not provide acute burn management.
• All hospitals offer Dilatation and Curettage, vacuum extraction and cesarean section but the obstetric fistula repair only offered by the university, general and the private hospitals (46.2%) and the district hospitals in addition to HIO transferred those patients with fistula repair to other hospitals because of lack of skills and lack of supplies.
• District hospitals don’t provide tubal ligation or vasectomy (46.2% of hospitals).
• District hospitals don’t provide abdominal wall defect, colostomy, imperforate anus, intussusception because of lack of skills and supplies. District hospitals don’t provide clubfoot repair because of lack of skills. All hospitals stock vaginal speculums.
• District hospitals (46.2% %) don’t have stock of eye protection equipment. District hospitals, private and HIO hospitals (61.5%) don’t have stock of protective gowns in the emergency department; however, they are available in the operating rooms.
• District hospitals (46.2%) don’t have stock of do not stock Magill forceps (adult or pediatric).
• District and HIO hospitals (53.8%) don’t have stock of cricothyroidotomy sets.
• The general (7.7%), the university (7.7%) and the private hospitals (30.75) have all surgical care supplies and equipment 100% availability all the time. There are shortages of highly specialized supplies in the HIO and the district hospitals as Magill forceps, chest tube insertion equipment and cricothyrodotomy set.
II-Regarding the results of focus group discussion, it was felt from these FGDs that first group in the district hospital wasn’t satisfied with the emergency services in the district hospital due to lack of supplies and specialists and they do not know about the pre hospital services or emergency services but, the private hospital group saw that the general health services don’t satisfy them because of over crowdedness and they saw that they should pay to gain more services finally the university hospital group were satisfied as they saw that the university hospital contains all qualified specialists and most of required investigations.
III-Regarding the self-structured questionnaire for pre-hospital and hospital emergency services assessment among the injured patients admitted to Beni-Suef university hospital:
• It was found that mean age of the studied subjects was 24.9±17.9 years. There was an overall predominance of males among the studied subjects (67.4%). The majority of the studied patients (70.7%) were rural inhabitants and urban residence was (29.3%).
• There were 546(86.4%) of injured patients conscious and 86(13.6%) unconscious also 173(27.4%) of questionnaires were filled from patients themselves and 459(72.6%) were filled from relatives or attendees. Most of accidents were dangerous (60.1%) and the injury itself was severe in 60.3%.
• About one third (35.3%) of the studied injured patients were transported to the hospital by the mean of the ambulance and about two thirds (65.2%) didn’t try to call the ambulance. This was explained by the fear of the ambulance may coming late (37.1%), having mean of transportation (16.7%) and the injury was simple (13.6%).
• from all patients 220 who reached to the hospital via ambulance, there were (88.1%) who were asked for the type of accident or injury. There were (70.9%) of participants satisfied with the ambulance service meanwhile (29.1%) were unsatisfied.
• Regards the first aids were done for injured patients, from all 632 participants there were only (1.6%) of patients who received an ambulance services as suturing and bone fixation. Unfortunately, there were no patients or their relatives trying hospital contact.
• There were (67.6%) of the injured patients delay from occurrence of the accident till the hospital entry. The main cause of delay was previous hospital visit and referral to university hospital (63.5%) followed by deficient of transportation (15%) then ambulance delay 63(14.8%).The duration of delay from occurrence of the accident and reach the hospital was 2.7±1.7 hours.
• It was obvious that about half of the studied injured patients (42.9%) were referred from another hospital to Beni-Suef University hospital. Majority of cases (53.9%) were referred because of the closed other emergency departments in the other hospitals followed by lack of supplies (28.4%) in the health facility whereas, (13.3%) were referred due to absence of specialized physicians while (3.7%) of them couldn’t pay for the expensive cost in the private hospital and only (0.7%) of cases didn’t find empty ICU beds. Majority of cases (77.9%) weren’t transported from another hospital by the mean of the ambulance to Beni-Suef University hospital while, only (22.1%) were transported by it.
• There was only (1.6%) of the studied injured patients had difficult prolonged administrative procedures for entering the emergency unit. 1.7% of the studied injured patients had to wait 0.86±0.3 hour to see a specialized physician.
• There were (11.4%) of cases who needed blood transfusion and only (41.7%) of the needed blood was brought by the hospital and the remaining was brought by patients’ relatives (58.3%).
• Majority of blood (85.7%) was offered by the university hospital center and only (14.3%) was offered by the local center and almost of the needed blood was found fast (97.6%) but (2.4%) of cases was difficult to be obtained due to rarity of the ABO group.
• There were (16.5%) of cases who needed urgent surgical operation. 59.6% of the studied injured patients had to wait 1.6±0.12 hour to receive an urgent surgical management.
• There was only 3.2% of the studied injured patients who needed an urgent surgical operation delayed due to physicians’ delay while, the majority of cases, the unsuitable condition of the patient was the cause of delay (64.5%).
• Majority of cases had a good prognosis after the emergency care either conservative or operative management (87.2%)
• There were (10.1%) of patients needed external drugs or accessories. Regards the patient and or relatives’ satisfaction with emergency services; 89.2% were satisfied with the emergency services and (10.8%) unsatisfied due to; delay of the service (48.5%), ignorance and bad dealing (17.6%), shortage of drugs or accessories (25%) and absence of ICU places (8.8%).
• Regarding the difficulties in emergency services; patient transfer was difficult in (51.7%) of patients, hospital entrance procedures were complicated in (0.2%) of patients, health service itself as (delay-ignorance-shortage of supplies -unsanitary environment-no ICU places) in (9.2%), shortage of drugs or accessories was in (1.3%) of patients, the incident itself was the most difficult thing in (27.8%) of patients for themselves or their relatives but (9.8%) of patients didn’t face any difficulties at all.
• There was a significant difference in prognosis of the studied cases regarding their consciousness level at admission, severity of injury, the need to blood transfusion and the delay of surgical intervention.
• For prediction of bad prognosis of injured patients from the listed independent variables, it was found that the unconscious patients, patients with severe injury, patients who needed blood transfusion and patients delayed till the operating room entry were more susceptible to bad prognosis with odds ratio (2.01, 11.7, 1.2 and 10.7), respectively.
• For prediction of the determinants of ambulance use from the socioeconomic characteristics, it was found that the following parameters: urban residence, working injured patients and the unconscious patients determined the use of ambulance with odds ratio (1.9, 6.6 and 4.9), respectively.
IV-Regarding the WHO questionnaire for assessment of the integrated strategy for blood transfusion safety, it was concluded that:
• The officially recognized and the nationally coordinated blood transfusion service (BTS) found in both banks.
• There is a national blood policy but it is highly implemented in the regional blood bank than the university blood bank. There is a national BTS management committee in both banks. There is no an advisory group of blood transfusion in the university hospital blood bank but it is active in the regional blood bank
• There is a medical director responsible for the BTS in both blood banks. Also there is a national quality system in both banks.
• There is no a specific officer responsible for quality assurance in the university hospital bank but there is a quality assurance system in the regional blood bank. There is adequate number of trained administrative staff in the regional blood bank only. There is a specific budget provided for blood transfusion services in both banks.
• There is a mechanism for calculating total BTS costs in both banks. The approximate cost in US$ of producing one unit of whole blood is approximately 10 dollars (about 170 LE) in both banks. Also there is a system of stock control in both banks.
• There is partial shortage of the general supplies in the last 12 months in the university bank only.
• Concerning the responsibility for the management of blood transfusion services, the governmental hospitals were responsible for more than 90% of the services and the private hospitals were responsible for the minority of the services.
• There is a specific department responsible for all activities related to blood donors in both banks. All donors have a haemoglobin estimation done before donation in both banks. There is a system of blood donor counseling in both banks. There is a system of blood donor records in both banks (paper in the university blood bank but computerized in the university bank).
• Most of donations are collected from family and replacement donors. The prevalence of transfusion-transmissible infections is calculated in the blood donor population in both banks. Both banks have a national strategy on blood screening. There is a confidentiality of blood donors assured in the laboratory of both banks.
• There is a full-time availability of test kits/reagents in both banks.
• All blood donations are tested for HIV, HBV (HBsAg), HCV and Syphilis. HIV tests are performed by EIA (ELISA). The distribution of prevalence of HIV (1%, 1%), HBV (2%, 1.5%), HCV (4%, 3.5%), syphilis (0.5%,0.5%) and Chagas (0%) was almost equal in the university and the regional blood banks respectively.
• The total percentage of blood discarded after testing for transfusion-transmissible infections is about 5% in both banks. The compatibility testing routinely performed before transfusion in both banks. There was no participation of both banks in the external quality management on the either on the national or the regional levels.
• there are standard operating procedures in both banks. The blood and blood products are stored in temperature-monitored cold storage equipment both banks.
• The temperature is monitored in boxes used for the transport of blood and blood products in both banks. The reagents stored in temperature-monitored cold storage equipment in both banks. There is a national policy and/or guideline on the clinical use of blood for both banks. There is a system for monitoring/evaluating clinical transfusion practice (audit) in both banks. The post-transfusion reactions monitored and reported by both banks. The blood is transfused as whole blood constitutes 90 % for all transfusion done by both banks but, there is no colloids available as alternative to blood products in both banks.
• There was no post-transfusion follow up of infection in both banks. The percentage of hospitals with hospital transfusion committee was unknown for both banks.
• the blood coagulation factors (e.g. Factor VIII, Factor IX, prothrombin complex concentrate) are partially produced by both banks but, there are no other fractionated plasma-derived medicinal products produced by both banks.
• There are other facilities in Egypt for plasma fractionation and both banks referred the cases that need the plasma fractions to the blood banks in Cairo.
• There are 7000 liter of recovered plasma in the university blood bank and 6500 liter in the regional blood bank but, there were 500 liter of the apheresis plasma in both banks.
• In spite of the availability of the WHO learning materials, Safe Blood and Blood Products, available and in use, there is a shortage in some of the training courses in the university blood bank but the training process in the regional blood bank is available at different levels.
• There is availability of the WHO learning materials, the Clinical Use of Blood in both banks. In spite of the presence of the national regulations/legislation and authority for covering blood transfusion, it is not highly applied in the university hospital blood bank but, it is well applied in the regional blood and supervised by the ministry of health.
• There is a system of regular inspection of blood transfusion services in both banks but it is not done by specialized inspectors in the university hospital blood bank.
• There is a computerized system for data management in the regional blood bank but it is still not developed in the university blood bank. Both blood banks are in need for more training to increase the capacity building of human resources. There was no a program for data consolidation in the university blood bank.