Abstract
Background:
The World Health Organization predicts a striking rise in the burden of traumatic brain injury (TBI) burden in the next decades. A disproportionately large increase is predicted in low and middle income countries, which have brain injury rates three times higher than high income countries. The aim of this study was to identify current TBI practices and treatment capacity in three LMICs: Republic of Armenia, Georgia and Republic of Moldova.
Methods:
After a national inventory of hospitals treating TBI, a situational analysis was conducted in the highest volume adult and pediatric hospital in each country. The situational analysis included key informant interviews with content analysis and a quantitative checklist of treatment resources.
Results:
All three countries follow international, national and hospital protocols for TBI treatment, and the in –hospital management of patients with TBI is similar to international standards in all three countries. Although healthcare specialists were well trained, however, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas and lack of rehabilitation services were mentioned in interviews from all three countries.
Conclusions:
Particular gaps were found in pre-hospital and rehabilitative care, as well as national leadership and data collection. Surveillance and standardized data collection are important measures to fill treatment gaps and reduce the burden of TBI.
Keywords: acute care, Low and Middle-Income Countries, pre-hospital care, rehabilitation services, Traumatic Brain Injury
INTRODUCTION
The burden of Traumatic Brain Injury (TBI) disproportionately affects Low- and Middle Income Countries (LMICs), as patients from LMICs are twice as likely to die following TBI as in High-Income Countries.1 The World Health Organization predicts a striking rise in the TBI burden in the next decades, with a disproportionately large increase in LMICs, having three times more TBI-cases than High Income Countries2,3 TBI is predicted to become the third major cause of disease morbidity by 2020.4 The burden is particularly high among children and young adults, whose TBIs can lead to severe individual and family disruption and life-long disability.3
Both in the United States and in Europe,2,5 2.5 million reported cases of TBI are estimated annually, out of which more than 1 million will require medical care. However, many LMICs lack standardized monitoring and surveillance of TBIs and data registries, which hinders capacity to identify, implement, and evaluate prevention and intervention programs or to develop and evaluate standardized treatment guidelines.5–9 Many factors influence the outcome of TBI ranging from individual factors (age, mechanisms and severity of injury) and systems-level factors (pre-hospital care, specialty treatment, access to rehabilitative care).10 At the sociopolitical level, policies can influence prevention activities, organization of treatment from the pre-hospital through rehabilitation, and access to care for the population.
In LMICs, documentation on the impact and outcome of TBI is limited. Hospital patient surveillance has focused mostly on communicable diseases, which are an important priority for health systems in transition, but have also led to neglect for other patient surveillance priorities, such as trauma and TBI.11–13
Three LMICs were the focus of this study: Republic of Armenia, Georgia, and the Republic of Moldova. These countries are located between Europe, Russia, and the Middle East, and each has a centralized healthcare system. Republic of Armenia and the Republic of Moldova have a health care system that is in transition, being a combination between privatized healthcare and some remains of the Soviet Semashko-style carried over when they were part of the Soviet Union.11,13,14 Georgia’s health care system has evolved more and includes both state and private financing and mainly private healthcare provision.12 All three countries have struggled through various reforms in order to raise the accessibility and quality of the healthcare services and are striving to reduce the burden of TBI.11–20
The objective of this study was to identify and describe current TBI data collection practices and capacity in three LMICs: Republic of Armenia, Georgia and Republic of Moldova as part of a larger study whose major goal is to assess and build TBI research capacity in order to systematically prevent, treat, and optimize recovery from TBI.
MATERIALS AND METHODS
Study design and sample
This study was conducted as part of the INITIatE Project (International Collaboration to increase Traumatic Brain Injury Surveillance in Europe; NIH/NINDS R21 NS098850) which aimed to assess and build TBI research capacity in Republic of Armenia, Georgia, and Republic of Moldova. These countries were chosen based on their high TBI rates, similar basic medical systems, and their participation in an NIH-funded injury and violence prevention training grant (NIH/FIC D43 TW0007261). The objectives of the project were to understand data and treatment capacity and national leadership for TBI, and to establish TBI registries. This manuscript reports findings on TBI data and treatment capacity for adult and pediatric TBI patients in Republic of Armenia, Georgia and Republic of Moldova.
A national hospital assessment was conducted to identify the trauma hospitals treating the highest volumes of adult and pediatric TBI patients and using the levels of trauma-care capacity according to the classification system of the American Trauma Society.21 Hospitals were selected for inclusion based on the volume of TBI patients, if known, or volume of overall patients, if not, and operating as a level I or II trauma center (Table 1). We excluded all hospitals that were not operating as level I or II trauma center, and we aimed to have at least one hospital operating as level I trauma center if it was existent in the country. The last inclusion criteria was determined by the openness of the selected hospitals to participate in the study. One adult and one pediatric hospital in Republic of Moldova and Georgia and two mixed (adult and pediatric) hospitals in Republic of Armenia were included for participation.
Table 1.
Hospital assessment
| COUNTRIES | ||||||
|---|---|---|---|---|---|---|
| Republic of Armenia | Georgia | Republic of Moldova | ||||
| No of existent hospitals’ | No of hospitals included in the study | No of existent hospitals’ | No of hospitals included in the study | No of existent hospitals’ | No of hospitals included in the study | |
| Level I Trauma Center | 3 | 1 | 8 | 2 | 0 | 0 |
| Level II Trauma Center | 2 | 1 | 4 | 0 | 3 | 2 |
The hospitals from Republic of Moldova included in the study are The Emergency Medicine Institute and The Municipal Children Clinical Hospital „Valentin Ignatenco.” Both are government-owned hospitals located in the capital city, Chisinau, and serve as the main trauma hospitals for the country of 3,5 million residents. The Emergency Medicine Institute treated more than 77,000 patients in 2018, out of which more than 25,000 were admitted for traumatic injury. The Municipal Children’s Clinical Hospital treated more than 46,000 children in 2018, out of which 11,000 were due to injuries.
The hospitals from Georgia included in this study are Gudushauri Hospital and Iashvili Children’s Central Hospital, both private hospitals located in the capital city, Tbilisi. Both hospitals offer services for the 1,175,200 inhabitants of the city, and they also act as regional trauma hospitals for referral for the 3,716,900 inhabitants of Georgia. Gudushauri Hospital is an adult hospital that in 2018 treated 8,723 patients, of which 328 were diagnosed and treated for TBI. Iashvili Hospital is a pediatric hospital that in 2018 treated 2,992 patients of which 296 had a TBI diagnosis.
The hospitals from Republic of Armenia are Armenia Republican Medical Center (ARMC) and Izmirlian Medical Center (IMC), both located in the capital, Yerevan. Both hospitals admit adults and children. Armenia Republican Medical Center serves the entire population of 2,965,000 of the republic, while officially Izmirlian Medical Center only servers 1,075,000 people from Yerevan but they will admit all patients in need of medical services. Armenia Republican Medical Center is operated by the Ministry of Health and in 2018 had 13,745 admissions, with 589 injuries of which 94 had a TBI diagnosis and 85 with spinal injuries. Izmirlian Medical Center is a private hospital operated by a church, and in 2018 had 6,533 admissions of which 980 were traumatic injuries.
Study Protocol
A situational analysis was conducted to identify capacity in the leading trauma hospitals. The situational analysis included key informant interviews with content analysis and a quantitative checklist within the leading trauma hospitals. A Standard Operation Procedure (SOP) was developed containing the steps of the situational analysis, the script for the interview guide, the semi-structured interview guide with open-ended questions about capacity, leadership, resources and policies, and the quantitative checklist. Interviews with key-informants were conducted by one research assistant for each hospital trained in data collection procedures beforehand. Key-informants included healthcare providers or administrators in the neurosurgery or emergency medicine departments and had experience working with TBI patients in their daily job. Healthcare providers also had experience in pre-hospital care. At least two key informant interviews including a healthcare providers in the emergency medicine and neurology, as well as an administrator from each hospital, were conducted (Table 2). Participants were senior members of the hospital staff. Each participant also completed a quantitative checklist to identify the resources and protocols for treatment. This project was deemed non-human subject research because no information about individual patients was collected. Except for their profession, no other identifiable data was collected from the key informants during the interviews. Moreover, only the research team had access to the data and their responses were not shared with their employers.
Table 2.
Number of respondents participating in the interviews**
| Republic of Armenia | Georgia | Republic of Moldova | |
|---|---|---|---|
| Medical Doctor | 2 | 2 | 5 |
| Resident Doctor | 0 | 2 | 0 |
| Nurses | 1 | 0 | 0 |
| Leadership position | 2 | 0 | 2* |
| Total no of interviews | 5 | 4 | 7 |
includes chief-nurse, and head of neurology department.
Interview occupation is not nested within hospital to avoid potential for individual identification.
Data Collection
Key informant interviews and the quantitative checklist were organized around pre-hospital care, in-patient care and rehabilitation in order to identify which are the existing practices and policies on TBI treatment and rehabilitation in the three countries. The pre-hospital care component focused on any emergency medical service before arriving at the hospital in order to identify any trauma surveillance system that can be used to further document TBI treatment and care and how the pre-hospital system is organized and how it works. The acute-care component focused on admitted patients that received active but short-term treatment for a TBI, the treatment frameworks, if any, hospital care facilities for TBI patients and the flow of patients with TBI. The rehabilitation component focused on any services aiming to help patients improve their physical, mental, and/or cognitive abilities after the TBI, the discharge information mainly for severe patients who needed long-term care and specialized care. Additionally, the key-informants had the opportunity to identify any gaps in treatment and care, and discuss about additional resources that they have to learn, treat and care for patients with TBI.
Interviews were conducted in the national language of each country by interviewers with medical and public health backgrounds. Before the interview, all respondents were provided information describing the aims of the study, the risks, confidentiality and seeking permission to audiotape the discussion. With the permission of the key-informants, the interviews were audiotaped and the interviewer took notes during the interview. The recording was to accurately record the information provided and was used for transcription and translation purposes only, respecting the ethical clearance and hospital requirements in each of the setting. Interview recordings were transcribed and notes were compiled by the interviewer, and these were coded based on a data collection and coding procedures developed as part of the INITIatE Project. Each interview was coded to capture main points, and then interviews were compared to capture common themes. Double-coding was conducted until high reliability (above 95% agreement) was met.
Analysis
For the qualitative analysis, the interviews were translated in English by the research staff collecting the data. Transcribed interviews were reviewed to develop and broaden the understanding of the content as related to project-specific questions and to identify discussion themes. Using inductive methods, text segments were assigned codes on the basis of emergent themes or themes extracted from the interview guide, by two bilingual researchers. The researchers coded all the interviews using the codebook to establish consensus reliability, whereby findings were compared and disagreements resolved through discussion.
Data from the quantitative checklist was aggregated and analyzed using Excel to identify distributions.
RESULTS
Results of the interviews emerged in four main themes and several sub-themes presented in Table 3. The main themes revealed from the interviews are: pre-hospital care practices, acute care practices, rehabilitation services for TBI management, TBI resources, and Gaps in TBI treatment and care.
Table 3.
Themes and sub-themes
| Theme | Sub-theme |
|---|---|
| Pre-hospital care practices | Transportation decisions and transfers Transport of patients practices Limitations of emergency services |
| Acute care practices | Protocols of care Resources of care Expertise of medical personnel |
| Rehabilitation services for TBI management | Existent rehabilitation services Gaps in rehabilitation services |
| TBI resources | |
| Gaps in TBI treatment and care | Gaps in primary prevention Lack of equipment Lack of trained healthcare providers Lack of resources and medication |
Pre-hospital care practices
In all three countries pre-hospital management of all patients, including TBI, rely on the ambulance service as first responders (Table 4). All three countries have adopted 112 as a universal emergency number organized by the Center for Emergency Coordination.22 The initial triage is made by the dispatcher, who sends an ambulance with the necessary equipment, based on the triage assessment, to stabilize and transport the patient to a medical facility. The transportation to medical facilities is usually done with land ambulances, and helicopters are available for military zones in Republic of Armenia and rarely used for very urgent cases in Georgia and Republic of Moldova. In the two largest population centers in Republic of Armenia, Yerevan and Gyumri, ambulance companies operate independently. In the remaining regions of Republic of Armenia, the ambulance services are coordinated by the local medical centers. In Georgia and Republic of Moldova, the ambulance system is coordinated by the Ministry of Health, under the Center for Emergency Coordination and Ambulance Service. In all three countries, some private hospitals have their own paid ambulance services and in Republic of Armenia a private company, contracted by the Ministry of Health since 2018, offers some limited helicopter ambulance services.
Table 4.
Pre-hospital care assessment
| COUNTRIES | |||
|---|---|---|---|
| Pre-hospital system | |||
| Organized | Ambulance | Ambulance | Ambulance/AVIASAN |
| Unique emergency no | 112 | 112 | 112 |
| Ambulance team | |||
| physician | Yes | Emergency physician/not always | |
| paramedic | Yes | Emergency technician | |
| nurse | Yes | Yes | Yes |
| driver | Yes | Yes | Yes |
| TBI patient transport | |||
| Ambulance | Yes | Yes | Yes + AVIASAN* |
| Private car | Yes | Yes | Yes |
| Helicopter | Yes | Yes | Yes |
| Patient destination | |||
| Nearest facility | Yes | Yes | Yes |
| Resources | Yes | Yes | Yes |
| Insurance | No | Yes | No |
| Pre-hospital categorization and triage | |||
| Triage protocol | Yes - Glasgow | Yes - ABC | Yes - ABC |
| Yes | No | No | |
| Inter-hospital transfer | |||
| Transfer protocol | No | No | No |
| Frequency** | Frequent | Rarely | Rarely |
| Reasons for transfer | Equipment, specialists, surgery needed | Patients’ wishes; Lack of specialized services in rural areas | Equipment, specialists, surgery needed |
special emergency service provided by the Republican Clinical Hospital for specialized emergency care for cases admitted to hospitals in territories
frequency was defined/was measured
The ambulance staff slightly differs between the three countries: in Republic of Armenia and Georgia the ambulance always has a physician or a paramedic, a nurse and a driver, and the Republic of Moldova the ambulance usually has an emergency technician and a (less trained) medical assistant. Furthermore, depending on the initial triage of the dispatcher, an emergency doctor or even a cardiologist/intensive care specialist may be sent to the scene. In the Republic of Moldova, the Ministry of Health, Labor, and Social Protection identifies hospitals that are eligible to receive trauma cases, and the field emergency physician makes the transport decision. In Georgia and Republic of Armenia, ambulance providers have flexibility in transport decisions. Some ambulance companies have agreements with different hospitals, therefore transportation is based on where these agreements are established, as well as on distance to nearest hospital and available hospital beds.
Transport is influenced by the severity of the injury, and respondents reported both over- and under-use of emergency transport. Most mild TBI patients that do not require ambulance transportation arrive at the hospital by private vehicle, and the majority of severe cases arrive by ambulance. However, respondents in Republic of Moldova mentioned overused of the ambulance service by mildly injured patients.
“Transport by ambulance should be when the patient is severe, but sometimes they are brought with the ambulance even those with a mild scratch that we end up wiping with a napkin, not even a tegument penetration. I can’t understand why; each ambulance-transport costs money
[Neurosurgeon, Republic of Moldova]
Respondents in Republic of Armenia and Republic of Moldova commented on concerns when severely injured patients, including TBI and spinal injuries, are transported by relatives or witnesses who are not aware of field care or transport practices. Under-use of emergency transport is considered to be a direct consequence of the low health-literacy of the general population.
“If a simple car will take the patient and drive for 10 minutes with him, nothing will change, yet he/she will not know how to immobilize him. If there’s a backbone fracture it’ll raise it and leave it invalid.”
[Emergency technician, Republic of Moldova]
“Very commonly patients arrive on their own and even more commonly friends and family bring them in. This is probably some mentality issue, when something happens neighbors and friends just get the patient in the car without thinking about the consequences. Also, people don`t take traumas seriously.”
[Neurosurgeon physician, Republic of Moldova]
“If injury happened close to a hospital family members or friends, or even random people in the street will gather and decide how and where to take that patient. But of course, that is not a right thing to do.”
[Emergency physician, neurosurgeon, Republic of Moldova]
The patients are transported with ambulances to the nearest hospital, based on the resources available. For Georgia, the component of insurance and patients’ choice in some cases, are influencing factors as well.
Several limitations regarding the patient transportation were described in Republic of Armenia: the main obstacle was considered to be the geographical aspects as mountain roads especially during winter, followed by, the main localization of the hospital within the capital which might worsens the prognostic of the TBI-patient due to the longer response time and transportation time:
“If somebody is injured in Hamzachiman [a remote urban area to the north of Yerevan], they sometimes even cannot get help from a medical professional/general practitioner, the best option that they have is a paramedic, and the closest hospital is in 1–2 hour driving distance.”
[Medical Doctor, Republic of Armenia]
Transfers between the hospitals have been reported to be rarely done in Georgia and Republic of Moldova, while in Republic of Armenia are considered to be frequent and towards a hospital located in the capital Yerevan from the territories. The reasons for transfer were: lack or damaged equipment, family wish, need of surgery or TBI/spinal specialist.
Acute-care practices
In all three countries acute care management begins in the emergency department by a multidisciplinary team, guided by various protocols (Table 5). In Republic of Armenia and Georgia both international and national guidelines are followed, and in the Republic of Moldova national protocols are implemented. A particular aspect regarding Georgia and Republic of Armenia is that each hospital usually decides which protocol to follow for acute care management, as a result of the privatized healthcare system, resulting in different protocols being used for similar cases.
Table 5.
Acute care management and guidelines
| Republic of Armenia | Georgia | Republic of Moldova | |
|---|---|---|---|
| Acute care management | ED* | ED | ED |
| Implemented protocols and standards | |||
| International guidelines | 100% | 100% | 100% |
| National guidelines | 100% | 100% | 100% |
| Hospital guidelines | 100% | 100% | 100% |
ED – emergency department
In the Republic of Moldova, the existing frameworks are based on national requirements developed by the “Ministry of Health, Labor, and Social Protection”. The protocols are usually made by specialists affiliated with university departments and not by the neurosurgeons. Subsequently, respondents reported difficult situations in which they do not feel it is best for the patient to follow protocols. In these cases, a Commission is assigned to include a professor, the head of the department, a neurosurgeon, and a surgeon to decide the best therapeutic approach. The Commission’s decisions are protected legal repercussions.
“(…) make a council consisting of a professor, a head of department, a surgeon and a neurosurgeon; And here the council beats any standard or protocol. That’s what we do in all serious cases to protect ourselves from the legal point of view.”
[Neurosurgeon, Republic of Moldova]
Rehabilitation services for TBI management
All respondents identified a lack of rehabilitation services for TBI patients. In Republic of Armenia, the existing rehabilitation system focused on acute physical recovery, with no cognitive or mental rehabilitation services in place. An exception is a Veteran’s Center under the administration of the Yerevan State Medical University offering rehabilitation services to military personnel. Children under the age of 14 can receive rehabilitation services provided by the network “Arbes” and an additional resource is the Red Cross Foundation in Yerevan. In case of severe injuries, the patients are advised to go to specialized centers, while for mild injuries the rehabilitation is followed-up by the neurologist as an outpatient.
“Of course TBI patients need rehabilitation, but I don`t think that available services are enough to provide most patients with the rehabilitation they need. […] There are a lot of patients that need psychological help, or with limited movements that need physical rehabilitation. I don`t know any rehabilitation centers that will provide the whole range of rehabilitative services.”
[Emergency doctor, Republic of Armenia]
In Georgia the main gaps stated were: the financial availability, “as the services are not covered by the government nor the private insurance providers” the quality of the rehabilitation services and the few hospitals providing it. Quality of care and financial availability were mentioned as gaps to access rehabilitation care for patients with TBI. In the Republic of Moldova, the responders stated that there is no specialized rehabilitation for TBI patients and the only three public hospitals that provide rehabilitation services are the “Institute of Neurology and Neurosurgery, Republican Experimental Center Prosthesis, Orthopedics and Rehabilitation, and the Municipal Clinical Hospital “Sfânta Treime”, all located in the capital city.
All respondents mentioned that the hospitals do not have full capacity to address all patients who need rehabilitation care, therefore patients sometimes receive care from private clinics. In most of the cases the recommendation for rehabilitation is made by the general practitioners:
“But people who suffered trauma practically receive rehabilitation very rarely. There are about 20 beds at the Institute of Neurology and Neurosurgery for national coverage. There is also the former Krepor Factory, now it has been turned into a rehabilitation service, called Republican Experimental Center Prosthesis, Orthopedics and Rehabilitation. Thus, there are going to private centres, the patients are addressing themselves, through the family doctor or other ways”
[Chief of Neurosurgery, Republic of Moldova].
TBI resources
The existent resources for TBI surveillance and treatment in each hospital from all the three countries are presented in Table 6. The Ministries of Health are the regulatory body for national policies and frameworks regarding the care and treatment of TBI patients in all three countries (Table 7). Research funding in Republic of Armenia and Republic of Moldova is mainly provided by national bodies, while in Georgia funding is mainly from international bodies, through competitive calls for proposals.
Table 6.
TBI surveillance and treatment resources
| Republic of Armenia | Georgia | Republic of Moldova | ||||
|---|---|---|---|---|---|---|
| ARMC | IMC | Adults | Pediatric | Adults | Pediatric | |
| Number of neurologists available | 11 | 2 | 2 | 10 | 18 | 2 |
| Neurologist work schedule | 24h | 24h* | 24h | 24h | 24h** | 8AM - 3:30PM |
| Number of neurosurgeon available | 8 | - | 3 | 10 | 9 | 5 |
| Neurosurgeon work schedule | 24h | - | 24h | 24h | 24h | 24h**** |
| Number of radiologist available | 5 | 10 | 3 | 2 | 18 | 4 |
| Radiologist work schedule | 24h | 24h* | 24h | 24h | 24h*** | 24h***** |
| Number of ENTs available | 10 | 6 | Only on call | 7 | 1 | 5 |
| ENTs work schedule | 24h | 24h* | On call | 24h | 24h** | 24h****** |
| CT scans available | Yes | Yes | Yes | Yes | Yes | No |
| Availability schedule for CT scans | 24h | 24h | 24h | 24h | 24h | - |
| MRI devices available | No | Yes | No | No | Yes | No |
| Availability schedule for MRI devices | - | 24h | - | - | 24h | - |
| Number of ICU beds | 30 | 8 | 12 | 60 - neonatal unit 40 - pediatric unit |
50 | 20 |
work schedule – 9AM – 5PM, on call 24 hours
work schedule – 8AM – 3.30PM, on call 24 hours
work schedule – 8AM – 3.30PM, on call 24 hours
work schedule – 8AM – 3:30PM, on call 24 hours
work schedule – 8AM – 3:30PM, on call 24 hours
work schedule – 8AM – 3:30PM, on call 24 hours
Table 7.
TBI resources country level
| COUNTRIES | |||
|---|---|---|---|
| Treatment | |||
| Ministry of Health level* | Yes | Yes | Yes |
| Ministry of Health level* | Yes | Yes | Yes |
| Ministry of Health | No | No | Yes |
| Ministry of Education | Yes (limited) | Yes (limited) | Yes |
| NGOs | No | No | No |
| International grants | Yes (limited) | Yes | Yes |
| Association of Neurosurgery | Yes | Yes | Yes |
| Association of Neurology | Yes | Yes | Yes |
| Association of Emergency physicians | No | Yes | Yes |
| Association of Hospital | Yes | No | No |
| Managers | |||
| Association of Nurses | Yes | Yes | Yes |
- the ministries of health have different names in each country
In all three countries a National Associate of Neurosurgery organizes scientific sessions on TBI, and, if required, oversees continuing education, although availability of courses on TBI was identified as a gap. In Georgia, one respondent stated that there are no continuous medical education courses regarding TBI prevention in particular, which might be due to the fact that there is no mandatory continuous medical education system in Georgia. Courses are offered by various ministries, medical schools, and non-governmental bodies, and content was reported to focus on pre-hospital care than in-hospital care. Republic of Armenia and Georgia have four, and the Republic of Moldova two, Medical Doctor Associations that would include members with various specialties that work with TBI patients.
Identified gaps in TBI treatment and care
Respondents were asked to identify the biggest gaps regarding the prevention of TBI. The main topics for primary prevention identified in all three countries were “road safety” and “improved health literacy”. The respondents mentioned that stricter road safety policies would decrease the number of traumatic brain injuries. Furthermore, in Republic of Armenia the responders recommended that a stricter driving license exam would reduce TBIs related to traffic. Quality of the roads was also identified as a gap. In Republic of Moldova, the respondents identified more enforcement of traffic safety laws and increased personnel in kindergarten and primary school to supervise children would decrease the incidence of TBI.
All three countries reported that gaps in treatment of TBI included lack of equipment, trained healthcare providers, resources, and rehabilitation. Republic of Armenia also identified lack of hospitals to treat TBI patients (Table 8). Expertise among existing medical personnel was not identified as a gap.
Table 8.
Gaps in treatment and care of TBI
| Expertise of existing providers | ||||||
|---|---|---|---|---|---|---|
| COUNTRIES | ||||||
| Republic of Armenia | Yes | Yes | Yes | Yes | Yes | No |
| Georgia | Yes | Yes | Yes | No | Yes | No |
| Republic of Moldova | Yes | Yes | Yes | No | Yes | No |
Equipment overall was considered to be deficient in all three countries, starting from the pre-hospital care phase, such as C-collars, to lack of adequate diagnostic equipment In Republic of Armenia, the main related issue was the lack of equipment and the scant number of hospitals outside the capital region, thus increasing the time needed for the TBI diagnosis and treatment especially for patients outside Yerevan. If a patient is sent to Yerevan, an ambulance from the hospital located in the capital has to be dispatched, given the fact that is better equipped. However, this situation doubles the time needed for patient transportation, resulting in a worse outcome of the patient.
“If the case is severe, or if the patient may require any form of neurosurgery, one of the better equipped hospitals in Yerevan will be called to retrieve the patient with a team of specialists and a specially equipped ambulance. These specialists will then direct the Goris physicians [where the TBI patient is located] over the phone on which medications and medical procedures to provide while they are in-route. The total journey can be expected to take more than 8 hours - 4 hours and 235 km each way from Yerevan to Goris.”
[Neurologist, Republic of Armenia]
Additionally, shortages of medication was reported in both the capital city of Yerevan and rural regions.
Respondents in Georgia and the Republic of Moldova reported the main gap to be the poor quality and often inoperable equipment including computed tomography scan machines and magnetic resonance imaging machines. The lack of diagnostic and treatment equipment outside the capital areas was noted, such as this quote from the Republic of Moldova:
“All these investigations are done not only here in our hospital, that is a national requirement, but all these investigations are possible only at EMI and INN. Unfortunately, the district hospitals do not have all of these possibilities.”
[Neurosurgeon, Republic of Moldova]
Lack of healthcare personnel, particularly outside the main cities, was a common theme. In particular, lack of specialists such as neurosurgeons, radiologists, and anesthesiologists was mentioned. In Republic of Armenia some specialists and nurses are not available 24-hour a day and most work on-call from home. The respondents stated that the TBI management and treatment would be more efficient if the personnel needed for the treatment and care of TBI patients, for example, radiologists, were available in the hospital at all times. There is a lack of nursing personnel as well (Republic of Armenia):
“In our hospital CT doctors or nurses who are on shift are working “on call”. They are not available at the hospital for 24 hours, so there may be some delays in examination or surgery before everyone would arrive. I think that if specialists who are on shift will be in the hospital for their shift-hours, and not at home waiting for a call from the hospital, that will be so much more efficient for the patient.“
[Neurologist, Republic of Armenia]
“It is different for the districts of the Republic; they need CT, neurosurgeon consultation, and not only. There are no neurosurgeons, where traumatic brain injuries are treated by traumatology. In more complicated cases they are transported directly to the Institute of Neurology and Neurosurgery.”
[Neurosurgeon, Republic of Moldova]
Insufficient expertise of physicians regarding TBI management and treatment outside of the trauma hospitals was noted as a gap, especially since early diagnosis and management are so critical.
DISCUSSION
We examined current TBI data collection practices and treatment capacity for adult and pediatric TBI patients in Republic of Armenia, Georgia and Republic of Moldova. Our results showed that similarities exist between countries even though their health systems are different. While Georgia has moved primarily to privatized healthcare services, the Republic of Moldova and Republic of Armenia have a mix of private and state healthcare that remains from the former soviet system. All three countries follow international, national and hospital protocols for TBI treatment, and the flow of patients with TBI is similar in all three countries. While responses to our interviews tended to offer similar information, some differences in knowledge were observed between respondents, depending on their level on involvement with TBI patients. Their responses showed similar topics for prevention, mainly focusing on road traffic safety and increasing health literacy levels.
Our results show tangible shifts towards improved healthcare services in all three countries, such as implementation of a universal emergency number adopted according to European level standards.23 All three countries have some organized and specialized emergency transport, but none have a coordinated pre-hospital system. In all countries, triage and transport decisions rely on some factors unrelated to patient needs, such as ambulance contracts with hospitals. Both over- and under-use of emergency medical transport was identified. Research shows that such practices are common in LMICs where resources are scarce and pre-hospital care is not properly organized.24,25 Findings from the literature show that it is common for TBI patients in LMIC to arrive at hospital by private vehicles and unaccompanied by trained personnel and stress on the importance of an ambulance system with proper equipment and trained personnel for preventing secondary brain injuries.24 As with many regions, challenges in geography and care organization may delay patient’s arrival at definitive care in a timely manner. Specialized care is concentrated almost exclusively in urban centers, while outer regions lack diagnostic equipment, TBI specialists, and have mountainous regions that challenge transport systems. Use of helicopters for hospital transfers were available in only very limited circumstances in Republic of Armenia, despite the measurable benefits of reducing transport time in TBI outcomes.26
Although healthcare specialists were well trained, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas, and lack of rehabilitation services were mentioned in interviews from all three countries. Similar studies in other LMIC countries show not only the same shortage in critical care supplies and equipment, but also the same problems in infrastructure development.27 These gaps are consistent with findings other from other LMICs, and are present despite evidence that such problems contribute to poorer health outcomes.24,25 Recommendations existent in the literature urge towards available trained personnel and equipment and well-established evidence based systems developed for high level intensive care.24,28 Despite a strong and growing evidence base regarding TBI standard of care, protocols in hospitals indicate that multiple approaches are used and not consistently applied within or between hospitals.29 Rehabilitation services in particular were lacking and nearly non-existent outside of the capital cities. Research conducted in other LMIC showed a lack of access to rehabilitation services, even in well-resourced hospitals.30 These gaps likely impact long term outcomes severely, especially in guiding long-term independence and return-to-work.24
National leadership in TBI care can support integration of best practices. Lack of continuous education regarding TBI prevention can offer a window of opportunity for development of TBI treatment and care, by training specialized personnel in the TBI field, since the institutions meant to offer such courses are present in all three countries. All three countries have national legislation on continuing medical education and courses on TBI prevention would help covering some gaps identified in our research. Despite the fact that no overarching legislation regarding continuing medical education exists in Europe, physicians still belong to the same profession, share the same principles and professional practice and could benefit from continues training on TBI.31 Research conducted on this topic shows that personnel training and continuing education are scant in LMIC leading to shortage of qualified staff, especially during the night27, and opportunities for future development of medical personnel, therefore actions are needed in this direction.32
Developing data infrastructures and collaborative research networks are the first critical steps in building improved treatment and research capacity in LMICs. Such data infrastructures can serve as the foundation for the development of standardized treatment guidelines and the implementation of trials to improve TBI outcomes.3,11 Surveillance and standardized data collection are important measures recommended to help loosening the burden of TBI. Previous research in the field demonstrated that having not only valid regional and national epidemiological data, but standard data collection processes and coding formats for TBI constitutes the solid foundation of trauma management and advancement of care for TBI patients.33 Data registries are effective tools successfully used to guide policies to prevent and optimize treatment and recovery for the TBI patients.10 In response to the findings of this study, the research team has initiated data registries to monitor incidence and outcomes in hospitalized TBI patients.
The present study has some limitations. The hospital sample was not intended to be representative of the entire country, but instead to represent views of strengths and barriers from the perspective of the highest level of trauma care in the country. Thus, the information in not nationally representative (although, as the main trauma hospitals in these countries, the participating hospitals treat the majority of severe TBI). A limited number of interviews were collected from the hospitals due to the study timeline and personal availability. This aspect may have led to underrepresentation of certain categories of medical personnel.
Although our interviews identified substantive gaps in TBI care, many aspects of state-of-the-art systems are in place, as is investment in health infrastructure in these three emerging economies. Further studies should focus on including healthcare providers from other cities as well, as this can offer valuable information for regional actions and initiatives to improve the outcomes of TBI.
ACKNOWLEDGEMENT
This publication was funded by the NIH-Fogarty International Trauma Training Program “iCREATE: Increasing Capacity for Research in Eastern Europe” and “INITIATE: International Collaboration to Increase Traumatic Brain Injury in Europe”, both at the University of Iowa and Babes-Bolyai University (National Institutes of Health, Fogarty International Center 2D43TW007261 and 5R21NS098850). The authors gratefully acknowledge all members of the iCREATE and INITIatE grants for their work on the project overall and for the contributions of project documentation used in this manuscript.
ABBREVIATIONS LIST
- ARMC
Armenia Republican Medical Center
- IMC
Izmirlian Medical Center
- INITIatE
International Collaboration to increase Traumatic Brain Injury Surveillance in Europe
- LMICs
Low- and Middle Income Countries
- TBI
Traumatic Brain Injury
Footnotes
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DISCLOSURE OF INTEREST
The authors report no conflict of interest.
DECLARATION OF INTEREST
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper
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