Inefficient referral pathways delay lifesaving care for millions of injured people

Many seriously injured patients in Global South countries are failing to reach medical care within the lifesaving 'golden hour' and ambulances are often associated with these delays.

Publishing their findings today (23 March - UK), in BMJ Global Health, an international research team led by University of Birmingham and Stellenbosch University reveals that - in Ghana, Pakistan, Rwanda, and South Africa - more than half of patients with serious injuries failed to reach medical care within an hour of being injured.

Reaching care within the 'golden hour' has become a guiding principle for patients with moderate or serious injuries and evidence suggests that arriving after this time is associated with increased risk of death and disability. However, the study done in these four low- and middle-income countries (LMICs) found that 57 % of all patients arrived more than one hour after being injured, with 34% arriving more than two hours later.

In all, 46 % of patients were transported by ambulance, with use varying between countries. Ambulances transported around 20 % of injured people in Ghana, 50 % in Pakistan and South Africa, and 65 % in Rwanda.

Although ambulances were associated with reaching care after the golden hour, patients using informal means such as private cars, taxis, or motorbikes arrived for treatment quicker than those travelling by ambulance.

Professor Justine Davies, from the University of Birmingham, said: "In low resourced settings, understanding where and why healthcare is failing is one of the smartest ways to save lives and ensure limited resources are invested in solutions delivering greatest impact.

Investing in expensive ambulance services, as many LMICs are considering, needs to be carefully thought through. Ambulances alone won't reduce deaths after injuries-the entire pre‑hospital system needs to be strengthened, with better trained staff, good referral pathways and co-ordinated solutions."

Justine Davies, University of Birmingham 

Injuries are a growing health crisis in LMICs, mainly affecting young people in the prime of their working lives. They leave lasting strain on families, communities, and society. Each year, more than 4 million deaths are caused by injuries with 90% of these happening in LMICs and 40% of these deaths considered avoidable.

Funded by National Institute for Health and Care Research (NIHR), the researchers analyzed information from 8,331 injured patients admitted to 19 hospitals across the 4 countries – the first major study of its kind. They looked at serious injuries resulting from interpersonal violence, road traffic collisions, falls, being hit, fire or heat injury, and cuts.

Over 50% of patients had not gone directly to the facility which could provide definitive treatment and around 20% of patients sought care first at primary care. This suggests that patients didn't recognize that their injury was serious enough to merit higher care levels available only in hospital. It also suggests that, for patients transported by ambulance, the referral pathways to ensure that patients go directly to the hospital that can provide definitive treatment were not in place.

However, despite these measured delays – which were experienced more in poorer, less‑educated and older patients--only 19% of patients believed they had experienced a delay, with many who reached hospital after several hours still felt they were 'on time'.

Dr Leila Ghalichi, from the University of Birmingham, said: "Too many seriously injured patients lose precious time before reaching the care that they need - delays begin long before patients reach hospital doors and are made worse by fragmented pre‑hospital systems. Improving early access to the right hospital could significantly reduce preventable disability and deaths."

The study sets out the following recommendations for policy makers:

• Strengthening pre‑hospital care systems-not just ambulance services
• Improving transport options and considering alternatives to ambulances
• Streamlining and improving referral pathways
• Addressing inequities affecting poorer, older, or less educated patients
• Integrating injury‑care improvement with urban planning and congestion solutions
• Increasing public awareness about the urgency of getting care quickly
• Developing national public health messaging that encourages direct attendance at capable facilities but avoids overwhelming tertiary centers

Researchers note that investing in quality and efficient pre-hospital emergency care systems is resource intensive. Investment is needed in trained human resources, medical equipment and technologies, data infrastructure, an organized ambulance dispatch center, an ambulance fleet, and policies to ensure that ambulances have the right of way on roads. Systems from High Income Countries, such as the United Kingdom, are not necessarily transferable to LMIC settings, given lower resources and different health system contexts.

Professor Davies is working with IT developers in Rwanda and international partners to create the 912Rwanda software. This helps ambulance crews and hospitals coordinate faster care for emergency patients by automatically recommending the nearest available facility which can provide the care that the patient needs.

Backed by more than £3 million funding from NIHR and nearly $1 million from the United States National Institute of Health, this innovative software could reduce serious disabilities for an estimated 250 million people who suffer injuries each year in LMICs.

It will also reduce deaths and disability from emergency medical conditions, like post-partum hemorrhage, sepsis, malaria, heart attacks, or strokes – conditions which cause around 50% of deaths in LMICs.