Methods
Contextual factors
In Mumbai, there are multiple ambulance services, including the statewide 108 emergency
response service. Most ambulances are stationed at the sites of frequent trauma, such
as train stations. Ambulances are staffed with a paramedic, who receives training
on cardiopulmonary resuscitation, wound care, and medical stabilization, and driver,
who is not formally trained as a physician or a paramedic, but may help with patient
stabilization when asked.
There are four government-funded trauma centers that manage the majority of traumas
within Mumbai. These include Lokmanya Tilak Municipal General Hospital (LTMGH) and
King Edward Memorial Hospital (KEMH). In the trauma ward, anesthesia and general surgery
residents generally perform the initial evaluation and management of trauma patients
and consult the neurosurgical team when there is a concern for TBI. These four large
public trauma centers have a dedicated trauma operation theater (OT). Private hospitals
in Mumbai require out-of-pocket payment by patients or their families for admission.
Objectives
The primary objective of this study was to identify provider-perceived themes – including
strengths and weaknesses – related to care for TBI in Mumbai. The secondary objectives
included identifying portions of TBI care – including medical, surgical, and process
factors – that were perceived to be efficacious and contrasting public and private
hospitals' approaches to TBI care.
These questions were framed around the Lancet Commission for Global Surgery's organizational
framework around safe, affordable, and timely care.[[7]]
Study design
This was a qualitative, semi-structured survey of care providers for TBI patients
in Mumbai, India. Three categories of participants were selected: Surgeons (including
neurosurgeons and general surgeons), anesthesiologists, and paramedics. These participant
categories were selected to include the physicians most directly involved in TBI care
from stabilization in the field to eventual evaluation, management, and discharge
from the hospital. Semi-structured interview questionnaires were developed for each
participant category to address the aforementioned research objectives [Supplementary
Files 1-3] [SUPPORTING:1]. Questionnaires underwent multiple reviews (by SG, MK, HS,
and VK) prior to their finalization and were piloted in Mumbai prior to implementation.
Interviews were conducted by the same interviewer (SG) in English or Hindi depending
on the preference of the interviewee and were audio-recorded with no identifying information
included in the recordings. All interviews were conducted in person during the on-duty
shifts of interviewees.
Participant sample
Convenience sampling was used to select interviewees based on professional contacts
of two coauthors (MK and VK) and contacts of these interviewees. Interviews were conducted
at the offices or wards of surgeons and anesthesiologists and the locations throughout
Mumbai where paramedics were stationed. After identifying potential interviewees,
all interviews were approached and consented to participate. In total, 60 participants
were invited to participate, and 50 ultimately consented to be interviewed. Interviews
were conducted from March 6, 2018, to April 23, 2018.
The sample was enriched in participants from LTMGH, the largest of four full-service
trauma centers in Mumbai, and KEMH, one of three other full-service public trauma
centers in Mumbai. Recruitment was stopped when response saturation was reached. All
survey responses were included in the analysis.
Coding manual and thematic analysis
Audio recordings in Hindi and English were transcribed by SG. Thematic analysis was
then utilized as previously described.[[8]] Audio recordings were analyzed by SG to derive coding manual inductively, which
were iteratively refined to arrive at the final coding manual used for this thematic
analysis.
Ethics approval
This study was approved by the LTMGH Institutional Ethics Committee (IEC06/18) and
the Harvard Medical School Institutional Review Board (IRB17-2034). All participants
provided written informed consent to participate in this study.
Results
A total of 50 participants were recruited including 9 neurosurgeons, 9 general surgeons,
15 anesthesiologists, and 17 paramedics [[Table 1]]. All participants completed interviews.
Table 1: Profile of interviewees
Theme 1: Workforce
The amount of care providers available, referred to as the workforce, featured prominently
throughout most interviews [[Table 2]].
Table 2: Summative table of themes and thematic elements raised during interviews
Paramedics are stationed with a driver and no additional medical support, which occasionally
limits care during transport, such as when patients need multiple interventions simultaneously.
Paramedics receive help from police and family members. Mumbai's Government Railway
Police and citywide police force often accompany paramedics during transport to provide
assistance during transport. Family members are occasionally called to assist paramedics
during transport by assisting with basic first aid tasks when they were present on
scene. Trauma bays at public hospitals can be overcrowded due to a lack of ample registrars
to process the incoming patients:
”If there are 4-5 patients already in queue [at the trauma ward], then after that,
you will be attended by the doctor… They take time to admit that patient, 15-20 min,
sometimes half an hour. The patient is having bleeding and if the doctor attends to
the patient after half an hour, then the patient deteriorates” (Paramedic).
This overcrowding raises concern for paramedics, who noted that patients' clinical
condition can worsen during this wait. Physicians who receive patients in these trauma
bays often do not have a notification system that tells them which patients are in
queue and how to triage them. However, neurosurgical care and other specialty consultations
are available at all times of the day and week at all sites where interviews were
conducted.
While nurse-to-patient ratios are noted to be as low as 1:1 in private hospitals,
they are higher in public hospitals. Most hospitals have physical therapists (PTs)
and occupational therapists (OCTs) to create rehabilitation plans and teach the families
how to administer these plans at home. Workforce limitations of nursing and PT/OCT
staffing were noted by participants to contribute to potentially preventable medical
complications such as bedsores and infections.
Clinical teams dedicated to trauma patients exclusively are present in some hospitals
and facilitated evaluation and management. Paramedics suggest that each hospital receiving
trauma patients should have a process of trauma triage and evaluation and a dedicated
team to ensure an efficient patient handover. Physicians believe that specialized
teams and operating theatres could result in tailored and higher quality care for
TBI patients.
”[For] pure neurosurgical head injuries, they should have a dedicated ward [and] dedicated
ICU where everything from the palliative care, treatment, occupational therapy, physiotherapy,
diet, and supportive care are all taken care of under one roof and with a dedicated
team who is very isolated to taking care of these specific needs”(Surgery attending,
public hospital).
Where personnel shortages exist, such as in ambulances and in the wards, complications
and delays could arise. Providers utilize teamwork – including with nonmedical personnel
such as the help of families for rehabilitation on the wards – to mitigate the consequences
of personnel shortages.
Theme 2: Equipment
All parties are aided in their evaluation and management of TBIs by equipment and
technologies [[Table 2]]. Nearly all paramedics mention that the equipment stocked in their ambulances,
including basic first-aid material, cervical collars, suctions, and supplemental oxygen,
are critical in managing TBIs and are consistently well stocked by their management.
They also discussed their new innovative motorbike ambulances, which allow them to
maneuver through urban congestion and reduce a potential delay in care.
”(The bikes) help us a lot. There was even a case today from the center here. I went
on bike and a transport ambulance went. I headed out faster than the ambulance. As
soon as I got there, I began management, [evaluated the patient], [followed] the ABC
rules of trauma. I could see if the patient's situation was down trending, and immediately
[started] managing oxygen for example... The bikes just get there quickly and [allow]
for a faster response. Life can be saved with these bikes” (Paramedic).
Upon their arrival to some public hospitals, paramedics note that lacks of hospital
gurneys can result in the reliance of trauma ward physicians on the ambulance's stretcher
to transport patients for testing and imaging, which can delay paramedics' return
to their stations.
Anesthesiologists and surgeons discussed that having computed tomography scanners
within trauma wards significantly reduces delays in diagnosis and facilitates management.
Anesthesiologists made frequent use of multiparameter vital sign monitors, ventilators,
and blood work in the trauma wards and intensive care units (ICUs). Sometimes, there
are not enough devices for each TBI patient who requires one in public hospitals.
”If the ABG [arterial blood gas] machine suddenly goes out of order, then the technician
comes to repair it like six hours later. So, for six-seven hours if we have a bleeding
patient coming in, I would not be able to do his ABG, would not know if there is (an)
acidosis and then arbitrarily, I would give sodium bicarb… I think all the doctors
here have a good clinical acumen because of working with lesser facilities. But yeah,
I think in the end patient care, it must be getting affected” (Anesthesia attending,
public hospital).
Equipment shortages and malfunctions result in periods of time when patient monitoring
or care may suffer. Clinicians who face these scenarios can adapt by developing strong
clinical acumen to manage patients during these times.
There are similarly not always enough ICU beds in public hospitals for each critical
patient, requiring some patients to stay in floor beds. These deficits result in physicians'
utilizing resource allocation by providing the sickest patients to the best devices
and highest level of care to maximize lives saved.
Anesthesiologists and surgeons discussed that invasive intracranial pressure monitors
(ICP) could be a useful adjunct in managing TBI patients, but these were not available
in public hospitals and were variably available in private hospitals. Physicians have
adapted by relying on clinical symptoms and signs, in conjunction with imaging, to
arrive at estimations of ICP changes.
Surgeons emphasized the importance of having an OT readily available to prevent delays,
but in the public sector, delays occasionally arose if another emergent case was ongoing
in the trauma OT.
”What we are having is [an] OT that is for general surgical cases and traumatic brain
injury… So, most of the times, we get [the OT] quick, but…sometimes with [subdural
hematoma] and contusion, these patients get delayed. And sometimes … it has happened
that patients have deteriorated over time … and we had to intervene later than we
wanted to” (Neurosurgery resident, public hospital).
Equipment plays a significant role in the care of TBI patients. Providers in ambulances
and in public hospitals discussed that their equipment is sufficient to manage patients;
increasing the amount and quality of monitoring tools and specifying exclusive neurosurgical
trauma OTs were raised as potential areas for improvement.
Theme 3: Financing care
Underlying all interviews were issues related to financial access [[Table 2]]. Anesthesiologists and surgeons comment that when an uninsured patient presents
to a private hospital and was unable to pay out of pocket, the patient would be stabilized
and transported to a public hospital in one of the private hospital's ambulances.
Patients in private hospitals need to pay for their care daily, resulting in some
patients' running out of funds after a few days in the hospital.
”And it's really, really sad [that] just because they don't have money, they cannot
take further treatment in this corporate setup and then they need to move, and I have
seen a lot of number of patients who have done that” (Anesthesiologist attending,
private hospital).
In these scenarios, finances can limit a patients' continuity of care. When this happens,
physicians facilitate transfers using their own hospitals' ambulances and communicating
with a physician at the receiving hospital to discuss the patient.
Physicians at public hospitals uniformly state that the acute phase of care is not
significantly impacted by the financial consideration. These hospitals are financed
such that nearly all components of care are free, and even supplies and medicines
that are not provided for free can usually be sanctioned for free by social workers.
”They pay around 2500 [rupees]… so it was down to roughly 50 US dollars. So, you get
a neurosurgery for 50 US dollars …and forward stay, they have to pay 5 or 10 rupees…
and even if they are not able to pay, we make [it] free. There's always options” (Neurosurgeon
attending, public hospital).
While public hospitals are usually able to fully subsidize care, situations do arise
when certain supplies and expensive medications are not available in the hospital
and must be procured by patients' families from pharmacies outside of the hospital.
When families cannot do this or patients' families have not been identified, physicians
can adapt by providing less expensive alternatives and drawing from previously stockpiled
resources.
”Somewhere down the line, we have to keep a stock for the patients who have nothing.
Like sometimes, prescribe an additional drain [for one patient] and you keep one in
stock for the next patient who may not have” (General surgeon, public hospital).
Patients' finances can hinder their access to care at private institutions, thus limiting
their choices. Public hospitals use all available resources to provide free care for
these patients with the assistance of government programs, and in the uncommon circumstances
when patients do need to pay for an element of care, physicians can adapt by providing
whatever treatments are available.
Theme 4: Family and public role
The importance of the family of patients, the general public, and the government was
frequently discussed by interviewees [[Table 2]].
Paramedics discussed that the public often alerts them about nearby accidents and
even carries injured patients to them. This decreases the time to management by paramedics,
but these helpers usually do not know about cervical spine protection during transport,
which can worsen injury. During transport to the hospital, patients' family members
can assist with basic first aid when they are available.
Patients' families play a key role in management in public hospitals by paying for
supplies and medicine when able and by assisting with rehabilitation and nursing tasks
when workforce is limited. Physicians, nurses, PTs, and OCTs teach family members
how to perform these tasks, such as turning a patient to prevent bedsores and assisting
with chest physiotherapy.
”The relatives are given guidance, and then they take care of a lot of the nutritional
needs, they help … attach the nutrition for the patient, they take care of the rotation
of the patient for the bed sores, they even take care of the hygiene of the patient.
So, I believe the relatives are a lot more involved which may or may not be a great
thing, but it is more than a professional help, I believe relatives take care of a
lot [and] take a forefront in the management of these patients in the allied aspects”
(Surgery attending, public hospital).
Physicians commended the government for funding largely free care for trauma patients
at public hospitals who could not afford it at private hospitals. Physicians often
stockpiled government resources that could be bought at pharmacies relatively cheaply
(i.e., drains and sutures) and allocated these to patients who could not afford them.
Expensive medications, such as certain narrow-spectrum antibiotics, were not always
provided by the government, so when patients could not afford these, physicians relied
on cheaper alternative medications.
While a minority of patients are brought to the trauma ward by trained paramedics,
an increase in the amount of trained personnel in public prehospital care systems
would aid in getting TBI patients to the hospital more quickly and safely.
”[Having prehospital care] makes a difference because at least you would have evaluated
a simple thing, like would have done some suctioning, some O2 mask, something at least-at
least [giving] proper positioning…[to avoid] cervical trauma… Either the police [are]
getting them or the people by the road [are] getting them” ( Anesthesiologist attending,
public hospital).
Discussion
This survey identified key themes related to care for TBI in Mumbai, including workforce,
equipment, financing care, and the family/public role [[Figure 1]]. These themes were often discussed in the context of reducing or increasing complications
and delays, which are the two critical components in the final outcome of TBI patients.[[9]],[[10]],[[11]],[[12]] When interviewees identified limitations in the major themes, they used teamwork
to mitigate workforce shortages and resource allocation, affordable alternatives,
and stockpiling to mitigate shortages in equipment and patient finances.
Figure 1: A diagrammatic representation of thematic elements and related subthemes raised by
interviewees is presented. The four major themes (blue) were frequently raised in
the context of promoting and preventing complications and delays (gray). Adaptations
(orange) can mitigate shortcomings in workforce, equipment, and financial access when
they arise
The workforce was consistently brought up as vital to managing TBI, from paramedics
stabilizing patients to teams of anesthesiologists and surgeons evaluating them in
trauma wards. Teamwork was especially important in the scenarios of workforce shortage,
including such examples as paramedics receiving help from policemen during ambulance
first aid and rehabilitation plans made after discussion between surgeons and PTs.
Lapses in communication often exacerbated workforce shortages, such as during the
handover process between paramedics and physicians in the trauma bay. Initiatives
such as prehospital notification systems can help to alleviate this lack of communication
and prepare trauma wards for critical incoming patients.[[13]] Building capacity through increasing trained members of the workforce remains a
key priority in global health, especially as India and other middle-income countries
are estimated to remain understaffed in the health-care sector for possibly over a
decade.[[14]],[[15]],[[16]]
Equipment was vital to managing TBI patients in all phases of care – from the ambulance,
the OT, and to the postoperative period. In public settings, equipment to monitor
vital signs was sometimes faulty or in too low quantity, which led to the need for
resource allocation. This may hamper TBI management by decreasing physicians' ability
to know when patients' vital signs have changed. The lack of ICP monitors in most
centers was also raised. ICP monitors have shown efficacy in increasing survival for
severe TBI.[[17]]
Financial access played a significant role in TBI management. Patients who were initially
brought to private hospitals but required transfer due to an inability to afford care
had delays in definitive management. Public hospitals financially covered nearly all
aspects of care, including neurosurgical operations, for free for patients who could
not afford it. The government of India aims to establish universal health care, which
will continue to improve the care provided to TBI patients who cannot afford basic
supplies.[[18]] The family plays a significant role alongside paramedics and physicians as allies
in management, and their involvement may improve patient outcome since families will
continue to interact with the patient after discharge daily but may also hurt the
outcome because they do not have the formal education of health-care providers.
As exemplified by the interviewees in this study, local providers readily identify
strengths and gaps in care and often create work-arounds to mitigate their effects.[[19]] Multi-institutional partnerships between the Indian hospitals, including trauma
centers in Mumbai, and outside institutions have allowed for progress in understanding
trends and gaps in trauma care within the city.[[19]],[[20]],[[21]],[[22]] Further collaborative efforts between Mumbai health institutions and their local
and international partners to address the barriers to care we identify will be crucial
to preventing and managing TBI.
This study has pertinent limitations. Most interviews were conducted while providers
were on-duty at work, which was purposefully done to provide convenience for participants,
minimize recall bias, and facilitate convenience sampling. However, this method also
resulted in occasional interruptions for patient care and the potential for decreased
participant focus as they balanced answering questions and thinking about patients.
All interviews were conducted by providers located at an urban site within Mumbai,
which limits our generalizability to suburban and rural areas around the city. The
sample of surgeons and anesthesiologists is enriched in two large trauma centers and
may not reflect barriers specific to smaller tertiary hospitals or community centers.
Further, given logistical constraints, we were unable to include opinions of all relevant
providers, such as nurses in the trauma wards or general wards and PTs.
