Abstract

Background of the Study: Trauma has long been a major public health problem worldwide, particularly affecting developing countries. It is a leading cause of morbidity and mortality and accounts for about 10% of the global burden of disease and over five million deaths, as well as 52 million disability-adjusted life years annually. Despite the impact of the ATLS protocol on injury management, its awareness and use remain questionable. Thus, this study aimed to assess the ATLS knowledge, attitude, and practices of health personnel involved in the management of injuries in 4 hospitals in Cameroon. Methodology: This was a cross-sectional, hospital-based study. A questionnaire was used to assess the knowledge, attitudes, and practices of healthcare providers on the ATLS protocol in four hospitals (Regional Hospital Limbe (RHL), Regional Hospital Bafoussam (RHB), Laquintinie Hospital Douala (HLD), and the Edea Regional Hospital (HRAE)). Results: Out of the 225 personnel enrolled in the study, 155 (71.4%) were females, 65 (29.1%) were state-registered nurses, and 40 (17.9%) were general practitioners. The overall knowledge was poor (71%), while 29% had good knowledge. There was a significant association between health facility personnel and knowledge (γ² = 20.26, p < 0.001), and the association between qualification and knowledge was also statistically significant (γ² = 13.14, p = 0.009). Specialist doctors demonstrated significantly higher knowledge than the other cadres involved in the study. The majority of participants (191; 85%) had a good attitude towards ATLS. The association between the health facility and attitude towards ATLS was statistically significant (γ² = 9.963, P = 0.029). A total of 147 (65%) participants demonstrated good practice of the ATLS protocol. Specialist doctors were four times more likely to have good knowledge compared to other health professionals, AOR 4.737 (95% CI: 1.272 - 17.636, p = 0.02). Conclusion: Knowledge of the ATLS protocol was poor among study participants. However, attitudes and practices towards ATLS were good. Knowledge, attitudes, and practices of the ATLS were significantly influenced by the level of education and the location of the participants. Training on ATLS is recommended for healthcare personnel to improve care for injured patients.

Keywords

Injury and Trauma, Adverse Event, Health Education, ATLS Protocol, Impact

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1. Introduction

Trauma is a leading cause of morbidity and mortality worldwide and accounts for about 10% of the global burden of diseases, with over five million deaths [1] [2] and 52 million disability-adjusted life years annually [3]. Over 45 million people globally sustain moderate to severe disability each year due to trauma, with more than nine people dying every minute from injuries or violence [4]. Although the identification of trauma as a global health concern can be traced back to the last century [5], trauma still holds a significant share of the global burden of disease. In the United States, more than 50 million patients receive some form of trauma-related medical care annually, and trauma accounts for approximately 30% of all intensive care unit (ICU) admissions [6]. Low and Middle-Income Countries (LMICs) are disproportionately affected by trauma, with about 90% of injury-related mortality occurring in these settings. Over 90% of the global burden occurs in LMICs, which lack the capacity to address the morbidity and mortality associated with injury [7]. To curb this burden, the use of a standardized and widely accepted method for the initial control of multiple trauma patients and the establishment of treatment priorities is essential. Today, the Advanced Trauma Life Support (ATLS) protocol is the most widely accepted method for the initial control and treatment of severe and multiple trauma patients [8].

The ATLS is a training program for medical providers used in the management of acute trauma cases, developed by the American College of Surgeons [9]. The goal is to supply its participants with a safe and reliable method for immediate treatment of injured patients and the basic knowledge necessary to: 1) assess a patient’s condition rapidly and accurately; 2) resuscitate and stabilize patients according to priority; 3) determine whether a patient’s needs exceed the resources of a facility and/or the capability of a provider; 4) arrange appropriately for a patient’s inter-hospital or intra-hospital transfer; and 5) ensure that optimal care is provided and that the level of care does not deteriorate at any point during the evaluation, resuscitation, or transfer process [9]. ATLS is divided into primary, secondary, and tertiary surveys. The primary survey is the first and key part of the assessment of patients presenting with trauma. Life-threatening injuries are identified, and simultaneously, resuscitation is begun following the mnemonic ABCDE (A: Airway, B: Breathing, C: Circulation, D: Disability, E: Exposure), which details the order in which problems should be addressed. The secondary survey involves a head-to-toe evaluation, complete history, physical examination, and reassessment of all vital signs. The tertiary survey involves careful and complete examination to recognize missed injuries, allowing definitive care [10].

In Cameroon, the first practitioners who come in contact with injured patients are nurses and general practitioners; thus, appropriate knowledge of the ATLS protocol is mandatory in order to provide organized and fast lifesaving care to injured patients. Poor adherence to the ATLS protocol by practitioners can be detrimental to the outcome of the patient [11]. Deviations from ATLS guidelines could be due to poor knowledge of practitioners involved in the management of patients [12], leading to poor compliance with established guidelines in the management of the injured [13]. Thus, this study sought to investigate the knowledge, attitude, and practice of health care workers regarding the ATLS protocol in the management of the injured.

2. Materials and Methods

2.1. Study Site

Cameroon is a sub-Saharan country made up of 10 regions with a population of over 27 million inhabitants [14]. This study was implemented in four hospitals involved in the management of injured patients in Cameroon. They included: the Regional Hospital Limbe (RHL), which is the largest hospital in the Southwest, with more than a 200-bed capacity and the principal referral hospital in the Southwest Region [14]; the Regional Hospital Bafoussam with over 250-bed capacity and the largest in the West region, the Laquintinie Hospital Douala (LDH) and the Regional Hospital Annexe Edea (HREA), both in the Littoral Region. They are found along the Douala-Yaoundé highway, which is known to be among the deadliest roads in Cameroon, as it records the highest number of accidents.

2.2. Study Design and Population

This was a cross-sectional hospital-based study conducted between May 2023 and October 2023 in four selected hospitals in the South West, Littoral, and West regions of Cameroon. The study involved medical doctors and nurses working in the emergency, surgical unit, theatre, and intensive care (ICU) units and directly involved in the management of injuries. The sample size was calculated using the single population proportion formula for epidemiological cross-sectional studies. A consecutive sampling method was used to recruit participants into the study. To adjust for the design effect of the sample design, the sample size was multiplied by the design effect. The minimum sample size for this study was 145 at 20% attrition. Hence, a total of 225 participants were finally recruited into the study. The number of participants that were sampled in each treatment center was determined based on the probability proportionate to size.

2.3. Data Collection

Data were collected by trained research assistants (one per hospital) with a minimum qualification of a Bachelor of Science in Nursing Sciences. The data collection tool was a structured questionnaire consisting of 4 sections (demographic data, knowledge of ATLS, attitude towards the ATLS protocol, and practice of the ATLS). The questionnaires were printed in French and English and administered to doctors or nurses involved in care and who consented to participate in the study. Before data collection, the questionnaires were pretested at the District Hospital, Limbe.

2.4. Data Analysis

Data were entered using a template developed in Kobo Collect and analyzed in SPSS version 26. Knowledge scores were grouped into good and poor knowledge. Poor knowledge referred to scores less than 50%, while good knowledge referred to scores above 50% on the knowledge section. Poor attitude referred to scores less than 50%, while good attitude referred to scores above 50%. This was set at 50% because it is the average. In the case of practice, poor practice referred to scores less than 75%, while good practice referred to scores above 75%. The 75% mark was set because error in practice directly impacts morbidity and mortality outcomes compared to knowledge and attitudes. The Chi-square test was used to determine the associations between demographic data and knowledge, attitude, and practice of the ATLS protocol. A logistic regression model was used to identify factors independently associated with the knowledge, attitude, and practice of the ATLS protocol.

3. Results

3.1. Socio-Demographic Characteristics of Medical Personnel Enrolled in the Study

Out of the 225 healthcare personnel interviewed, 76 (33.9%) came from LDH. The majority of the participants (106; 48.6%) were aged 21-30 years old. More than seventy percent (155; 71.4%) were female. Most of the health workers, 100 (44.8%), were nursing assistants, and 40 (17.9%) were general practitioners (Table 1).

3.2. Knowledge of the ATLS Protocol by Health Care Providers

Our study revealed that only 23 (10.2%) of the study participants considered addressing respiratory insufficiency as the highest priority in managing a patient whose injuries included a closed extremity fracture (Table 2). When assessing knowledge of ATLS, less than half of the participants, 110 (48.9%), did not know the next step in addressing a patient with a deviated trachea and chest pain. The

Table 1. Socio-demographic characteristics of study participants.

SRN: State-registered nurse; B.Sc.: Bachelor of Science.

Table 2. Knowledge of health care providers on ATLS protocol.

overall knowledge of health personnel on the ATLS protocol was poor for the majority of the participants, 160 (71%), while 65 (29%) of participants had good knowledge. The mean knowledge score was 6.44 ± 2.008 on a scale of 10. Mean knowledge score per health facility was highest (7.28) for HRAE and lowest (5.33) for RHB (Figure 1). There was a significant association between the knowledge of ATLS and health facility (γ² = 20.26, p < 0.001) and between qualification and knowledge (γ² = 13.144, p = 0.009) (Table 3). The participants from RHB were less likely to have good knowledge of the ATLS protocol than those from RHL (AOR = 0.166: 95% CI = 0.056 - 0.487, p = 0.001). Specialist doctors were 4 times more likely to have good knowledge (AOR = 4.737; 95% CI = 1.272 - 17.636, p = 0.020) than SRN/B.Sc. nurses (Table 4).

3.3. Attitude of Health Care Personnel towards the ATLS Protocol

In this study, 161 (73.5%) of the participants thought that the most important

Figure 1. Distribution of knowledge scores for the various health facilities.

Table 3. Association between knowledge of the ATLS protocol and demographic characteristics.

Table 4. Factors independently associated with knowledge of health personnel on ATLS.

reason for the ATLS protocol course was that it is important in the management of trauma patients. Up to 83 (37.2%) of the participants think the ATLS protocol is a major advantage on their CV (Table 5). The majority of the participants, 191 (85%), had a good attitude towards the ATLS protocol. The mean attitude score was 6.22 (Figure 2). There was a significant association between health facility and attitude towards ATLS (γ² = 9.963, p = 0.029) (Table 6).

Table 5. Attitude of health care providers towards ATLS protocol.

Figure 2. Variation in overall attitude per health facility.

Table 6. Association between attitude towards ATLS and demographic characteristics of study participants.

3.4. Practice of Health Care Providers on the ATLS Protocol

Our study revealed that 57 (26%) participants were very likely to suction the patient in case of trauma with dyspnea, and 59 (26.8%) were very likely to place a neck collar during the primary survey. Only 122 (55.7) were very likely to auscultate the patient’s chest in a trauma case. Also, 142 (64.5%) of health workers were very likely to place 02 large-bore IV access during resuscitation. (Table 7). Overall, 147 (65%) participants had good practice, while 78 (35%) had poor practice. The mean practice score was 20.3 on a scale of 1 to 29 (Figure 3). There was a significant association between the practice of the ATLS and health facility (χ² = 23.585, p < 0.001). Among health personnel with good practice, 34 (15.2%) were general practitioners, while 3.5% were specialist doctors. There was an association between qualification and practice of ATLS (γ² = 19.42, p-value 0.002) (Table 8). There was a statistically significant association between knowledge and practice γ² = 8.681, p-value 0.003. There was also an association between attitude and practice γ² = 22.819, <0.001 (Table 9). The participants from LDH were less likely to practice the ATLS (AOR = 0.19: 95%CI = 0.077 - 0.471, p < 0.001) compared to those from RHL. General practitioners were 5 times more likely to practice the ATLS protocol (AOR = 0.166: 95%CI = 0.056 - 0.487, p = 0.001) than SRN/B.Sc. nurses. The participants with a negative attitude were less likely to practice ATLS than those with a positive Attitude (AOR = 0.213: 95%CI = 0.089 - 0.509, p < 0.001) (Table 10).

Table 7. Practice of health care providers on ATLS Protocol

Figure 3. Distribution of practice variation in overall practice per health facility.

Table 8. Association between practice and demographic characteristics.

Table 9. Association between practice, knowledge, and attitude towards the ATLS protocol.

Table 10. Factors independently associated with the practice of the ATLS protocol among health care providers.

4. Discussion

Studies on ATLS knowledge, attitudes, and practices among healthcare workers show a mixed picture, with some revealing deficiencies in knowledge and practice, while others highlight positive attitudes and a desire for training. In this study, the socio-demographic factors of age, gender, and years of experience, in relation to ATLS practices, were similar across the different health facilities involved in the study (p > 0.05). This is similar to the results of the study carried out across three hospitals in Pakistan with a similar demography, where 75% of healthcare workers were female and less than 55% were below 25 years of age [15].

In this study, 65 (29%) of the participants involved in trauma management had adequate knowledge of the ATLS protocol. The knowledge levels were shown to vary significantly (p < 0.05) among staff with different levels of training and from one health facility to another. Reviews of articles examining healthcare workers’ knowledge of the ATLS protocol consistently highlight a significant concern regarding inadequate knowledge and potential associated risks, which can lead to poorer patient outcomes in trauma situations due to missed critical interventions and delayed management. The knowledge level in this study was, however, lower than that obtained in Nigeria by Amaraegbulam et al. in 2013 [12], where 60% of the general practitioners (pre-specialist) with different levels of educational backgrounds had adequate knowledge of the ATLS protocol. The majority of our study participants were nurses, who are usually not very knowledgeable about the ATLS protocol and its applicability when compared to doctors, who probably take ATLS training as a compulsory course during their training. Additionally, this also reflects rote learning, where participants with poor knowledge simply memorized information through repetition and only focused on recall rather than deep understanding, institutional protocols that guide practice, or it may have been a potential limitation in the assessment tools.

According to a study carried out by Campbell et al. in 2020, over 90% of the participants demonstrated a good attitude towards the ATLS [16]. Similarly, Girma et al. in Ethiopia obtained 98.6% of the participants who had a positive attitude towards ATLS [17]. Although there are slight differences in the results obtained in these studies, the overall trends indicate that the overwhelming majority of healthcare workers demonstrate positive attitudes towards the ATLS protocol. A study in Kenya also showed a positive attitude towards ATLS principles among the participants [18]. Research consistently indicates a strong positive association between healthcare providers’ knowledge of the ATLS protocol and their positive attitudes towards it, which often translates into improved practices when managing trauma patients. In this study, observed practices of ATLS protocols by healthcare providers were significantly influenced by the level of participants’ knowledge of the ATLS protocol (p = 0.003) and their attitudes (p = 0.001), because the higher the knowledge on a subject, the better the awareness of its value and its application. In Sudan, a study in a State Hospital showed 77% of the study participants stated that their teaching skills affect how they apply ATLS and demonstrated a positive attitude towards ATLS [19]. Studies have also concluded that by embracing the principles of ATLS, healthcare providers uphold the gold standard for safe, effective, and compassionate trauma management, ultimately saving lives and restoring hope in times of crisis [20], and have also demonstrated the positive relationship of increased knowledge and attitudes with improved practices of the ATLS protocol [21].

5. Conclusion

Health personnel in the four hospitals had poor knowledge of the ATLS protocol and demonstrated a positive attitude towards ATLS. The study highlights the importance of proper ATLS training among healthcare personnel in the management of trauma and injury. The study recommends investing in ATLS training at the institutional level to reduce the burden of traumatic injuries, as well as incorporating standardized trauma modules into medical and nursing curricula. Other recommendations include incorporating formal ATLS training into medical school or pre-internship curricula, rather than relying on informal learning from seniors during clinical practice. Integrating mandatory ATLS certification for emergency unit staff will also improve injury management.

Consent and Ethical Approval

The study protocol was approved by the Faculty of Health Sciences Institutional Review Board of the University of Buea (Application number: 1517-03). Administrative authorization was obtained from the Regional Delegation of Public Health for the West, Littoral, and South Regions and the directors of the various health facilities where data were collected. All eligible participants were asked to provide their consent by signing an informed consent form before enrollment in this study.

Limitations of the Study

Reliance on self-reported data for practice, where participants tend to over-report “good” and under-report “bad” behaviors, threatens the internal validity and accuracy of the data because the self-reports may not have reflected actual practices. The sample, drawn from a limited number of specific institutions (four hospitals), may not be representative of the broader population of all hospitals in Cameroon. This limits the external validity of the study, as the results may not apply or be transferable to other settings.

Acknowledgments

We would like to thank all participants and each member of our team who participated to ensure the realization of this project.

Authors’ Contribution

Mary-Magdalene Signe: Conceptualization, data curation, formal analysis, supervision, methodology.

Chichom Alain Mefire: project administration, supervision, review, and writing.

Nicholas Tendongfor: supervision, investigation, review, editing.

Puis Fokam: investigation, review, editing.

Gustave Tsiagdigui: investigation, writing, review, editing.

George EnowOrock: investigation, writing, review, editing.

Theophile Chuteng Nana: investigation, writing review, and editing.

Mebouize Nyankoue: investigation, writing, review, editing.

Funding

This study was funded by D-SINE Africa(P08).

List of Abbreviations

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References