Cross-sectional study of the educational background and trauma knowledge of trainees in the “China trauma care training” program

Background Since the trauma knowledge of trauma providers correlates with the outcomes of injured patients, this study aims to assess the socio-demographic characteristics and levels of trauma knowledge of trainees in the China trauma care training (CTCT) program in addition to their post-course test results to provide support for the development of trauma care training programs and trauma systems in China. Methods A cross-sectional study was conducted by collecting demographic information, hospital-related information and trauma knowledge of the trainees from 19 regions in China. All participants were assessed by questionnaires collecting the socio-demographic data, the trauma care knowledge levels and the information of the hospitals. Results There were 955 males (78.9%) and 256 females (21.1%) enrolled. Among them, 854 were physicians (70.5%), 357 were registered nurses (29.5%). In addition, 64 of them also played an administrative role in the hospitals (5.3%). The score of the trainees who were members of the emergency department staff (72.59 ± 14.13) was the highest among the scores of all the personnel surveyed, followed by those of the trainees from the intensive care unit (ICU) (71.17 ± 12.72), trauma surgery department (67.26 ± 13.81), orthopedics department (70.36 ± 14.48), general surgery department (69.91 ± 14.79) and other departments (69.93 ± 16.91), P = 0.031. The score of the professors (73.09 ± 15.05) was higher than those of the associate professors (72.40 ± 14.71), lecturers (70.07 ± 14.25) and teaching assistants (67.58 ± 15.16), P < 0.0001. The score of the individuals who attended experts’ trauma lectures (72.22 ± 14.45) was higher than that of individuals who did not attend the lectures (69.33 ± 15.17), P = 0.001. The mean scores before and after the training were 71.02 ± 14.82 and 84.24 ± 13.77, respectively, P < 0.001. The mean score of trauma knowledge after the training of trainees from different provinces and with different educational backgrounds was higher than that before the training, with a statistically significant difference (P < 0.05). Conclusions The level of trauma knowledge of trauma care providers was associated with their department, professional position and previous participation in related academic conferences. Trauma care experience and participation in academic lectures and training program including CTCT may effectively improve individuals’ level of trauma knowledge.


Introduction
With social developments and scientific advancements, injuries caused by trauma, such as motor vehicle crashes and terrorist attacks, are becoming increasingly serious. Among the causes of death in mainland China, trauma ranks fifth, and there are 700,000 deaths each year that are caused by trauma [1,2]. The emergency medical service for trauma in mainland China is not ideal; only the emergency medical service system is responsible for trauma care. Providing high quality trauma care requires professionals with extensive experience in dealing with trauma. The systematic management of trauma patients according to protocols for prompt and proper trauma care could help improve the quality of trauma care and thus save the lives of trauma patients.
Adequate and experienced trauma providers are critical for reducing deficiencies during trauma care. Trauma care training for specific trauma providers can effectively improve the general concepts and techniques employed in trauma care. However, because trauma care providers have different educational backgrounds, they may exhibit different levels of understanding of the information provided in trauma care training. In the United States, different levels of trauma care courses are available for personnel with different educational backgrounds; for example, an advanced trauma life support (ATLS) course and a trauma evaluation and management course are available for medical students to learn ATLS-related concepts during their clinical training year [3][4][5]. China trauma care training (CTCT), initiated by the Chinese Medical Doctor Association, is a standardized training program for trauma providers in China that targets the deficiencies in trauma care in mainland China [6,7]. The 1.5-day course includes lectures, videos, a case conference and workshops. The CTCT program aims to train medical practitioners to independently and effectively assess and treat patients with severe trauma, such as polytrauma. Initially launched in July 2016, the program has been held more than 80 times, and has included 5000 trainees in 22 provinces in mainland China through January 2019 [7,8].
The purposes of this study were to collect information on the educational backgrounds of the trauma providers in mainland China and to evaluate the correlation between their background and trauma care knowledge to provide empirical support for trauma care training and the establishment of a trauma care system.

Questionnaire design and definition
The questionnaire was designed and administered using the Wenjuanxing software (Changsha Ranxing Information Technology Co. LTD). The questionnaire consisted of 3 parts: 1) collections of socio-demographic data (sex, age, professional position, department, type of personnel (physician, nurse; administrative staff or not), practicing years in trauma care, and previous trauma training experience); 2) information on the hospital in which the participant provides treatment (tier of hospital, trauma care regimen, and the self-estimated number of admitted major trauma cases); and 3) trauma care knowledge evaluated by the scores on the questionnaires.
For the part of participant's demographic data, the specific definition for some items include: 1) the professional positions included senior level, subsenior level, intermediate level, and junior level; 2) the departments included emergency department, ICU, department of traumatology, department of orthopedics, general surgery department and others; 3) the types of care worker included physician and registered nurse. At the same time, whether the participants played an administrative role was also surveyed; 4) the years of experience in trauma care were classified as 0-1 years, > 1-3 years, > 3-5 years, and > 5 years; and 5) the types of traumarelated continuing medical education (CME) training included regular internal special study, hospital learning of case analysis, trauma-related academic conferences, domestic/overseas training, nonstandard trauma courses, and self-study.
As for the hospital information, three aspects were covered: 1) The hospital level was classified according to the tiers certificated by the Ministry of Health, which include Grade III-A, Grade III-B, Grade II-A, Grade II-B or below. 2) The intrahospital trauma care regimen was classified as one of the following regimens: emergency department + multidisciplinary consultation + dispersed treatment in multiple departments of surgery; centralized treatment in the emergency department; centralized treatment in general surgery department; centralized treatment in the department of orthopedics; or other.
In the last part of the questionnaire, trauma care knowledge was evaluated. The participants received the evaluation about trauma care knowledge twice (i.e., before and after the training). The questions covered three aspects: initial knowledge assessment, knowledge reassessment and case analysis of trauma care. There were 20 questions in total, with 5 points for each question and a possible total of 100 points (Fig. 1).

Statistical analysis
A normal distribution test and a homogeneity test of variance were performed for the quantitative data, which are expressed as the mean ± SD. Attribute data are expressed as constituent ratios. A generalized linear model was used to analyze the different background factors and questionnaire scores. The scores on the trauma knowledge test before and after the training were compared by a paired samples t test. All analyses were performed using SAS 9.13 (SAS Institute Inc., USA), and P < 0.05 was considered statistically significant.

Socio-demographic characterization of the participants
A total of 1212 trainees who participated in the surveys were from 19 regions; one participant was excluded, and therefore, a total of 1211 participants were included in this study. The highest and the lowest number of participants among the surveyed regions was 119 and 39, respectively. There were 955 males (78.9%) and 256 females (21.1%) with an average age of 37.19 ± 7.12 years. Of the care providers, 854 (70.5%) were physicians, 357 (29.5%) were nurses. In addition, 64 of them also played an administrative role in the hospitals (5.3%). There were 496 (41.0%) intermediate-level staff, which was the job title that corresponded to the most individuals in this survey. In terms of the departments in which the care providers served, the number of personnel from an emergency department was 501 (41.4%), which was the highest number for any department in this survey. For years of experience in trauma care, 749 (61.9%) care   Table 3.

Evaluation of trauma care knowledge
The total mean score on the trauma knowledge test after the training (84.24 ± 13.77) was higher than that before the training (71.02 ± 14.82), P < 0.001 (Table 1). When evaluating the participants' performances considering the years of experiences in trauma care, professional title, past trauma training or trauma care mode, all of the exam scores for trauma care after the training were significantly higher than that before the training (P < 0.05, Table 4). Tables 5 and 6 show the actual content and number of correct answers on the examinations of trauma care knowledge administered before and after the training. Among all the scores of trauma knowledge before training, the highest score was 75.97 ± 12.77, and the lowest score was 60.77 ± 10.29. The overall average score was 71.02 ± 14.82. The score for the care providers from emergency departments was 72.59 ± 14.13, which was higher than that for those from intensive care units (ICUs) (71. 17

Discussion
This study investigated the educational backgrounds of trauma providers and their trauma care knowledge test results through a multi-center cross-sectional survey with the aim of analyzing and understanding the correlation between individuals' backgrounds and test results. The care providers who work in an emergency department, have a senior level title and have previously received expert-led training have the highest level of trauma care knowledge, and previous experience in trauma care and expert-led training can improve the level of trauma care knowledge of an individual. The exam scores for all participants with different backgrounds after the training were higher than those before the training, indicating that CTCT played a significant role in improving trauma care knowledge. In terms of the care of patients with severe trauma, accurate assessment and immediate treatment affects the outcome of trauma patients [9,10]. However, a lack of knowledge regarding the diagnosis and early treatment severely limits the administration of optimal treatments for trauma patients. The results of our study are similar to those of many trauma knowledge surveys conducted in countries other than China. In 2018, Yigit et al. [11] conducted a questionnaire survey on the knowledge, educational level and confidence level of 109 doctors attending the Turkish National Symposium on Emergency Medicine regarding dental trauma diagnosis and treatment. The authors found that a physician's years of emergency care experience, his or her age, and whether he or she was a family dentist were the factors that most strongly correlated with trauma knowledge. In 2013, Nasr et al. [12] conducted a questionnaire survey on dental trauma knowledge among physicians at 9 emergency hospitals in New South Wales, Australia. The results showed a strong correlation between physician titles and trauma care knowledge, but there was a significant linear correlation between previous training of the physicians and dental trauma knowledge [4,13,14].
The medical staff in the emergency department received the highest score on the exam of trauma care knowledge, and this result may be related to the following factors: the trauma care system in China is different from the hierarchical trauma care systems in the United States and New Zealand [15,16]. In the inland areas of China, the prehospital care system for trauma patients is mainly managed by the emergency department of hospitals. China has established a trauma care system with an emergency department in accordance with the "three-link theory", that is, there is a prehospital emergency department for trauma care, in-hospital care and intensive care [9,13,15]. The "three-link theory" similarly reflects the early damage control surgery, resuscitation care and post rehabilitation care components of the trauma care law. In addition, the staff in the emergency departments were the first individuals to accept the idea of trauma care and practice trauma care, which helped them to learn and accumulate trauma knowledge [7,17,18]. The reasons that the participants with a senior professional title obtained higher scores than individuals with lower ranking titles may be as follows: in China, before being transferred to other professional departments for treatment, the emergent critical trauma patients need a prehospital consultation, which is most frequently conducted by the medical staff with a senior professional title. In recent years, trauma medicine in China has been advancing. Trauma is gaining more attention in the medical field and society. A regional trauma care system has been established in each region according to the regional characteristics, and in this process, the staff with a   senior professional title plays an important role [14,15,19]. The staffs with a senior professional title are more exposed to critical trauma cases, participate more in the development of the trauma care system, and accumulate more trauma care knowledge, so they have a higher level of trauma care knowledge [20,21]. The individuals who participated in trauma conferences received high scores on the exam of trauma care knowledge. The reasons that these individuals received higher scores after CTCT than before the training may be as follows: the core knowledge of trauma care and the theory of levels of care in   [n (%)] to a car accident; a splint is adopted to fix the wound after restoration. The patient is transferred 36 h later due to right leg swelling and sharp toe pains. The examination results are as follows: obvious swelling, cyanoderma and numbness on the right toe, and poor toe movement are present, capillary filling still exists after the splint is removed, the right leg is quite swollen, the skin temperature is high and blisters appear on the skin. The most likely complication is: This study has some limitations. The inclusion criteria for the participants had certain limitations and can only partially represent the current situation of trauma providers in China. Trauma care knowledge involves a wide range of subjects, and a relatively small number of questions were addressed in this survey, which can only partially reflect the level of trauma care knowledge of the participants.

Conclusions
The levels of trauma care knowledge of trauma providers in China are related to their backgrounds. Previous experience in trauma care and participation in expert-led academic training conferences for trauma care can improve individuals' knowledge of trauma care. CTCT can improve trainees' level of trauma care.