Trauma Nursing Core Course TNCC This course is run by the

Emergency Nurses Association and is oriented towards nurses working in emergency departments in developed countries. It runs for 16 hours and covers principles of acute management in the emergency department setting. It includes lectures and skill stations, including trauma nursing process, airway and ventilation interventions, and spinal immobilization. The course provides core-level knowledge and psychomotor skills associated with implementing the trauma nursing process (www.ena.org).

• Trauma Team Training (TTT): This course is run collaboratively by the Injury Control Centre in Kampala, Uganda, and the Canadian Network for International Surgery. This course is designed to create trauma teams that can function with the personnel found in under-resourced health centres in rural Africa. The instructional target is the team, which consists of a clinical officer, an anaesthetic officer, an orthopaedic technician, a registered nurse and an aid. It lasts three days and consists of lectures, skill stations and team exercises. The purpose of the lectures is to assure that all team members have a common understanding of key issues in clinical trauma care, and of the importance of the trauma team. The skill stations assure that all participants can proficiently perform their role in the skills necessary for the initial care of the injured patient and the preparation of the patient for definitive care. At the end of the course, the institution gains a cohesive team. TTT has trained around 200 people from 10 hospitals in Uganda since 1998, and plans are in place for its translation into Portuguese for use in Mozambique.

Much could be achieved towards assuring the services outlined in the Guidelines for essential trauma care by promulgating some or all of these courses, depending on the context. It is the feeling of the authors of this manual that part of the EsTC process would involve countries defining which of the continuing education courses best suit their particular needs. This might include a definition of which courses suit their needs at a national level. It might also include which courses best suit a particular subset of providers, or geographic area, or level of institution. In some cases, this might imply developing their own courses, as in the example of Ghana mentioned above.

In some cases, this might also imply establishing plans to facilitate and promulgate the particular continuing trauma training selected. For example, in some middle-income countries in which the ATLS programme has already been formally established, its availability has been impaired by high cost relative to local salaries and by a low number of courses relative to those who would benefit from this type of training (15). Nationwide plans to remove these barriers and thus facilitate increased utilization of such training constitute one means to be considered in efforts to promulgate the Guidelines for essential trauma care. As mentioned above, this might not necessarily imply all trauma care providers. Depending on resources to be deployed, it might imply special efforts to subsidize, reduce the cost or otherwise increase availability to certain critical providers. These might include the lead trauma care providers in emergency departments in hospitals who have no one with such certification. Other possibilities might include increased availability to doctors in rural hospitals with limited access to specialists. Finally, it might also imply widespread certification for all doctors providing care in busy urban trauma centres. Similar considerations would apply for a nursing staff training course such as the TNCC.

Another example of the utilization of continuing education to promote the Guidelines for essential trauma care in low-income countries comes from Ghana. It has been suggested to the Ministry of Health that a low-cost means of promoting improvements in trauma care in the country would include providing the KNUST trauma course regularly for general practitioners in hospitals located along busy roads.

In addition to the considerations noted above, the Guidelines for essential trauma care could be promoted by several other educational means. These include developing and promoting educational resources for trauma care in hospitals. Prior surveys from some countries have indicated a dearth of such educational materials (12). Larger institutions might reasonably develop their own continuing education plans, including not only doctors and nurses but also ancillary personnel. Finally, countries with heavy burdens of trauma care could consider making trauma care rotations mandatory, either in medical schools or postgraduate programmes, in the same way in which rotations in Obstetrics & Gynaecology are required in some countries.

Finally, these guidelines are written as a planning tool, oriented primarily towards planners and administrators (see Executive summary). As part of plans to implement the guidelines on a national basis, it would not be unreasonable to consider developing training courses or other training materials for planners and administrators. These courses would address the topic of the critical elements of personnel, staffing, equipment, supplies and organization, of which planners/administrators need to be aware and whose provision they need to help to assure.

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