{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T11:38:35Z","timestamp":1774438715494,"version":"3.50.1"},"reference-count":40,"publisher":"BMJ","issue":"4","license":[{"start":{"date-parts":[[2023,4,25]],"date-time":"2023-04-25T00:00:00Z","timestamp":1682380800000},"content-version":"unspecified","delay-in-days":24,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100002076","name":"Emergency Medicine Foundation","doi-asserted-by":"publisher","award":["2017-2019 research fellowship award"],"award-info":[{"award-number":["2017-2019 research fellowship award"]}],"id":[{"id":"10.13039\/100002076","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100006108","name":"National Center for Advancing Translational Sciences","doi-asserted-by":"publisher","award":["UL1 TR002535"],"award-info":[{"award-number":["UL1 TR002535"]}],"id":[{"id":"10.13039\/100006108","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000050","name":"National Heart, Lung, and Blood Institute","doi-asserted-by":"publisher","award":["1K12HL137862-01"],"award-info":[{"award-number":["1K12HL137862-01"]}],"id":[{"id":"10.13039\/100000050","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100009898","name":"Defense Health Agency","doi-asserted-by":"publisher","award":["FA8650-18-2-6934"],"award-info":[{"award-number":["FA8650-18-2-6934"]}],"id":[{"id":"10.13039\/100009898","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2023,4,13]]},"published-print":{"date-parts":[[2023,4]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>This project seeks to improve providers\u2019 practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>We conduct a two-arm, controlled, mixed-methods, hybrid type II study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcome measures<\/jats:title>\n                    <jats:p>We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (\u22121.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2021-060338","type":"journal-article","created":{"date-parts":[[2023,4,25]],"date-time":"2023-04-25T11:49:18Z","timestamp":1682423358000},"page":"e060338","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4303-6903","authenticated-orcid":false,"given":"Nee-Kofi","family":"Mould-Millman","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julia","family":"Dixon","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brenda L","family":"Beaty","sequence":"additional","affiliation":[{"name":"Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7785-3536","authenticated-orcid":false,"given":"Krithika","family":"Suresh","sequence":"additional","affiliation":[{"name":"Department of Biostatistics & Informatics, University of Colorado School of Public Health, Aurora, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shaheem","family":"de Vries","sequence":"additional","affiliation":[{"name":"Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Beatrix","family":"Bester","sequence":"additional","affiliation":[{"name":"Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fabio","family":"Moreira","sequence":"additional","affiliation":[{"name":"Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8188-0307","authenticated-orcid":false,"given":"Charmaine","family":"Cunningham","sequence":"additional","affiliation":[{"name":"Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Belville, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kubendhren","family":"Moodley","sequence":"additional","affiliation":[{"name":"Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Radomir","family":"Cermak","sequence":"additional","affiliation":[{"name":"Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Steven G","family":"Schauer","sequence":"additional","affiliation":[{"name":"US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joseph K","family":"Maddry","sequence":"additional","affiliation":[{"name":"US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3456-6008","authenticated-orcid":false,"given":"Corey B","family":"Bills","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Edward P","family":"Havranek","sequence":"additional","affiliation":[{"name":"Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vikhyat S","family":"Bebarta","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adit A","family":"Ginde","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2023,4,25]]},"reference":[{"key":"2025121222353615000_13.4.e060338.1","unstructured":"World Health Organization . 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