Trauma team members’ perceptions of the effectiveness of the current trauma care system in Addis Ababa, Ethiopia: a phenomenological study

Abstract

Background

Trauma is a leading cause of mortality and disability in low- and middle-income countries (LMICs). Among African nations, Ethiopia has one of the highest trauma fatality rates at 26.7% per 100,000 population, significantly exceeding rates in many other LMICs. Most trauma cases occur in the capital, Addis Ababa. Despite this significant burden, the effectiveness and quality of trauma care in Addis Ababa vary widely across hospitals, driven by disparities in available resources and the knowledge levels of trauma team members.

Objective

This qualitative study aimed to explore trauma team members’ perceptions of the effectiveness of the current trauma care system in Addis Ababa, Ethiopia.

Methods

This study used a qualitative phenomenological design to analyze trauma care team members’ perceptions of the current trauma care system in Addis Ababa, Ethiopia. The population included trauma team members, healthcare personnel, hospital leaders and coordinators from nine hospitals. The data were collected through semi-structured interviews and focus group discussions. The study used the Colaizzi approach and ATLAS.ti 23 software for data analysis. An inductive-deductive strategy, alternating between data analysis and emergent concepts and theories to identify patterns. Memos and display matrices were generated for in-depth analysis.

Results

This study identified several challenges with the trauma care system in Addis Ababa, Ethiopia, including a lack of effective leadership, coordination, and teamwork spirit; insufficient referral connections in the trauma care system; knowledge gaps among health-care professionals; and poor organization of the emergency room and trauma center. In addition, participants perceived that factors such as insufficient pharmaceutical and medical equipment and ineffective ambulance services may have contributed to the increased number of deaths and disabilities among trauma patients in the country.

Conclusion

The qualitative report highlights the gaps in Ethiopia's emergency trauma care system and recommends strategies for improvement, including clear leadership, policies, resources, communication, and continuous training.

Introduction and background

Trauma or injuries are a major global health crisis. Annually, over 5 million people die from injuries, accounting for 9% of worldwide deaths. This surpasses the combined fatalities from HIV/AIDS, tuberculosis, and malaria by nearly 1.7 times [1]. Road traffic accidents (RTAs) remain a major global burden of disease [1]. In 2021, over 1.19 million individuals lost their lives due to RTAs [2]. These incidents are the leading cause of death for children and young people aged 5 to 29 years and rank as the 12th leading cause of death across all age groups [1]. Low- and middle-income countries, particularly in Sub-Saharan Africa, bear a disproportionate burden of these fatalities, with a staggering fatality rate of 26.6 deaths per 100,000 population. This rate is significantly higher than the global average [2]. The impact of RTAs extends beyond the loss of life, with 20 to 50 million people suffering nonfatal injuries [1]. These injuries often lead to long-term disabilities and significant socioeconomic consequences, affecting those who survive [1]. The economic cost of road traffic injuries is estimated to be 3–5% of a country's gross domestic product (GDP), further straining health systems and development efforts [3].

In Ethiopia, the situation is particularly alarming, with a road traffic fatality rate of 26.7 deaths per 100,000 people in 2016 [4]. This is significantly higher compared to high-income countries, where the rate is as low as 2.8 to 3.1 per 100,000 people [5]. This high incidence of RTAs places a heavy burden on the healthcare system, impacting individuals in their most productive years and contributing to high rates of disability and premature mortality [5].

Effective trauma care facilities are crucial for improving patient outcomes and reducing injuries. However, in most low-income countries, such facilities are lacking, and district hospitals often serve as makeshift trauma centers despite limited resources and staff [3, 6, 7]. Furthermore, the prehospital care systems, which are essential for stabilizing patients before they reach the hospital, are underdeveloped in LMICs [8,9,10]. This lack of standardized trauma systems, inadequate training on advanced trauma life support, and poor infrastructure contribute to higher mortality rates [11,12,13,14,15,16,17]. To address these issues, it is crucial to improve leadership, communication, and emergency preparedness, along with addressing infrastructure deficiencies, to enhance trauma care delivery across sub-Saharan Africa [4, 18, 19]. The WHO's Trauma System Agenda emphasizes the need for coordinated care and infrastructure improvements to address these challenges [20,21,22,23].

Ethiopia, like many LMICs, faces significant challenges in providing effective trauma care. Despite the Ministry of Health (FMOH) establishing two trauma centers and emergency departments in all hospitals in Addis Ababa, these facilities often struggle to deliver comprehensive care. Many emergency departments are overwhelmed by various emergencies, resulting in fragmented trauma services [8, 10]. Furthermore, the absence of a robust prehospital care system, including emergency transport and triage, leads to treatment delays and worsened patient outcomes [8, 10]. There is a critical research gap in understanding how these challenges impact the quality and accessibility of trauma care in Addis Ababa.

This study aims to explore the perceptions of trauma team members in Addis Ababa on the current state of the trauma care system and its effectiveness. Identification of gaps in the system seeks to inform future efforts to strengthen trauma care delivery, reduce trauma-related mortality, and improve patient outcomes in Ethiopia.

Methods

Design

In this study, the researcher employed a descriptive phenomenological qualitative approach to gather contextual data from trauma team members regarding the effectiveness of the current trauma care system in Addis Ababa, Ethiopia. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was utilized to report the findings from the interviews and focus groups [24].

Study setting

Ethiopia operates under a federal administrative system with 12 autonomous regional states and 2 city administrations, with its health system structured in parallel through autonomous Regional Health Bureaus (RHBs). The Ministry of Health (MOH) works both directly and indirectly with these RHBs. The Addis Ababa City Administrative Health Bureau (AAHB) is an autonomous body responsible for all health-related matters within the Addis Ababa City Administration. In Addis Ababa, healthcare services are delivered through 14 public hospitals, 42 private hospitals, and 99 health centers. To ensure a representative sample, this study purposively selected nine public hospitals across seven sub-cities, including two trauma centers. The rationale for including only public hospitals is that they serve the majority of Addis Ababa's population, particularly in road traffic accident (RTA) cases, where most patients are transferred. Public hospitals under the MOH and AAHB follow standardized care protocols, providing a consistent and reliable sample. By excluding private hospitals, the study focuses on the public healthcare system, which is responsible for most of the city's healthcare services.

Study population

The population for this study comprised a total of 40 trauma team members working in trauma centers in the nine public hospitals in Ababa, 23 participants for in-depth interviews and 17 participants for a focus group discussion. We used both focus groups and in-depth interviews to gather diverse perspectives from trauma team members. Focus groups explored shared experiences, while in-depth interviews provided detailed insights into individual perspectives [25].

Sampling procedure and sample size

Purposive sampling was used to select participants for this study. Along with the emergency department (ED) coordinators and leaders, the researcher chose participants who were knowledgeable about or had experience with the phenomenon being studied. The sample comprised only trauma team members and clinical staff who had worked for more than six months at any of the nine selected study hospitals. Health-care workers who did not provide emergency trauma care in the selected hospitals were excluded from participation in the study. The sample size for the in-depth interviews was determined by data saturation, which was reached when no new themes emerged after conducting a specific number of interviews. This methodology aligns with established qualitative research practices [25].

Data collection methods and procedures

The interviews were conducted by the Primary investigator and focus group discussions were conducted by a team of experienced qualitative researchers, including three senior anesthetists, all well-trained and working under the supervision of the lead researcher. These discussions involved participants with at least six months of experience in emergency trauma care. The participants included medical directors, emergency department coordinators, liaison officers, one trauma team member from each discipline in the emergency department (such as emergency nurse specialists, emergency medicine physicians, nurses, anesthetists, and residents, and senior specialists from various fields), as well as patient assistants. A total of 40 healthcare workers from nine hospitals were purposefully selected, with 17 participating in five focus groups (each consisting of 3–4 participants) and 23 in in-depth interviews. The in-depth interviews were conducted in person at the participants' or managers' offices to ensure privacy, while the FGDs were held in person at the Health Sciences College of Addis Ababa University. Both methods ensured confidentiality and adhered to informed consent procedures.

An interview guide was used to obtain data from the participants to discuss the challenges and practices of trauma care. Data saturation was achieved through repetitive coding. Interviews were transcribed, translated, and coded as they were conducted, allowing us to keep track of emergent themes. Recruitment ended when no new themes were discovered, according to the idea of data saturation [25].

The interview guide was developed based on a literature review of similar studies [11] and the WHO guidelines for essential trauma care [3]. The interview guide included three main domains with the following probing questions: assessing the trauma and emergency care system, assessing the preparedness continuum of care and coordination of trauma care, and assessing the healthcare team’s preparation and competence. Both the interviews and the focus group discussions were conducted in Amharic, which is the official working language of Ethiopia. The interviews and focus group discussions lasted 30 to 60 min. All interviews were audio recorded, and field notes were also taken.

Data analysis

For accurate analysis, the audio recordings were translated into English, and a qualified qualitative researcher verified the accuracy of the translation. The data from both the in-depth interviews and FGDs were analyzed using the seven-step Colaizzi approach (Fig. 1). Colaizzi's phenomenological data analysis technique involves capturing individuals' lived experiences by identifying significant statements in the data and translating them into meaningful expressions.

Fig. 1

Steps of the Colaizzi analysis of the phenomenological data

The seven-step Colaizzi approach was used to analyze qualitative data, including familiarization with the data, extraction of significant statements, formulation of meanings, clustering of themes, and validation of those themes. Researchers immerse themselves in the data to identify key phrases and ensure the theme accuracy. This flexible process, as depicted in Fig. 1, aims to capture and describe people’s lived experiences by translating noteworthy statements into meaningful insights. Establishing credibility entails testing the final description and essential structure against current studies and gaining confirmation from participants. During the analysis, the validation phase of Colaizzi's technique was addressed, including the major synthesis statement, which highlights the important discoveries and insights generated from the dataset. Any changes to this synthesis statement resulting from participant comments during the review process have been documented. This strategy assures that the validation of the findings with participants is clearly presented and consistent with Colaizzi's methodology, correctly reflecting their actual experiences.

This active technique also helps participants better understand their experiences [26].

The analysis phase involved the preparation of the data, which consisted of transcripts of in-depth interviews. The aim was to identify recurring themes and establish a coding structure. Regarding the coding process, the researcher employed a combination of inductive and deductive approaches. Inductive coding allowed themes to emerge directly from the data, while deductive coding was guided by predefined theoretical frameworks relevant to trauma care. The two approaches were integrated by first allowing themes to surface naturally and then mapping these against existing frameworks to ensure that the analysis was both data-driven and informed by established knowledge. In the initial step of analysis, the transcribed data were imported into ATLAS.ti version 9 (Atlas 23) for coding and analysis. Each text segment was assigned relevant codes, and memos and display matrices were created to facilitate a comprehensive examination of each code.

This process allowed for the identification of subthemes, nuances, and patterns across the interviews. All the transcripts were coded, resulting in a total of 180 distinct codes being used to represent the transcribed interview material, which were further organized into 17 code groups or categories. From these 17 groups, five overarching themes and 17 subthemes emerged, as displayed in Table 1.

Table 1 The identified themes and subthemes (category)

Ethical considerations

Ethical approval was obtained from the Addis Ababa University Health Sciences College Ethical Review Committee (Protocol number 089/21), the Addis Ababa Regional Health Bureau (AA/HB/8501/227), and the study hospitals (PM23/160, PO/14/22, PO/210/22, V409/24/1/2022). All research proposals involving human subjects must be approved by an Institutional Review Board (IRB) or faculty panel. Approval was also granted by the University of South Africa (Unisa) Ethics Committee, along with the regional Health Bureau and the Higher Degrees Committee of Unisa’s Department of Health Studies. Informed consent was obtained from all participants before data collection, and the principles of anonymity, autonomy, confidentiality, justice, non-maleficence, and beneficence were maintained throughout the study.

Rigour

To ensure the rigour of this qualitative study on trauma team members' perceptions of the trauma care system, several strategies were employed. Credibility was achieved through triangulation of semi-structured interviews and document analysis, alongside member checking and peer review for validation [27]. Transferability was enhanced by providing detailed context and participant descriptions, while negative cases were discussed to challenge assumptions [27]. Dependability was ensured through a comprehensive audit trail and regular discussions for establishing intercoder reliability [28]. Confirmability was maintained by acknowledging researchers' biases through reflexivity [27]. Authenticity was prioritized by capturing participants' voices with direct quotations. Ethical considerations included informed consent, confidentiality through pseudonyms, and addressing dilemmas with ethical review boards [27].

Results

Demographic characteristics of the participants

Demographic characteristics of the participants in in-depth interviews

The in-depth interview involved 23 trauma team members from nine hospitals, including 19 men (82.6%) and four women (17.4%) working in emergency trauma centers or emergency departments. The participants comprised different groups of healthcare workers, ranging from nurses and specialists to emergency and critical medicine specialists. The majority (65.2%) of the participants were aged 30 to 39 years. The characteristics of the sample are displayed in Table 2.

Table 2 Demographic characteristics of participants in in-depth interviews (n = 23) and FGD (n = 17)

Demographic characteristics of the focus group discussions

Seventeen participants took part in the focus group discussion. Of these, 76% were male, 70.6% were aged between 30 and 39, and 52.9% had a first degree in a health profession. All participants had 6–10 years of work experience as healthcare providers, with the majority being emergency and critical care nurses (29.4%) nurses (29.4%). In terms of their roles in the emergency department, most were unit heads (58.8%). The demographic characteristics of the participants are detailed in Table 2.

The perceptions of trauma team members toward the trauma care system

The perceptions of trauma team members toward the trauma care system were categorized based on the identified themes, including the basic trauma care system, prehospital trauma care service, preparedness, coordination, continuum of trauma treatment, competency of trauma team members, and solutions, opinions, and desires regarding the trauma care system. The results are presented as follows:

Basics of the trauma care system

Organization of the trauma center/emergency department

According to the study’s findings, participants expressed concerns about the structural organization of the emergency department and trauma center, which is not in accordance with WHO standards for well-planned service delivery, adequate space, ventilation, basic medical equipment and special diagnostic areas on the same floor.

“According to emergency department standards, there is no separate laboratory, pharmacy, imaging, operating room or intensive care unit (ICU) room in this emergency department. We are making use of the central departments. This makes it difficult to give RTA patients the essential evaluation and management.” (IDIP-5)

The research showed that the current emergency department organization hinders systemic trauma care for injured patients, as stated by a senior trauma team member.

“When I evaluated the trauma care system in this country, I concluded that both private and public hospitals provide substandard care. No single hospital fulfills the standard trauma care system. Even the MOH-established trauma center in one of the hospitals is not categorized according to which category of trauma care service it provides.” (IDIP-3)

The research revealed that trauma care centers are not designed to facilitate acute trauma care. All types of emergency patients were admitted to the emergency department, and there was no separate trauma care center. This caused the emergency room to become crowded.

“Currently, the emergency department is under [the] emergency directorate led by [an] emergency and critical care specialist directing both the trauma and non-trauma emergency units [which have] merged. Previously, there was a trauma head leading the trauma center managing only trauma cases, while the non-trauma emergencies were in a separate place where all non-trauma emergencies were managed.” (IDIP-1)

Utilization of policy in the trauma care system

According to the findings of this research, emergency departments do not have unique or customized policies or guidelines. The national guidelines are followed by limited EDs. Even trauma team members are unaware of the existence of these policies, protocols, and standard operating procedures (SOPs).

“I feel lost and helpless in the emergency department. I don’t know who to turn to for guidance or direction. No one ever told me about the guidelines and protocols that I should follow. There is no policy or standard that applies to all the cases I encounter.” (IDIP-12)

The research revealed that the WHO and national standards and protocols should have been customized to the specifics of the hospital, as noted by two superspecialist neurosurgeons.

“This is a very important question; unfortunately, the guidelines, protocols, and standard of practice relevant to trauma care are not prepared. We are working without this protocol. I thought preparing this protocol and using it is necessary. We can customize the international protocols. This is a weakness we both share with our trauma center.” (FGDp-6)

In contrast, some facilities have customized national and WHO guidelines to meet their specific needs.

“… if you come to an emergency, there are many customized protocols in an emergency department, so if someone is confused, they can refer to the protocols. In general, the emergency department has its own guidelines.” (IDIP-6)

Leadership, coordination, and teamwork

The research findings indicate a lack of effective leadership, coordination, and teamwork in emergency trauma centers. This is supported by the trauma team members who participated in the study as follows:

“There is no obvious leadership or structure. Many patients come here every day, but they do not receive sufficient care. They are forced to lie on the floor, with no privacy or supervision. These issues may be resolved, but no one is in charge of this department. It lacks coordination between the staff and the departments.” (IDIP-14)

Access to trauma care

In-depth interviews revealed that patients involved in road traffic accidents overwhelmingly crowded hospitals in Addis Ababa. This overcrowding is primarily attributed to the lack of access to trauma care services in other provinces, resulting in patients being referred to the capital city for treatment.

“The government should prioritize improving hospitals in regions (Province) rather than overspending on Addis Ababa’s overcrowded and resource-dense hospitals, as well as addressing the imbalance in doctor distribution, with half of Ethiopia’s doctors working in Addis Ababa, to ensure better access to trauma care.” (IDIP-3)

The findings of this study also indicate that establishing trauma care centers across the country is a challenging task due to the excessive costs involved in providing trauma care. During an interview, a senior physician emphasized the following:

“One such challenge is the issue of affordability – trauma care comes at a high cost. This makes emergency medical services inaccessible to a large segment of society.” (IDIP-2)

Barriers to effective trauma care

During in-depth interviews, trauma team members shared their perceptions of the challenges within the current trauma care system. The authors understand that the trauma care system is considered unsuccessful due to critical barriers such as the absence of clear guidelines, shortages of essential drugs and medical equipment, limited physical and human resources, poor coordination, and gaps in prehospital care. A senior super-specialist physician with 12 years of hospital experience summarized these issues, stating:

“A lack of sufficient space, resources, staff that is not well trained or is not organized into a team, and a lack of roles that are clearly defined for emergency trauma care are the major challenges.” (IDIP-16)

Another specialist expressed the following concern:

“The patient was rushed to an emergency trauma care center after a serious accident. You are in pain, bleeding and scared. You hope that the doctors and nurses will be able to help you quickly and effectively. However, what if they do not have the supplies, equipment, or diagnostic facilities they need to do their job? What if they cannot even perform a simple CT scan or MRI to determine what is wrong with you?” (IDIP-17)

Another barrier to trauma care is that some road traffic accident patients are unknown and without family. This makes it difficult to provide continuous trauma care, as there is no one to help them. One of the respondents from a trauma center hospital noted the following challenge:

“The other significant problem is the RTA patients who are being brought in by traffic officers. Even as Mr. X patients, these patients are admitted. The patients may not have had any family members. It is exceedingly difficult for them to obtain medicine, and it is also quite difficult for the hospital to dispose of them in a timely manner.” (IDIP-8)

Documentation in trauma care

Trauma team members often fail to properly record the information they obtain from patients and the information they produce when administering medication or planning procedural activities. One actively engaged physician in emergency trauma care said:

“The documentation on the patient chart is unclear and not recorded in accordance with the WHO trauma registry; in other words, it is of poor quality.” (IDIP-3)

Another interviewee highlighted this frequently and mentioned the limitations of the documentation provided by the prior participant.

The patient’s medical record was incomplete. This makes it difficult to obtain information regarding the patient’s treatment and the management plan that was considered for their condition. This may result in the next doctor repeating the same treatment or ordering the same diagnostic tests or procedures.” (IDIP-20)

Another female focus group discussion (FGD) participant mentioned the problem of incomplete referral forms, which can make it difficult to provide continuous trauma care. She explained with the following example:

“The referral paper for RTA patients is often incomplete, with preceding actions not documented. For instance, an old man with rib fractures was arrested after an accident. His relatives confirmed that he had received trauma care at the hospital, and CPR was performed, but this was not documented on the referral page.” (FGDP-13)

Prehospital trauma care

According to in-depth interviews, prehospital care for road traffic accident (RTA) patients is significantly lacking at the national level. According to one respondent, this problem has multiple causes.

"The government and the Ministry of Health are not paying sufficient attention to prehospital care. I believe the fundamental challenge is that it is not a priority, which is why prehospital treatment has not improved” (IDIP-2)

The other participant who took part in the in-depth interview also described his feelings:

“We lost many RTA patients since we didn’t have a well-organized structure and implemented prehospital care. If the ambulances are well equipped, if the RTA patients receive the appropriate prehospital care, we would have saved them.” (IDIP-10)

Ambulance service

Participants in in-depth interviews often criticized the prehospital ambulance service for providing inadequate care, citing a lack of emergency medical supplies and life-saving medications, as well as inadequate equipment.

“Addis Ababa’s ambulances are like minibuses or taxis and cannot provide efficient emergency response. Most RTA patients are transported by private cars and taxis without medical personnel. I suggest building an ambulance dispatch center in each sub city to provide prompt, expert trauma care and smooth transfer.” (IDIP-2)

Communication

Participants in the in-depth interviews agreed that communication is critical for emergency trauma care but is frequently absent or informal in their environment. Poor communication between departments within the same hospital and with various hospitals prevents RTA patients from receiving effective trauma care.

“There are serious problems with communication. I can mention them. For instance, RTA victims either self-refer to our hospital or arrive there without any communication. Some of these patients might need intensive care unit care, at which point the ICU beds might be occupied. other similar cases in this situation are challenging to handle.” (IDIP-8)

Health professionals discussed communication failure during refer-out and refer-in, highlighting that a communication gap leads to congestion in trauma centers, patient complications and even death.

“Poor communication with other hospitals hinders patient referrals due to space and service issues, causing complications such as DVT and delayed wound healing. Situational analysis is needed for trauma patients. The concerned body should consider situational analysis for trauma patients.” (FGDP-3)

Preparedness, coordination, and continuum of trauma treatment

Physical and human resource availability

Interviewees rated the emergency department as too small but noted better staff and diverse health-care specialists. A top staff member, a department head, emphasized the available space:

“Very poor as it was not designed for emergency rather than for an office, and the space is not adequate and trauma and non-trauma patients are kept side by side.” (IDIP-1)

Similarly, another participant in this study, the director of the emergency department, stated the issue of space difficulty word for word as follows.

“The space at this hospital's emergency room is inadequate; it resembles a bazaar, with crowds, noise pollution, and difficulty moving through the crowd to provide care. The space is too small to handle the influx of trauma patients. This hospital has a large catchment area; however, there is insufficient space. Even the health professionals working in this room are subject to trauma.” (IDIP-7)

Trauma team members reported improved staffing levels and a variety of health-care providers with different skills and training levels in teaching hospitals. However, non-teaching hospitals face unfair staffing assignments and a lack of support staff. Patients were referred to teaching hospitals with a wider range of specialists.

“The other issue is a shortage of health workers in the emergency department. It is not appropriate to have a mix of health experts. Nurses make up most health professionals in the emergency room. There are a limited number of emergency and critical care health professionals as well as health officers. Seniors are frequently employed on a call base (they will be contacted as needed).” (IDIP-21)

Participants also noted that supportive staff such as porters, cleaners and patient-recording employees are insufficient.

“No adequate supporting staff helps the health professionals transfer patients to different departments.” (IDIP-7)

Drug and medical equipment availability

The study showed that the lack of medications and medical equipment in the trauma department is detrimental for staff. The interview participants angrily complained about the scarcity of resources. One of the final-year resident students working in the emergency department stated:

“The department does not receive adequate support from the government or the hospital administration. The department lacks sufficient resources, medications, and supplies to treat patients. This forces the team to turn patients away (ignorant). Let me give you a simple example: because there is no emergency drug (e.g., adrenaline) in the emergency department, we force the family to purchase it outside the hospital compound; when they return, the patient may be more complicated or may die. This occurred frequently, so what is the point at which health experts can be obtained if they do not have emergency drugs or equipment to save lives? This is why I said the health practitioners became ignorant.” (IDIP-3)

Participants emphasized the chronic shortage of medical drugs and equipment at their institution. Road traffic accident victims regularly suffer due to this lack of resources. A young emergency and critical care nurse said:

“The emergency department lacks airway equipment and C-collars, which are difficult to obtain. This poses a significant challenge for health-care providers, as they cannot save the lives of injured patients or assist individuals with spinal cord injuries without this essential equipment.” (IDIP−5)

Continuum of care (from acute care to rehabilitation)

The trauma care continuum ensures high-quality care for injured patients from injury to recovery, but its continuation in study hospitals is not adequately supported.

“The hospital's inadequate care for RTA patients is concerning, with patients often experiencing long delays and gaps in treatment and recovery, despite surviving initial emergencies.” (IDIP-12)

Another interviewee also said

“The challenge lies in transferring patients from emergency departments to their respective departments, especially when they require ongoing treatment. This is especially important when the ICU bed is full, as families may not be available to pay for the service.” (IDIP-5)

Participants in the in-depth interviews and focus group discussions revealed that ICU service, a pillar of the trauma care continuum, is limited and not readily accessible in the city.

“The city faces a shortage of ICU care services, with public hospitals occupied and private hospitals expensive. Rehabilitation services are also lacking, limiting patient therapy.” (IDIP-8)

Referral linkage

The respondents highlighted the referral linkage in the trauma care system, and while they all had varied viewpoints, they all agreed on the system’s inadequacies.

“The referral linkage is divided into three major categories: referral with prior communication, referral without prior contact, and self-referral. According to our institutional follow-up and records, only approximately 27% of patients underwent communication. The rest are arriving without warning. Sixty per cent of the total RTA patients were self-referrals. Overall, coordination, referral linkage and communication are inadequate.” (IDIP-8)

Competency of a trauma team member

Knowledge and skill gap in trauma care

Trauma team members need to be able to assess patients’ ABCs, control bleeding and splint fractures and initiate fluid resuscitation. However, participants in this study reported an enormous gap in knowledge and skills among healthcare teams in providing trauma care for road traffic accident patients. The responses were:

“… it is quite visible that staff working at the ED have different levels of experience and training in emergency trauma care. To my knowledge, staff physicians, residents and nurses working in the emergency room have poor organization and a poor knowledge gap in delivering organized holistic care.” (IDIP-16)

Senior physicians reported that health professionals’ incompetence in trauma treatment had a significant impact on patient care, even during transport and surgery.

“There is a significant knowledge gap in trauma care among trauma care team members. The knowledge gap is consistent across all levels of health workers. This shows that the work health force’s knowledge and skill in trauma care are insufficient.” (IDIP-7)

The focus group participants emphasized the need to update trauma team members’ knowledge and skills. The authors noted that the quality of trauma care for road traffic accident patients is declining due to insufficient trauma care training. According to one of the participants in the focus group discussion:

“I mean, I doubt everyone has received ATLS training. Triage, BLS and ATLS training was provided when the hospital first opened. However, it is impossible to say that all of the health professionals who worked at the time remained; some new employees were hired, some employees left the hospital, and there was rotation. It is impossible to say that everyone received training. Perhaps it’s because of the exposure, but those who haven’t had basic training should take it.” (FGDP-5)

Need for training

When asked about their preferred training subjects to improve their competency in providing high-quality trauma care for RTA patients, the interviewees emphasized the need for training on trauma care systems. They stated the following:

“I suggest that health professionals be prioritized when training them on the following major and important topics: Approach to treat critical[ly] ill patients (PTC, ATLS, BLS, ACLS, CRC). This is a critical issue in this institution, and the health workforce should be compassionate, respectful and caring. In this regard, there is an enormous gap, and health care ethics – mainly medical legal issues.” (IDIP-8)

Respondents advocated for the inclusion of trauma care in the curriculum of all health training fields, a new trauma care training programme for trauma nurses and traumatologists such as those in industrialized countries, and first aid and trauma care training for the entire community. Two trauma team members stated the following:

“Trauma care should be included in the curriculum of all health professional training programmes. I don’t think that the undergraduate degree and diploma level have this course in their training.” (IDIP-6)

“It is important, at least in our country, [that] traumatology and trauma nurses should be available, so trauma care will be efficient. The other important point is that if training is given to everyone in first aid, it will be very important. It’s good.” (IDIP-4)

Solutions, opinions, and desires regarding the trauma care system

Trauma care workers seek an improved system with leaders, dedicated units, compliance with guidelines, training, and government support to improve quality care for road traffic accident patients. An experienced senior neurosurgeon with more than 12 years of trauma center experience suggested performing clinical audits of trauma care. Although this activity is frequently disregarded, according to him, it can improve technical management, leadership abilities and the general standards of the trauma care system. He said:

“The clinical audit helps to discover the conceit gaps and provides viable improvement solutions. It is important to audit the trauma care process and outcomes. Only trauma care is not an audited clinical service. This audit will provide answers to the following questions: how many patients arrived, how many were seen, how many received treatments, how many died, and why?” (IDIP-2)

Discussion

The findings of this study reveal both the limitations and the strengths of the existing trauma care system and emergency care delivery in public hospitals in Addis Ababa city Ethiopia. The discussion focuses on key areas such as governance and organization, prehospital care services, the continuum of trauma care, communication and referral systems, knowledge gaps and training needs, and documentation. This comprehensive examination of trauma care delivery in Addis Ababa offers valuable insights into its current condition and areas for improvement.

Governess and organization

Governance

The governance of the trauma care system requires robust policies, regulations, strong leadership, and effective coordination. A spirit of teamwork and collaboration is essential for efficient service delivery. Effective trauma care coordination depends on leadership that spans all levels from trauma centers to the national healthcare system accompanied by community engagement to improve resilience and system functionality [5, 29, 30].

Organization

The WHO guidelines for essential trauma care categorize resources into three groups: physical resources, human resources, and process resources [4, 30, 31]. Standardized trauma facilities must include clearly defined and strategically located areas for clinical, diagnostic, and admission services based on injury severity. Proper layouts, clear directions, and accessible services are critical for optimal operations [2, 30]. In Addis Ababa, the quality of emergency trauma care is compromised by poor organization, inadequate infrastructure, and resource shortages. Challenges include insufficient operating rooms, ICU services, imaging facilities, water and electricity supplies, and shortages of qualified medical personnel, drugs, and medical equipment. Emergency trauma care centers are not designed to handle acute trauma optimally, leading to treatment delays, increased mortality, and morbidity. The lack of infrastructure and resources, particularly for nurses, further exacerbates the situation.

Studies from Southern India [32, 33] and Central Africa [34] report similar issues, such as insufficient infrastructure, absence of trauma teams, and limited specialty services for polytrauma patients, often forcing patients to travel to city hospitals for basic procedures. In low- and middle-income countries, these gaps contribute to high rates of surgical site infections and hospital-acquired infections due to inadequate healthcare infrastructure, lack of skilled personnel, and limited financial investment in trauma care systems [33, 35, 36].

Policies and leadership

This study revealed that emergency departments and trauma centers lack tailored policies, protocols, and practice guidelines. Hospital executives often possess relevant policies but fail to effectively communicate them to trauma team members. Similar findings have been reported in Nigeria [3], where poor coordination leads to suboptimal trauma services. Common barriers include insufficient funding, weak leadership, and inadequate regulation. Scholars suggest that improving trauma care requires expanding prehospital care, enhancing organizational frameworks, and strengthening leadership [29, 36, 37]. Effective trauma care coordination demands strong leadership, community engagement, and regional collaboration. However, many hospitals lack a designated individual to oversee emergency preparedness, response, and recovery, resulting in resource shortages, duplication of services, and decreased staff morale.

Clear policies, protocols, and standardized practice guidelines are crucial for improving trauma care outcomes [29, 30, 38, 39]. Addressing these challenges through improved leadership and organizational strategies will enhance the quality and efficiency of trauma care services.

Prehospital care service

Prehospital care is nonexistent in Addis Ababa due to poor coordination and lack of guidelines and protocols. Ambulances lack medical supplies and skilled staff. Patients are often transported to the hospital by private cars or taxis, delaying their arrival and worsening their injuries. Poor communication between departments and hospitals also delays referrals and complicates patient care.

According to our findings, prehospital care capabilities vary significantly between low- and middle-income countries but are less developed in low-income countries and rural areas [37]. Nigeria lacks a national prehospital trauma care system, while other African countries have improved prehospital services [3, 40]. In Ethiopia, taxis and minibuses are the most common means of transportation from the scene to the initial medical facility. Some form of care is provided at the scene in 46.2% of patients, but the most common reason for not providing care is a lack of knowledge and equipment [40, 41]. Studies from Ethiopia and Pakistan concur that a lack of information systems and poor communication are major obstacles to emergency trauma care in Addis Ababa [6, 7].

This study revealed that prehospital care in Addis Ababa is hindered by the lack of a legislative framework, universal access number, effective triage, and patient handover. To improve the situation, the government should develop a national plan, provide training, equip vehicles, and raise awareness about the importance of prehospital care.

Continuum of trauma care

The continuum of trauma care is crucial for injured patients [11, 42]; however, the findings of this study reveal that many hospitals cannot provide continuous care. This leads to delays and gaps in care, which can have negative consequences for patients and their families, including longer hospital stays, higher healthcare costs and adverse psychological effects. Rehabilitation and psychological therapy are essential for trauma patients, but they are often unavailable.

The findings of this study also showed that a city’s trauma care system is inefficient due to poor coordination, insufficient hospital capacity and lack of essential services. A study in Ghana revealed a similar problem with trauma care delays, with emergency surgery delayed by an average of 12 h [12]. This leads to delays and gaps in care, which can have negative consequences for patients, including increased mortality and morbidity rates, longer hospital stays, higher healthcare costs and adverse psychological effects.

Communication and referral system

Analysis of the referral linkage system revealed significant deficiencies, with most patients arriving without prior notification or communication. This lack of coordination, communication, and feedback hinders referrals for emergency specialist services and impacts ward bed availability. The system is passive, with patients remaining without definite trauma therapy for more than ten days. Contrary to the findings of this research, Cambodia, and sub-Saharan Africa face challenges in patient referral linkage due to inadequate formal mechanisms, informal networks, distances, transportation expenses and inability to document referral reasons [8, 9].

Similarly, Addis Ababa city faces higher road traffic accident mortality and morbidity due to a poorly coordinated referral system and inadequate documentation. Improving prevention and management is crucial and involves formal and informal networks, reducing costs and improving documentation.

Knowledge gap and training

The findings of this study indicate that health professionals have more knowledge gaps in airway management, circulatory management, disability management and the exposure phase of the ABCDE scheme of primary trauma care management. This is significant since trauma team members have deficits in knowledge of all parts of the ABCD steps except for breathing. This finding is consistent with the findings of previous studies in which medical professionals had a moderate understanding of the ABCDE scheme, with circulation management being the least understood component [14,15,16,17, 43,44,45]. Although medical practitioners are well-prepared to deliver primary trauma treatment using the ABCDE method, the findings suggest that further training and education may be needed. Updated training in ATLS, BLS, ACLS, PTC, and CRC is recommended for all health professionals.

Documentation

Prehospital care professionals must provide life-saving care and document vital signs, injuries, and patient responses [14, 15, 43]. Patient information is not properly recorded by trauma team members in trauma centers and emergency rooms, which could lead to delays in treatment, missed diagnoses and poor outcomes. In addition, training on the WHO trauma registry format should be provided, as should a system for tracking patient documentation and ensuring that it is completed accurately and in a timely manner. This study recommends strategies to address the challenges of the trauma care system in Addis Ababa, Ethiopia.

Strength of the study

Qualitative research offers a comprehensive understanding of trauma team members' perspectives, emphasizing participant-centricity and flexibility. This approach allows for contextual relevance, providing valuable insights into attitudes and experiences within the trauma care system.

Limitations of the study

The study of trauma care in Ethiopia has limitations, including limited generalizability, reliance on self-reported data, exclusion of certain facility types and private hospitals, and a focus on Addis Ababa. Additionally, it neglected the trauma of patient satisfaction, treatment quality, cultural factors, long-term conditions, and implementation costs. Qualitative data interpretation may be influenced by research bias, and findings may not apply to larger populations. Data collection, transcription, and analysis are time-consuming, and interpreting complex qualitative data requires skilled researchers. Miscommunication due to varying participant articulation skills could also affect data accuracy.

Conclusion and recommendations

The qualitative report in Addis Ababa, Ethiopia, highlights the gaps and challenges in the emergency trauma care system. Strategies, including clear leadership, policies, resources, communication, and continuous training, are recommended for improving quality treatment. A comprehensive and collaborative approach is needed to address these issues. Further research is suggested to evaluate the impact of the proposed strategy, explore implementation barriers and facilitators, and compare the cost-effectiveness of different interventions. This report underscores the importance of quality emergency trauma care and the need for continuous improvement in the healthcare system.

Operational definitions

The golden hour: is a critical concept in trauma care, emphasizing the urgent need for definitive medical intervention within the first 60 min of a severe injury.

Emergency trauma centre: A specialized medical institution that provides immediate and comprehensive care to patients who have suffered serious trauma-related injuries.

Trauma care: Care that is provided within structured care settings, such as pre-hospital care, acute care hospitals, rehabilitation centres and community health systems.

Trauma continuum: Extends from the time of injury, throughout recovery, and to the outcome.

Trauma team members: health professionals who provide care to injured patients in the Emergency department and include medical directors, coordinators, nurses, anesthetists, surgeons, neurosurgeons, Orthopedics surgeons and specialists from emergency medicine.

Patients: Persons who have suffered an acute injury.