Application of priorities

In the development of national trauma plans, the authors anticipate that many countries may very appropriately decide to convert some of the items in the desirable category to essential. The converse is not true. Items designated as essential should remain so designated except in extreme or very unusual circumstances, as changing these may result in trauma care falling below the EsTC standard.

Throughout these guidelines, more detail is provided on the elements of care that are deemed essential. However, it should be emphasized that items designated as desirable are also an integral part of these guidelines. They are considered somewhat less important or cost-effective than essential items, but are not to be ignored. Items designated as essential are those which should be able to be assured to all injured patients arriving at all facilities of a given level in all countries, even those of lowest income. Hence, the essential items are applicable to all health facilities, including the most basic of facilities of a given level in the countries of lowest income: e.g. village health posts at the basic level; small hospitals without surgical capabilities for the GP hospital level; specialist hospitals with only a general surgeon; and tertiary care facilities with a limited range of subspecialties. Hence, many of the items that are designated as desirable may indeed be applicable to many of these facilities, such as those in middle-income countries or those with high numbers of trauma patients in all countries. This is particularly an issue in the case of basic-level facilities, for which there is tremendous variation worldwide (Figure 1). Using the "least common denominator" of a village health post in a low-income country, the major emphasis at basic-level facilities in these guidelines is on rapid, basic first aid. Many other therapeutic items are listed as desirable (e.g. oxygen, most medications, and IV fluids), as these are not applicable to village health posts. In national plans that address the basic level, many such items might reasonably be upgraded to essential for higher-level basic facilities, such as those staffed by nurses or medical assistants.

By way of an example of how the terms "essential" and "desirable" are actually applied in the recommendations, we look at airway management (Table 1). At all levels of the health care system, it is deemed essential that health care personnel know the signs of airway obstruction and are skilled in manual manoeuvres to keep an airway patent. The probability of success in airway management is increased by the provision of specific equipment and the skills to utilize it properly and safely. This includes equipment and skills for basic airway management, including oral airway, suction and bag-valve-mask. These are deemed essential at hospital-level facilities. The probability of success of airway management is increased even further by the provision of equipment and skills for advanced airway management, including endotracheal intubation and cricothyroidotomy. These are deemed essential at specialist-staffed hospitals. At each level, the probability of success of airway management is increased. However, both the need for resources (both equipment and training) and the potential for harm are increased. In environments in which more resources are available, and/or in which specific facilities handle a greater than average volume of trauma, it may be appropriate to change the "desirable" designation to "essential" at some or all facilities of a given level.

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