Management of Traumatic Injuries of Road Traffic Accident Victims in the City of Ouagadougou at the University Hospital Trauma Emergency Department-Yalgado Ouédraogo

Purpose: To evaluate the management of traumatic injuries of accident victims in the city of Ouagadougou admitted to the trauma emergencies of the University Hospital of Ouagadougou. Material and Method: This was a descriptive prospective study of road traffic accident victims in the city of Ouagadougou on their arrival at trauma emergencies and on the 7th and 30th day after their discharge. A total of 991 patients were identified. The sex ratio was 1.94 with a male predominance. The average age of the patients was 31.5 years. The ratio of caregivers to patients on a 24-hour shift was 7/47, excluding patients hospitalized in the corridors. Results: We note that 81.94% of patients were transported by the fire brigade. The average time to first contact with a caregiver was 11 minutes. Upon admission, accident victims were accompanied in 84% of cases. The combination of paracetamol and néfopam was the most prescribed analgesic (50.2%). The average time between admission and X-ray completion was 101 minutes. Benign skin lesions were the most frequent (48.82%), followed by osteoarticular lesions of the limbs (frac-tures and dislocations). Ceftriaxone, ment. Conclusion: The management of patients admitted to trauma emergencies is satisfactory, but difficulties remain in terms of delays in management. It is imperative to take into account certain factors involving both staff and working conditions in order to reduce the time required to provide care and improve user satisfaction in this emergency unit.


Introduction
Today, road traffic accidents are a major public health problem [1]. According to the World Health Organization's 2014 report, road traffic accidents killed an estimated 1.25 million people worldwide in 2013 and injured between 25 and 50 million people. These accidents were the leading cause of death among young people aged 15 to 29 worldwide in 2012; and the highest rate was observed in Africa (26.6 deaths per 100,000 inhabitants) where road accidents are the 5th leading cause of death. Surgical emergency departments, the usual place of admission for accident victims, often have malfunctions, particularly in Africa [2]. At the Yalgado Ouédraogo University Hospital (CHU-YO) in Ouagadougou, road traffic accidents are the second leading cause of death, after malaria [3]. Timeliness and quality of care are factors that influence morbidity and mortality. Unfortunately, very high attendance in a hospital does not ensure optimal patient care. Nowadays, the real indicator for evaluating the performance of a health centre is not only its technical platform but also its ability to meet patients' needs and expectations in a global way [4]. The evaluation of the quality of care is an approach that makes it possible to guarantee each patient diagnostic and therapeutic procedures capable of ensuring a better result, in accordance with the current state of medical science [5]. Hence, the objective of this study, which is to evaluate the management of accident victims admitted to our trauma reference centre.

Materials and Method
This was a descriptive prospective study conducted over a period of 06 months,

Results
The mode of admissions to trauma emergencies: The National Fire Brigade (BNSP) urgently transported 81.94% of the injured (Table 1).
Waiting times: − The average waiting time was 11 minutes with extremes from one (1) minute to one (1) hour 14 minutes. We note that 97.2% of the injured had their first contact with a medical staff in less than 30 minutes after their admission. The results are presented in Table 2.

− Arrival times for accompanying persons
The average time of arrival of a companion was 07 minutes. We note that 84% of patients were accompanied by a parent when they were admitted to the emergency room.  Prescriptions for analgesics and/or anti-inflammatories: The combination of paracetamol and néfopam was prescribed for half of the injured (50.2%), compared to 27.21% for paracetamol and tramadol. Table 3 reports the prescription of analgesics and/or anti-inflammatories in 849 patients.
The delays between admission, the prescription of radiographic examina- Thus, the average time between admission and radiographs is 101 minutes (1 hour 41 minutes). The results of these delays are shown in Table 4.
The prescription of scan examinations: Eighty-nine patients (09%) were prescribed scans. The brain scan was per-    A total of 2540 different types of injuries were diagnosed in the 991 injured. We note that 48.8% of the accident victims in our series had minor skin lesions, followed by osteo-articular lesions such as fractures and dislocations (28%). The different types of injuries encountered are shown in Table 5.
The prescription of biological examinations: No biological examination was prescribed in 78.61% of cases. On the other hand, 212 wounded (21.39%) received a biological examination prescription, with a 93% completion rate (197 patients).
The prescription of care kits: − Seven hundred and seventeen patients (72%) received a prescription for kits for their management during their stay in trauma emergencies. A total of 709 patients (approximately 99%) honoured the prescription of their kit, including 304 kits for local care. Table 6 shows the distribution of patients by type of medical kit prescribed. − The average time between prescribing and obtaining the kits was 13 minutes with extremes of 02 minutes and 01 h 42 minutes. 76% or 540 patients obtained their kit in less than 15 minutes compared to 37 (5%) who obtained it after more than one (01) hour of waiting.  The prescription of medical treatments: A total of 536 patients had received a prescription for antibiotics, 531 (99%) of whom filled their prescriptions. Ceftriaxone, and the combination of Amoxicillin + Clavulanic Acid were the most prescribed antibiotics. Table 7 summarizes the different types of antibiotics prescribed.
Among other medical treatments administered, serum and tetanus vaccine prescriptions, and anticoagulants were the most frequent. Figure 2 shows the distribution of patients according to the drug treatments received.
Orthopedic and/or surgical treatments: Local care, in 44.62% of cases, accounted for the majority of emergency care through touching, sutures associated with simple dressings. Orthopedic care was followed in 37.91% and the trimming of open fractures in 14.34%. Emergency osteosynthesis was performed in 3.12% of cases. These different types of processing are represented in Table 8.  Delays between admission and therapeutic management: The average time between admission and orthopaedic and/or surgical treatment was 04 hours 25 minutes with extremes of 15 minutes and three (03) days.  Table 9 summarizes the distribution of patients by discharge and transfer mode.

Discussion
Surgical emergencies in Africa are characterized by a chronic mismatch between patient needs, diagnosis and treatment [2].
Pain is the primary reason for emergency trauma consultation and its management reveals the level of patient satisfaction [4] [6]. Its impact must be systematically assessed from the first contact with the patient, but unfortunately this is not systematic in our emergency department [6]. In our working context, paracetamol is the most prescribed analgesic for emergency pain management [6], and it has been administered to 74.75% of our patients. Paracetamol and Nefopam were prescribed in 42.98% of patients, followed by paracetamol and Tramadol in 23.3% of cases. In addition, combinations of Tier 1 and Tier 2 analgesics are commonly used, and aim to seek a synergistic analgesic effect, more powerful to act on pain [6]. It is important to have a pain assessment and management protocol in trauma emergency management units [6].
Reception and waiting time before treatment are among the factors that negatively influence patient satisfaction [4] [7] [8]. The average time for orthopedic or surgical treatment was 04 hours 25 minutes in our study. Adamou et al. [4] suggested that the existence of management kits and especially the severity of the trauma make waiting time significantly shorter. Our patients waited on average 53 minutes to have a prescription for radiographic and biological examinations and one (1) hour and 40 minutes for a scanner prescription. Ricroch et al. [9] observed: 30 minutes for the start of first aid; in case of hospitalization 126 minutes for the decision to hospitalize and 106 minutes in case of conventional radiography, 168 minutes in case of a biological procedure. The large number of short, these delays depend on the pathology, the type of establishment but also on the number of patients present in each structure, itself a function of the time of day [9]. Within our trauma emergency department, there is no medical imaging station or biology laboratory. These exams are sometimes even done outside the CHU-YO. In addition, radiography and laboratory examinations are no longer part of the non-prepaid care system. While this system was set up at the time to compensate for delays in treatment in the various surgical, gynaecological and medical emergency units. Abd Elaal et al. [5] in Sudan reported an average of 9.44 minutes of waiting time.
In our current study, 97.87% of patients performed the radiographic examinations prescribed for them. The low cost of standard radiography has enabled almost all of the injured to carry out this examination. The other patients who did not perform the radiographic examinations blamed the lack of financial resources. We noted an average time of 48 minutes between prescription and radiographic examinations. This relatively long delay could be explained by a number of factors: the comings and goings of accompagnants for invoicing between emergencies-the radiology service-the cash register, and the insufficient number of stretcher-bearers.
Ceftriaxone (29.94%) was the most prescribed antibiotic, followed by Amoxicillin-Clavulanic Acid (19.02%). Our results differ from those of Elkharrat et al. [1] who, in France, reported a predominance of penicillin prescription (57.2%), followed by fluoroquinolones (20.8%), and C3G (10.4%). The lack of follow-up of protocols and recommendations regarding the choice of antibiotics is a reality in our department. We noted a predominance of local care (simple dressings and sutures) in 32.83% of cases. At the time of our study, in the city of Ouagadougou, there were three medical centres with a surgical antenna and a university hospital located in the southern suburbs, which could accommodate moderate to severe traumatic emergencies; but the lack of sorting when the injured were picked up by the rescue workers of the National Brigade of Fire Brigades meant that even minor traumatic injuries were found in large numbers in our department. The average time of surgical treatment was 04 hours 25 minutes with extremes of 15 minutes and 03 days. Three factors can explain the slowness of surgical management in our emergency: the factor of the nursing staff, the quality of the technical platform and the solvency of the patient. Staff, although insufficient in number, are affected by a lack of willingness because they say they are sufficiently motivated financially, compared to the excessive workload. To this must be added frequent breakdowns both in the operating room (lack of oxygen and autoclave for sterilization), as well as in the medical imaging department (radiography and scanning). Consumable ruptures are also frequent: of labile pharmaceutical and blood products. In addition, there is a lack of financial resources for patients to pay for surgical prescriptions, which cost an average of 600 US dollars. The introduction of universal health insurance, which could help to reduce the time Satisfaction reflects an individual's judgment resulting from the transformation of objective findings into subjective judgments [8] [12]. Thus, it is seen as an emotional response, a value judgment of the subjective experience lived by the individual on the service he or she experienced on an initial baseline [12].
The evaluation of user satisfaction with public services has been widely used to improve the quality of service provided to users [4] [8] [12]. In our current study, 95% of our patients were satisfied, 66% of whom were very satisfied with their management. Compared to the literature, our rates are higher than those found by several authors [4] [8] [11]. Caregiver competence, courtesy and satisfactory reception are factors that positively influence patient satisfaction [7] [8].
This is reflected in the low rates of dissatisfied 5% in our series and 4.4% in Nguyen's in Vietnam [13].
Although prospective, our study had some limitations, namely that: − Some patients probably could not be collected; − The subsequent lack of follow-up of patients after they left the trauma emergency unit (after D30) did not allow us to assess the evolution and satisfaction rate in the medium and long term.

Conclusion
The care of road traffic accident victims in the city of Ouagadougou admitted to trauma emergencies is satisfactory, but difficulties remain in terms of delays in care, due to the inadequacy and "lack of motivation" of the medical staff, the inadequacy of the technical platform and the solvency of the patients. It is imperative to take these various factors into account in order to reduce the time required to provide care and improve user satisfaction in this emergency unit.