Dental Traumatology 2014; doi: 10.1111/edt.12155
Emergency management of traumatic dental injuries in 42 countries Doaa Alnaggar, Lars Andersson Department of Surgical Sciences, Faculty of Dentistry, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
Key words: injuries; trauma; organization management; treatment Correspondence to: Prof Lars Andersson, Oral and Maxillofacial Surgery, Department of Surgical Sciences, Faculty of Dentistry, Health Sciences Center, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait City, Kuwait Tel.: +965 24636695 Fax: +965 24636732 e-mail: [email protected] Accepted 25 October, 2014
Abstract Availability and quality of emergency services for traumatic dental injuries (TDI) are important as the prognosis of TDI is decided at the place of accident or during the first hours after the injury has occurred. – Aim: To report how emergency services for TDI are provided in some places around the world. Subjects and methods: This is a preliminary observational study of descriptive character. One-hundred and three participants from 83 cities in 42 countries described the emergency services in their city by answering a questionnaire related to: (1) availability of advice per telephone at the place of the accident; (2) availability of emergency treatment resources at different times of the day; and; (3) assessment of competence level of the person carrying out the service. Answers and comments were scored with regard to availability and level of competence. Results: 62% of the participants were not satisfied with their current emergency services. 50% reported organized emergency telephone service always available. 43% of the advice given by phone was from professionals with dental training. An organized on-call 24/7 service was available in 33%. Treatment of TDI within the first hour was available in 53%. A competent dentist was available in 40%. 56% reported compromised competency outside office hours. Places with a well-organized system built on a well-developed first-line care managed by trauma-trained general dentists, ideally on a 24/7 basis, supported by on-call specialists outside office working hours, achieved the highest scores. Conclusions: With all the limitations of a preliminary questionnaire study, we can conclude that there is a need to perform more comprehensive well-designed studies in this field to understand more of the varying quality of emergency services worldwide. The major problem today seems to be related to limited availability and competence, especially outside office working hours.
Oral trauma accounts for around 5% of all bodily injuries, with even higher occurrence among young children (1). Traumatic dental injuries (TDI) comprise 95% of all oral injuries and have a high incidence (1, 2). TDI are usually not a life-threatening emergency, and for that reason, it may be perceived as a less urgent condition by the public, as well as the staff in emergency departments (3). However, delay in providing appropriate care has been found to significantly jeopardize the treatment outcome and cause more complications (4–10). This will have negative consequences not only for the tooth but also on the growth and development of the alveolar bone, which would accordingly affect future treatment choices and outcomes, and cause functional and esthetic problems (9–14). Review articles and survey studies have demonstrated that the majority of patients with traumatized teeth around the world are not provided with the appropriate emergency care (15–18). This consequence will also potentially increase the financial burden when compared to cases when appropriate treatment is provided on-time (4, 19). There are no studies published on emergency treatment of TDI with a global perspective, so the evidence is © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
low regarding the status of emergency services worldwide. This study’s main objective was to describe how dental emergency services are provided in some cities in various countries around the world to stimulate further research in this field. Material and methods Participants
The method used was a preliminary observational study of descriptive character to report how TDI are managed in the emergency situation. All members of the International Association of Dental Traumatology (IADT) 2010 were contacted via e-mail and invited to participate in the study. Participation was voluntary, strict confidentiality was assured, and no information on cities, clinics, or individuals beyond the name of the country was going to be mentioned as part of the study results. The status of the participants, specialist or general dentist, city, and country was registered. The e-mail was sent out only once. Responses were collected through the period between February and March, 2010. 1
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Questionnaire and methodology
The questionnaire focused on three areas of the emergency treatment: telephone advice to the place of accident, availability of treatment resources, and competence levels of the treating staff. Before the questionnaire was sent out, a pretesting was carried out on one specialist with high experience in emergency management and one general dentist with little experience in emergency treatment. Some modifications and development of the questionnaire were made before the study was finally launched. Guiding introduction to the research area
To understand the purpose of the study and how the data were going to be used, a color picture of a TDI, a luxation injury requiring emergency intervention, was presented at the beginning of the questionnaire (Fig. 1). Participants were asked to describe what type of emergency management was available for such a case at different times of the day/night, week, weekend, and holidays in their city. Questionnaire
A questionnaire form of 10 questions was developed to investigate certain aspects regarding the provision of emergency dental service in the participants’ city. The questions were focused on three areas: 1 Availability of advice per telephone at the place of the accident; 2 Availability of emergency treatment resources at different times of the day; and 3 Assessment of competence level of the person carrying out the service at different times of the day. Participants were asked to choose one alternative for each question that best described the current situation in their own city. All questions were close-ended (multiple-choice questions) with an optional space for commenting or adding clarifications/explanation on the chosen answer. For questions with only ‘yes’ or ‘no’
answers, two points were given for an answer indicating positive quality and 0 for an answer indicating negative quality. Answers and comments were scored with regard to highest competence level of professionals available at different times of the day/night. Both answers and comments were taken into account when calculating the scores. An answer indicating the best possible model of service was given three points. If the respondent mentioned that there was no such service in their city, this answer was not given any points. When answers and comments indicated there was sufficient service, but not completely optimal, two points were given, and when the answers and comments indicated there was some service available but of insufficient quality, one point was given. Participants’ comments were also taken into consideration and could influence the scoring. An emergency clinic that offered service all around the clock all days and nights of the week (24 h per 7 days) with competent dentists was given three points. Clinics that offered on-call services with competent dentists available from their home were given two points. A hospital without dentistry competence available was given one point. If no service was available during nighttime, 0 point was given. Participants’ comments were also taken into consideration and influenced the scoring process. Scoring was carefully pretested before the scoring of the participants was carried out. Only the principal investigator (DN) scored the forms. However, when there was hesitation in how to score a participant, the other investigator was consulted before a consensus decision was taken. After scoring, all the data were entered on as an input in the software package SPSS version 17.0 for Windows (SPSS Inc, Chicago, Ill, USA). Descriptive methods were used to analyze and present the data. Results
At the time of the survey, IADT had 446 members of which 385 had indicated their e-mail address and these were invited to participate. Twenty-two e-mails bounced back because the receivers account was not available or closed. A total of 110 questionnaires were completed in the study period, of which 103 were included in the study. Seven forms were excluded because of incomplete answers and double registration. Most responses were received via e-mail and a few per fax or conventional postal service. Finally, 103 participants from 83 cities in 42 different countries in all continents worldwide as shown in Fig. 2 were included in the analysis. Most of the respondents were specialists (85%). Some of the participants were dual-qualified specialties (e.g., Ortho-Pedo). The distribution of various categories of specialists and general dentists is shown in Table 1. Telephone advice at the place of accident
Fig. 1. Clinical picture of a trauma patient presented to the participants.
Almost half of the participants reported an organized emergency telephone service to be always available (including daytime, nighttime, weekend, and holiday). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Global dental trauma emergency services
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Fig. 2. World map showing the distribution of participants in the study. Table 1. Distribution of participants Discipline
n
%
Pedodontists (pediatric dentists) Endodontists OMF surgeons General dentists Restorative specialists Emergency dentists Endo + Ortho (double qualified) Pedo + Ortho (double qualified) Total
39 21 20 16 4 1 1 1 103
37.9 20.4 19.4 15.5 3.9 1 1 1 100
This service could provide an immediate advice for the place of accident (Fig. 3). One-third of the participants mentioned that no such service was available in their cities. When asking whether people generally knew which telephone number to call from the place of accident for consultation, 56% denied that laypeople are aware of the specific emergency number to call from the place of accident. Almost 43% of the advice that was given through the phone was from professionals with dental training, while 57% was given by people with no dental background; 28% of that percentage was given by non-dentist professionals (nurse or physician), while 29% were only able to talk to an emergency telephone operator with no medical or dental formal education.
within the first hour (Fig. 4). An organized on-call or written and distributed lists of 24-h on-call service with a competent dentist or specialist to reach were available in 33% of the respondents’ cities. A competent dentist, who is well trained in trauma and hence can perform the correct treatment, was always (day and night) available in 40% of the cases. In 27% of the cases were only able to be seen by such professional only during daytime in weekdays. In 23% of the cases, such professionals were only available during daytime and not nighttime. When clinics were closed, and only emergency service was available, treatment by a competent dentist, well trained in dental trauma, was possible in 41% of the cities of the participants. Emergency treatment during nighttime
During night, specifically after midnight, the most common place where people sought treatment after dental trauma was found to be hospitals (Fig. 5). Some of these hospitals had an available dental on-call service, most often oral and maxillofacial surgeons, but sometimes also pediatric dentists or general dentists were on-call in hospitals. In some countries, dental emergency clinics with specially trained general dentists were available. When clinics were closed, 56% of participants reported that the competency of professionals providing treatment for dental trauma patients was compromised.
Emergency treatment resources
Answers to other questions
More than half of the participants reported that there was always a possibility to get to a clinic for treatment
Recent budget cuts were reported by 15% of participants. From the comments, it was noted that this had
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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Fig. 3. Bar chart showing the availability of emergency telephone service in the participants’ cities. ‘Is there an organized telephone service, where a patient with such an injury can get immediate advice at the place of accident what to do?’
Fig. 5. Bar chart showing places that were sought for treatment during night. ‘Where do people usually seek treatment during nights (after midnight) when ordinary clinics are closed?’
cities (>16) were found in Argentina, Brunei, China, the Netherlands, and South Korea. However, in these five countries, only one city per country was registered. In the remaining participating cities, lower scores were seen indicating less optimal emergency services. Discussion
Fig. 4. Bar chart illustrating availability of treatment by a well-trained dentist within the first hour after injury. ‘Is there in your city always a possibility to get treatment by a welltrained general dentist or specialist within the first hour after a serious injury to the oral region?’
resulted in recent cancellation of an already existing organized well-functioning on-call emergency service in their city. In general, 62% of participants perceived that there was room for improvement in the emergency dental service in their city, while 38% stated that they are satisfied with what they currently have. High-scoring cities
Of all the 42 participating countries, cities in thirteen countries scored a top score of 16 points or higher out of a maximum of 22 possible. Denmark, India, Japan, Sweden, and Switzerland showed high scores (>16) with a low range (16) were also found in USA (ranging 6–18), Chile (ranging 4–18), and UK (ranging 3–16). Other high-scoring
Trauma can occur any time of the day, any day of the year, and requires good preparation and quick delivery of proper management. According to this study, management of oral trauma varies greatly among different countries and communities. There were cities in which management of trauma seemed to be well organized and other places where there was little or no organized emergency service. Surprisingly, many cities in low-economy countries had much better dental emergency models than some other systems in more developed countries. The quality of care does not seem to be associated with how well economically developed a country is, and the amount of resources possible to assign for trauma service. Instead, an ability and willingness to locally or nationally plan and organize emergency services for TDI in an efficient way seem to be the most important. Advice to the place of accident
The prognosis for many injuries is decided at the place of accident. In this study, almost half of the participants reported the presence of telephone emergency service in their city. In many countries, there were such services such as emergency numbers 112 777 999, etc., but people were unaware of the number. The importance of telephone calls and competent guidance for trauma patients has been pointed out previously (20, 21). According to a multicenter evaluation from UK, almost quarter of the subjects in their study sought advice through the phone prior to presenting to emergency care, mostly calling their general dentist, or © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Global dental trauma emergency services emergency rooms (22). Therefore, they emphasized the importance of competent emergency telephone respondent in providing verbal instructions of trauma first aid advice through the phone or at least having access to emergency protocols (22). A study from Switzerland showed that telephone calls may provide valuable support when a dentist is not available (23). So, an emergency telephone services should be used in the emergency systems also for TDI. A prerequisite is to have at least an accessible list with the name and telephone number of the dentist on-call. This was lacking in many emergency telephone operators and even in hospitals. The importance of this has been stressed in a recent study from USA (21). A few countries have taken dental trauma as serious as any other medical emergencies by assigning an organized national emergency dental service and conducting awareness campaigns to provide immediate advice at the place of the accident (22, 24–26). Others aimed to enhance the knowledge of laypeople through media and out-reach dental education programmes to prepare them to handle such responsibility (27–32) (http://www. iadt-dentaltrauma.org/for-patients.html). Recently, a first aid application for handheld devices such as smart phones aimed for dental emergencies for the public has been launched. The application named ‘Dental Trauma.’ This application can be downloaded by visiting the web page of IADT or from the application stores (https://play.google.com/store/apps/details? id=com.dentaltrauma&hl=en) (https://itunes.apple. com/us/app/dental-trauma/id527527459?mt=8) (www. iadt-dentaltrauma.org). Handheld devices may be a good way to bring first aid information to the place of accident as handheld devices are always available today in people’s pockets and handbags. Availability of emergency treatment
There were places where patients always, regardless of time of the day, could get emergency treatment. However, study also showed that in many cities where patients were subjected to TDI, there were no proper treatment resources available. This is disappointing and not acceptable because dentists should today be aware of that certain dental injuries, such as tooth displacement injuries (i.e., avulsions and luxations and some root fractures of permanent teeth), require provision of an immediate and appropriate care of the traumatized teeth to insure optimal outcome and good prognosis (4–6) (www. iadt-dentaltrauma.org). The information what to do in an emergency situation can today be easily accessible on Internet (www.iadt-dentaltrauma.org) (www.dentaltraumaguide.org). The IADT guidelines for emergency treatment of TDI have been available since 2001 (33–35), revisions have been published in 2007 (36, 37), and the current IADT guidelines are from 2012 (38, 39). In spite of this, patients do not benefit from this knowledge in many places. Internet tools may possibly improve a rise of knowledge level worldwide in the future (https://play.google.com/store/apps/details?id=com.dental trauma&hl=en) (31) (https://itunes.apple.com/us/app/ dental-trauma/id527527459?mt=8) (www.dentaltrauma © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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guide.org). However, it is not only about education and knowledge level. As has been pointed out by the results of this study, it is also important that societies realize that organized emergency management has to be given a higher priority and funding. Without open clinics, there can be no emergency service regardless of knowledge level. It is also important for a good-quality assurance to create standardized record systems and core outcome sets to be able to compare change in knowledge levels for professionals and laypeople and analyze trends. The literature indicates that a minority of tooth displacement injuries and root fractures was seen within the first hour (4, 13, 40). There are many factors responsible for this. In UK, for example, the reason for such a delay was attributed to prolonged transit time in almost half the cases, delay in emergency room, dentists’ or parents’ delay (22). Several barriers to the provision of emergency treatment for dental trauma patients have been identified. Lack or poor knowledge, inadequate access to care, limited resources, time constraints, behavioral and patientrelated factors, financial problems, and management difficulties are only a few of the possible barriers to emergency care (15, 41, 42). Availability of a welltrained specialist staff on-duty or on-call around the hour has been proposed as a necessity, and general dentists have strongly agreed in several studies on their responsibility to provide initial treatment to patients with TDI (41–43). When patients present after oral trauma has occurred, they expect to receive competent management and appropriate treatment from the dentist or other emergency personnel. Unfortunately, the majority of dentists have little experience and inadequate knowledge in managing trauma cases (43). Other studies discussed dentists’ hesitation in providing proper treatment and found that the more complex the case, the less confident the dentist (41), and the more likely to provide inappropriate treatment (42). We conclude from the literature and from the results of our study that there is a need for education in traumatology. When dental trauma occurs late at night, during weekends or holidays, regular dental clinics are usually closed or out of hours. In this case, access to appropriate emergency dental care is challenging. Provision of out-of-hours emergency dental service was found to vary greatly between different cities, and this is in accordance with other studies (22, 24, 25, 44–46). Additionally, numerous studies have reported lack of knowledge and unacceptable level of competence among professionals other than dentists in emergency medical departments (47). Therefore, educating emergency physician and other primary care providers to minimally manage such cases is a must (21, 48–50). However, educating physicians is not enough, so postgraduate continuous education of dental professionals is crucial to increase their knowledge and capabilities in managing TDI (15, 41, 51). In times of economic constraints, budget cuts are seen sometimes affecting on-call services. Several participants had seen this in recent years. This is unfortunate as young children are the ones most often subjected to TDI, and if
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emergency service of TDI is given less priority the responsible person for prioritizing should be aware of that many young children are affected. We have abstained from ranking all cities and countries. However, it is worth mentioning that there were countries with high scores and small range between participating cities, indicating that systems are good not only in one city. The authors recommend further studies of the organization of emergency management in these countries to draw conclusions on how to create similar well-functioning systems in other places of the world. Some participants suggested what would make a good emergency model in their point of view. We learned from the answers that pediatric dentists, endodontists, and oral maxillofacial surgeons are the specialists who are most involved in dental trauma treatment. However, endodontists and pediatric dentists are in most countries available for trauma treatment only during daytime weekdays, but seldom outside office hours. Moreover, endodontists and pediatric dentists are generally not trained to manage all soft tissue injuries and bone fractures. Emergency physicians are not the ideal specialist to treat TDI, and a recent study showed that physicians do not feel confident to manage or give advice for TDI (47). In most countries, during evenings and nights, oral and maxillofacial surgeons seem to be the only available specialists with competence to manage emergency treatment of traumatic injuries. Some surgeons expressed their need for an update in dental traumatology to do the necessary emergency treatment needed. Many oral and maxillofacial surgeons are busy with more complex and time-consuming treatment such as maxillofacial fractures and soft tissue injuries and do not have resources, and in many situations are not interested, to take the responsibility for all emergency treatment of TDI in a city. The optimal emergency service
Although not the primary aim of this study, we learned from the comments and suggestions that in countries with a good organization, a system built on a welldeveloped first-line care ideally on a 24/7 basis seems to function well. If such a system is going to function outside office hours also during nighttime, the number of patients must reach a certain number to be enough to enable having staff serving around the clock. In some places of the world, this has been solved by giving the responsibility of the primary management of trauma-to-dental trauma-trained general dentists who already have emergency service duty for other dental emergencies such as pain of dental origin. With such an organization, TDI have been shown to comprise 66% of the emergency cases (52). Such emergency dentists can, after further education and training in dental traumatology, be ready to take responsibility for most of the dental trauma emergencies such as avulsions and replantation, repositioning of luxated and dislocated teeth, crown and root fractures, splinting and necessary pulp treatment. By organizing emergency services in this way, patients will not fall between the chairs out-
side office hours, as we often see today. In addition, the oral and maxillofacial surgeons’ on-call can take responsibility for the more complex dental trauma cases and only do the necessary emergency treatment. During office hours on weekdays, endodontists, pediatric dentists, and other specialist can be consulted when needed. There are apparently many cities where emergency service is functioning better than in other places because one-third of the participants expressed satisfaction with the current systems while two-thirds expressed that there should be improvement. The authors believe that for the best quality assurance of emergency services, there is a need to set up criteria for a well-functioning emergency service for TDI. There is also a need for cities to describe, measure, and compare these criteria. This can be started as national programmes, and later international comparisons can be carried out. By doing this, we can maximize the knowledge transfer from models that are well-functioning models and achieve a considerable improvement in the models that are not. Advantages and disadvantages in methodology
The present study is a preliminary observational study based on simple questionnaires. In this study, we asked general dentists and specialists with high motivation and interest in oral traumatology. This has most likely positively influenced their contribution because interested participants are usually well aware of the emergency model available in their city/country. The study should therefore be seen as a global survey, and in such studies, all countries are very seldom represented. Moreover, the results of such a screening study can neither be fully representative of the whole world nor a whole country. The 103 IADT members came from 42 different countries and 83 cities. Sometimes, a few participants reported from the same city, while in other times only one questionnaire was filled out for a whole country. Furthermore, the way information was collected about each system might not be accurate and influenced by subjective opinion. Obviously, it could have been more precise to collect information from official sources rather than personal opinions, but we preferred estimations of real-life performance, rather than the endorsed laws and regulations that might not be implemented in everyday life. Furthermore, using the members of IADT to record the current status in a city has the advantage that we are dealing with a group of participants who have interest and knowledge in TDI and they for sure know the emergency systems in their cities and the shortcomings of these systems, which was the intention of the study to investigate. The use of e-mail to distribute questionnaires has advantages and disadvantages, and this must be taken into consideration before drawing conclusions from the results. However, for a simple observational study to describe the present status in a number of cities/countries to stimulate interest in further research, the method may be appropriate. It is hoped that this will stimulate interest for more comprehensive studies in the future where a more developed survey instrument © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Global dental trauma emergency services should be used, using several rounds of questionnaires, extensive pretesting, and validation (53, 54). Such studies should also follow a careful standardized protocol for reporting and then followed by intervention in the emergency programmes. Moreover, measuring the status before and after such an intervention programme would be advantageous. In voluntary participation, we must protect the anonymity of the participant, who is going to reveal information that can be seen as sensitive. To protect the anonymity of individuals and clinics, we decided not to analyze other deeper levels than the city level. For the same reason, cities were not mentioned by name in the published results. We have also abstained from making any ranking list of the countries. Only the countries of the best scorers were mentioned in the results. The scoring system used in this study has many limitations, so we should be careful with drawing too far and wrong conclusions when interpreting the results. The purpose of the scoring system was only to identify whether there were places in the world with good models that others could learn from. And as seen from the results, there were actually some countries where all cities scored high, indicating an overall high national standard. We must also be aware of that points are given with no consideration to the relative weight of importance of each entity. Some features are perceived to be more important than others. This could result in systems that are lacking some crucial aspects, yet scoring a high score. On the other hand, in general, the more qualities a system had, the higher it scored. Nevertheless, in some of the countries that had an excellent-functioning model in one city still had other less perfect systems in others. This means that these systems were not implemented nationally, rather depended on local initiatives. With all the limitations of a study like this, one should be careful with drawing too far conclusions. However, if the results of this study can stimulate further research in this field, this study can lay a ground for more comprehensive well-developed study designs. We recommend local and regional initiatives for studies on the quality and availability of emergency services for traumatic dental injuries. Conclusions and recommendations
Dental emergency services are in many countries well functioning during office hours on weekdays with general dentists and specialists available. The major problem seems to be related to availability and competence outside office working hours, where many specialists are not available, although many TDI occur during this time. There is definitely room for critical improvement especially outside office working hours in many places worldwide. Emergency services should be organized using a list of telephone numbers to dentist oncall distributed to emergency telephone services and hospital emergency rooms. General dentists, experienced in emergency treatment, should be encouraged to be further educated and trained in primary management of TDI. Competent specialist should be available © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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for more complex injuries. National programmes for quality assurance of emergency services of TDI should be encouraged. Acknowledgements
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37. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007;23:66–71. 38. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88–96. 39. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012;28:2–12. Erratum in: Dent Traumatol 2012;28:499. 40. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics. Dent Traumatol 2004;20:203–11. 41. Jackson NG, Waterhouse PJ, Maguire A. Management of dental trauma in primary care: a postal survey of general dental practitioners. Br Dent J 2005;198:293–7. 42. Yeng T, Parashos P. An investigation into dentists’ perception of barriers to providing care of dental trauma to permanent maxillary incisors in children in Victoria, Australia. Aust Dent J 2007;52:210–5. 43. Kostopoulou MN, Duggal M. A study into dentists’ knowledge of the treatment of traumatic injuries to young permanent incisors. Int J Paediatr Dent 2005;15:10–9. 44. Anderson R, Thomas DW, Phillips CJ. The effectiveness of out-of-hours dental services: I. pain relief and oral health outcome. Br Dent J 2005;198:91–7. 45. Anderson R, Thomas DW, Phillips CJ. The effectiveness of out-of-hours dental services: II patient satisfaction. Br Dent J 2005;198:151–6. 46. Austin R, Jones K, Wright D, Donaldson N, Gallagher J. Use of the out-of-hours emergency dental service at two south-east London hospitals. BMC Oral Health 2009;9:19. 47. Trivedy C, Kodate N, Ross A, Al-Rawi H, Jaiganesh T, Harris T et al. The attitudes and awareness of emergency department (ED) physicians towards the management of common dentofacial emergencies. Dent Traumatol 2012;28:121–6. 48. Amsterdam JT, Wagner DK, Rose LF. Interdisciplinary training: hospital dental general practice/Emergency medicine. Ann Emerg Med 1980;9:310–3. 49. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med 2003;42:93–9. 50. Mclntosh M, Konzelmann J, Smith J, Kalynych CJ, Wears RL, Schneider H et al. Stabilization and treatment of dental avulsions and fractures by emergency physicians using just-in-time training. Ann Emerg Med 2009;54:585–92. 51. Frujeri MLV, Costa ED. Effect of a single dental health education on the management of permanent avulsed teeth by different groups of professionals. Dent Traumatol 2009;25:262– 71. 52. Bae JH, Kim YK, Choi YH. Clinical characteristics of dental emergencies and prevalence of dental trauma at a university hospital emergency center in Korea. Dent Traumatol 2011;27:374–8. 53. Burns KE, Duffett M, Kho ME, Meade MO, Adhikari NK, Sinuff T et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ 2008;179:245– 52. Review. 54. Bennett C, Khangura S, Brehaut JC, Graham ID, Moher D, Potter BK et al. Reporting guidelines for survey research: an analysis of published guidance and reporting practices. PLoS Med 2010;8:e1001069.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Emergency management of traumatic dental injuries in 42 countries Doaa Alnaggar, Lars Andersson Department of Surgical Sciences, Faculty of Dentistry, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
Key words: injuries; trauma; organization management; treatment Correspondence to: Prof Lars Andersson, Oral and Maxillofacial Surgery, Department of Surgical Sciences, Faculty of Dentistry, Health Sciences Center, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait City, Kuwait Tel.: +965 24636695 Fax: +965 24636732 e-mail: [email protected] Accepted 25 October, 2014
Abstract Availability and quality of emergency services for traumatic dental injuries (TDI) are important as the prognosis of TDI is decided at the place of accident or during the first hours after the injury has occurred. – Aim: To report how emergency services for TDI are provided in some places around the world. Subjects and methods: This is a preliminary observational study of descriptive character. One-hundred and three participants from 83 cities in 42 countries described the emergency services in their city by answering a questionnaire related to: (1) availability of advice per telephone at the place of the accident; (2) availability of emergency treatment resources at different times of the day; and; (3) assessment of competence level of the person carrying out the service. Answers and comments were scored with regard to availability and level of competence. Results: 62% of the participants were not satisfied with their current emergency services. 50% reported organized emergency telephone service always available. 43% of the advice given by phone was from professionals with dental training. An organized on-call 24/7 service was available in 33%. Treatment of TDI within the first hour was available in 53%. A competent dentist was available in 40%. 56% reported compromised competency outside office hours. Places with a well-organized system built on a well-developed first-line care managed by trauma-trained general dentists, ideally on a 24/7 basis, supported by on-call specialists outside office working hours, achieved the highest scores. Conclusions: With all the limitations of a preliminary questionnaire study, we can conclude that there is a need to perform more comprehensive well-designed studies in this field to understand more of the varying quality of emergency services worldwide. The major problem today seems to be related to limited availability and competence, especially outside office working hours.
Oral trauma accounts for around 5% of all bodily injuries, with even higher occurrence among young children (1). Traumatic dental injuries (TDI) comprise 95% of all oral injuries and have a high incidence (1, 2). TDI are usually not a life-threatening emergency, and for that reason, it may be perceived as a less urgent condition by the public, as well as the staff in emergency departments (3). However, delay in providing appropriate care has been found to significantly jeopardize the treatment outcome and cause more complications (4–10). This will have negative consequences not only for the tooth but also on the growth and development of the alveolar bone, which would accordingly affect future treatment choices and outcomes, and cause functional and esthetic problems (9–14). Review articles and survey studies have demonstrated that the majority of patients with traumatized teeth around the world are not provided with the appropriate emergency care (15–18). This consequence will also potentially increase the financial burden when compared to cases when appropriate treatment is provided on-time (4, 19). There are no studies published on emergency treatment of TDI with a global perspective, so the evidence is © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
low regarding the status of emergency services worldwide. This study’s main objective was to describe how dental emergency services are provided in some cities in various countries around the world to stimulate further research in this field. Material and methods Participants
The method used was a preliminary observational study of descriptive character to report how TDI are managed in the emergency situation. All members of the International Association of Dental Traumatology (IADT) 2010 were contacted via e-mail and invited to participate in the study. Participation was voluntary, strict confidentiality was assured, and no information on cities, clinics, or individuals beyond the name of the country was going to be mentioned as part of the study results. The status of the participants, specialist or general dentist, city, and country was registered. The e-mail was sent out only once. Responses were collected through the period between February and March, 2010. 1
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Questionnaire and methodology
The questionnaire focused on three areas of the emergency treatment: telephone advice to the place of accident, availability of treatment resources, and competence levels of the treating staff. Before the questionnaire was sent out, a pretesting was carried out on one specialist with high experience in emergency management and one general dentist with little experience in emergency treatment. Some modifications and development of the questionnaire were made before the study was finally launched. Guiding introduction to the research area
To understand the purpose of the study and how the data were going to be used, a color picture of a TDI, a luxation injury requiring emergency intervention, was presented at the beginning of the questionnaire (Fig. 1). Participants were asked to describe what type of emergency management was available for such a case at different times of the day/night, week, weekend, and holidays in their city. Questionnaire
A questionnaire form of 10 questions was developed to investigate certain aspects regarding the provision of emergency dental service in the participants’ city. The questions were focused on three areas: 1 Availability of advice per telephone at the place of the accident; 2 Availability of emergency treatment resources at different times of the day; and 3 Assessment of competence level of the person carrying out the service at different times of the day. Participants were asked to choose one alternative for each question that best described the current situation in their own city. All questions were close-ended (multiple-choice questions) with an optional space for commenting or adding clarifications/explanation on the chosen answer. For questions with only ‘yes’ or ‘no’
answers, two points were given for an answer indicating positive quality and 0 for an answer indicating negative quality. Answers and comments were scored with regard to highest competence level of professionals available at different times of the day/night. Both answers and comments were taken into account when calculating the scores. An answer indicating the best possible model of service was given three points. If the respondent mentioned that there was no such service in their city, this answer was not given any points. When answers and comments indicated there was sufficient service, but not completely optimal, two points were given, and when the answers and comments indicated there was some service available but of insufficient quality, one point was given. Participants’ comments were also taken into consideration and could influence the scoring. An emergency clinic that offered service all around the clock all days and nights of the week (24 h per 7 days) with competent dentists was given three points. Clinics that offered on-call services with competent dentists available from their home were given two points. A hospital without dentistry competence available was given one point. If no service was available during nighttime, 0 point was given. Participants’ comments were also taken into consideration and influenced the scoring process. Scoring was carefully pretested before the scoring of the participants was carried out. Only the principal investigator (DN) scored the forms. However, when there was hesitation in how to score a participant, the other investigator was consulted before a consensus decision was taken. After scoring, all the data were entered on as an input in the software package SPSS version 17.0 for Windows (SPSS Inc, Chicago, Ill, USA). Descriptive methods were used to analyze and present the data. Results
At the time of the survey, IADT had 446 members of which 385 had indicated their e-mail address and these were invited to participate. Twenty-two e-mails bounced back because the receivers account was not available or closed. A total of 110 questionnaires were completed in the study period, of which 103 were included in the study. Seven forms were excluded because of incomplete answers and double registration. Most responses were received via e-mail and a few per fax or conventional postal service. Finally, 103 participants from 83 cities in 42 different countries in all continents worldwide as shown in Fig. 2 were included in the analysis. Most of the respondents were specialists (85%). Some of the participants were dual-qualified specialties (e.g., Ortho-Pedo). The distribution of various categories of specialists and general dentists is shown in Table 1. Telephone advice at the place of accident
Fig. 1. Clinical picture of a trauma patient presented to the participants.
Almost half of the participants reported an organized emergency telephone service to be always available (including daytime, nighttime, weekend, and holiday). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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Fig. 2. World map showing the distribution of participants in the study. Table 1. Distribution of participants Discipline
n
%
Pedodontists (pediatric dentists) Endodontists OMF surgeons General dentists Restorative specialists Emergency dentists Endo + Ortho (double qualified) Pedo + Ortho (double qualified) Total
39 21 20 16 4 1 1 1 103
37.9 20.4 19.4 15.5 3.9 1 1 1 100
This service could provide an immediate advice for the place of accident (Fig. 3). One-third of the participants mentioned that no such service was available in their cities. When asking whether people generally knew which telephone number to call from the place of accident for consultation, 56% denied that laypeople are aware of the specific emergency number to call from the place of accident. Almost 43% of the advice that was given through the phone was from professionals with dental training, while 57% was given by people with no dental background; 28% of that percentage was given by non-dentist professionals (nurse or physician), while 29% were only able to talk to an emergency telephone operator with no medical or dental formal education.
within the first hour (Fig. 4). An organized on-call or written and distributed lists of 24-h on-call service with a competent dentist or specialist to reach were available in 33% of the respondents’ cities. A competent dentist, who is well trained in trauma and hence can perform the correct treatment, was always (day and night) available in 40% of the cases. In 27% of the cases were only able to be seen by such professional only during daytime in weekdays. In 23% of the cases, such professionals were only available during daytime and not nighttime. When clinics were closed, and only emergency service was available, treatment by a competent dentist, well trained in dental trauma, was possible in 41% of the cities of the participants. Emergency treatment during nighttime
During night, specifically after midnight, the most common place where people sought treatment after dental trauma was found to be hospitals (Fig. 5). Some of these hospitals had an available dental on-call service, most often oral and maxillofacial surgeons, but sometimes also pediatric dentists or general dentists were on-call in hospitals. In some countries, dental emergency clinics with specially trained general dentists were available. When clinics were closed, 56% of participants reported that the competency of professionals providing treatment for dental trauma patients was compromised.
Emergency treatment resources
Answers to other questions
More than half of the participants reported that there was always a possibility to get to a clinic for treatment
Recent budget cuts were reported by 15% of participants. From the comments, it was noted that this had
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Fig. 3. Bar chart showing the availability of emergency telephone service in the participants’ cities. ‘Is there an organized telephone service, where a patient with such an injury can get immediate advice at the place of accident what to do?’
Fig. 5. Bar chart showing places that were sought for treatment during night. ‘Where do people usually seek treatment during nights (after midnight) when ordinary clinics are closed?’
cities (>16) were found in Argentina, Brunei, China, the Netherlands, and South Korea. However, in these five countries, only one city per country was registered. In the remaining participating cities, lower scores were seen indicating less optimal emergency services. Discussion
Fig. 4. Bar chart illustrating availability of treatment by a well-trained dentist within the first hour after injury. ‘Is there in your city always a possibility to get treatment by a welltrained general dentist or specialist within the first hour after a serious injury to the oral region?’
resulted in recent cancellation of an already existing organized well-functioning on-call emergency service in their city. In general, 62% of participants perceived that there was room for improvement in the emergency dental service in their city, while 38% stated that they are satisfied with what they currently have. High-scoring cities
Of all the 42 participating countries, cities in thirteen countries scored a top score of 16 points or higher out of a maximum of 22 possible. Denmark, India, Japan, Sweden, and Switzerland showed high scores (>16) with a low range (16) were also found in USA (ranging 6–18), Chile (ranging 4–18), and UK (ranging 3–16). Other high-scoring
Trauma can occur any time of the day, any day of the year, and requires good preparation and quick delivery of proper management. According to this study, management of oral trauma varies greatly among different countries and communities. There were cities in which management of trauma seemed to be well organized and other places where there was little or no organized emergency service. Surprisingly, many cities in low-economy countries had much better dental emergency models than some other systems in more developed countries. The quality of care does not seem to be associated with how well economically developed a country is, and the amount of resources possible to assign for trauma service. Instead, an ability and willingness to locally or nationally plan and organize emergency services for TDI in an efficient way seem to be the most important. Advice to the place of accident
The prognosis for many injuries is decided at the place of accident. In this study, almost half of the participants reported the presence of telephone emergency service in their city. In many countries, there were such services such as emergency numbers 112 777 999, etc., but people were unaware of the number. The importance of telephone calls and competent guidance for trauma patients has been pointed out previously (20, 21). According to a multicenter evaluation from UK, almost quarter of the subjects in their study sought advice through the phone prior to presenting to emergency care, mostly calling their general dentist, or © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Global dental trauma emergency services emergency rooms (22). Therefore, they emphasized the importance of competent emergency telephone respondent in providing verbal instructions of trauma first aid advice through the phone or at least having access to emergency protocols (22). A study from Switzerland showed that telephone calls may provide valuable support when a dentist is not available (23). So, an emergency telephone services should be used in the emergency systems also for TDI. A prerequisite is to have at least an accessible list with the name and telephone number of the dentist on-call. This was lacking in many emergency telephone operators and even in hospitals. The importance of this has been stressed in a recent study from USA (21). A few countries have taken dental trauma as serious as any other medical emergencies by assigning an organized national emergency dental service and conducting awareness campaigns to provide immediate advice at the place of the accident (22, 24–26). Others aimed to enhance the knowledge of laypeople through media and out-reach dental education programmes to prepare them to handle such responsibility (27–32) (http://www. iadt-dentaltrauma.org/for-patients.html). Recently, a first aid application for handheld devices such as smart phones aimed for dental emergencies for the public has been launched. The application named ‘Dental Trauma.’ This application can be downloaded by visiting the web page of IADT or from the application stores (https://play.google.com/store/apps/details? id=com.dentaltrauma&hl=en) (https://itunes.apple. com/us/app/dental-trauma/id527527459?mt=8) (www. iadt-dentaltrauma.org). Handheld devices may be a good way to bring first aid information to the place of accident as handheld devices are always available today in people’s pockets and handbags. Availability of emergency treatment
There were places where patients always, regardless of time of the day, could get emergency treatment. However, study also showed that in many cities where patients were subjected to TDI, there were no proper treatment resources available. This is disappointing and not acceptable because dentists should today be aware of that certain dental injuries, such as tooth displacement injuries (i.e., avulsions and luxations and some root fractures of permanent teeth), require provision of an immediate and appropriate care of the traumatized teeth to insure optimal outcome and good prognosis (4–6) (www. iadt-dentaltrauma.org). The information what to do in an emergency situation can today be easily accessible on Internet (www.iadt-dentaltrauma.org) (www.dentaltraumaguide.org). The IADT guidelines for emergency treatment of TDI have been available since 2001 (33–35), revisions have been published in 2007 (36, 37), and the current IADT guidelines are from 2012 (38, 39). In spite of this, patients do not benefit from this knowledge in many places. Internet tools may possibly improve a rise of knowledge level worldwide in the future (https://play.google.com/store/apps/details?id=com.dental trauma&hl=en) (31) (https://itunes.apple.com/us/app/ dental-trauma/id527527459?mt=8) (www.dentaltrauma © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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guide.org). However, it is not only about education and knowledge level. As has been pointed out by the results of this study, it is also important that societies realize that organized emergency management has to be given a higher priority and funding. Without open clinics, there can be no emergency service regardless of knowledge level. It is also important for a good-quality assurance to create standardized record systems and core outcome sets to be able to compare change in knowledge levels for professionals and laypeople and analyze trends. The literature indicates that a minority of tooth displacement injuries and root fractures was seen within the first hour (4, 13, 40). There are many factors responsible for this. In UK, for example, the reason for such a delay was attributed to prolonged transit time in almost half the cases, delay in emergency room, dentists’ or parents’ delay (22). Several barriers to the provision of emergency treatment for dental trauma patients have been identified. Lack or poor knowledge, inadequate access to care, limited resources, time constraints, behavioral and patientrelated factors, financial problems, and management difficulties are only a few of the possible barriers to emergency care (15, 41, 42). Availability of a welltrained specialist staff on-duty or on-call around the hour has been proposed as a necessity, and general dentists have strongly agreed in several studies on their responsibility to provide initial treatment to patients with TDI (41–43). When patients present after oral trauma has occurred, they expect to receive competent management and appropriate treatment from the dentist or other emergency personnel. Unfortunately, the majority of dentists have little experience and inadequate knowledge in managing trauma cases (43). Other studies discussed dentists’ hesitation in providing proper treatment and found that the more complex the case, the less confident the dentist (41), and the more likely to provide inappropriate treatment (42). We conclude from the literature and from the results of our study that there is a need for education in traumatology. When dental trauma occurs late at night, during weekends or holidays, regular dental clinics are usually closed or out of hours. In this case, access to appropriate emergency dental care is challenging. Provision of out-of-hours emergency dental service was found to vary greatly between different cities, and this is in accordance with other studies (22, 24, 25, 44–46). Additionally, numerous studies have reported lack of knowledge and unacceptable level of competence among professionals other than dentists in emergency medical departments (47). Therefore, educating emergency physician and other primary care providers to minimally manage such cases is a must (21, 48–50). However, educating physicians is not enough, so postgraduate continuous education of dental professionals is crucial to increase their knowledge and capabilities in managing TDI (15, 41, 51). In times of economic constraints, budget cuts are seen sometimes affecting on-call services. Several participants had seen this in recent years. This is unfortunate as young children are the ones most often subjected to TDI, and if
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emergency service of TDI is given less priority the responsible person for prioritizing should be aware of that many young children are affected. We have abstained from ranking all cities and countries. However, it is worth mentioning that there were countries with high scores and small range between participating cities, indicating that systems are good not only in one city. The authors recommend further studies of the organization of emergency management in these countries to draw conclusions on how to create similar well-functioning systems in other places of the world. Some participants suggested what would make a good emergency model in their point of view. We learned from the answers that pediatric dentists, endodontists, and oral maxillofacial surgeons are the specialists who are most involved in dental trauma treatment. However, endodontists and pediatric dentists are in most countries available for trauma treatment only during daytime weekdays, but seldom outside office hours. Moreover, endodontists and pediatric dentists are generally not trained to manage all soft tissue injuries and bone fractures. Emergency physicians are not the ideal specialist to treat TDI, and a recent study showed that physicians do not feel confident to manage or give advice for TDI (47). In most countries, during evenings and nights, oral and maxillofacial surgeons seem to be the only available specialists with competence to manage emergency treatment of traumatic injuries. Some surgeons expressed their need for an update in dental traumatology to do the necessary emergency treatment needed. Many oral and maxillofacial surgeons are busy with more complex and time-consuming treatment such as maxillofacial fractures and soft tissue injuries and do not have resources, and in many situations are not interested, to take the responsibility for all emergency treatment of TDI in a city. The optimal emergency service
Although not the primary aim of this study, we learned from the comments and suggestions that in countries with a good organization, a system built on a welldeveloped first-line care ideally on a 24/7 basis seems to function well. If such a system is going to function outside office hours also during nighttime, the number of patients must reach a certain number to be enough to enable having staff serving around the clock. In some places of the world, this has been solved by giving the responsibility of the primary management of trauma-to-dental trauma-trained general dentists who already have emergency service duty for other dental emergencies such as pain of dental origin. With such an organization, TDI have been shown to comprise 66% of the emergency cases (52). Such emergency dentists can, after further education and training in dental traumatology, be ready to take responsibility for most of the dental trauma emergencies such as avulsions and replantation, repositioning of luxated and dislocated teeth, crown and root fractures, splinting and necessary pulp treatment. By organizing emergency services in this way, patients will not fall between the chairs out-
side office hours, as we often see today. In addition, the oral and maxillofacial surgeons’ on-call can take responsibility for the more complex dental trauma cases and only do the necessary emergency treatment. During office hours on weekdays, endodontists, pediatric dentists, and other specialist can be consulted when needed. There are apparently many cities where emergency service is functioning better than in other places because one-third of the participants expressed satisfaction with the current systems while two-thirds expressed that there should be improvement. The authors believe that for the best quality assurance of emergency services, there is a need to set up criteria for a well-functioning emergency service for TDI. There is also a need for cities to describe, measure, and compare these criteria. This can be started as national programmes, and later international comparisons can be carried out. By doing this, we can maximize the knowledge transfer from models that are well-functioning models and achieve a considerable improvement in the models that are not. Advantages and disadvantages in methodology
The present study is a preliminary observational study based on simple questionnaires. In this study, we asked general dentists and specialists with high motivation and interest in oral traumatology. This has most likely positively influenced their contribution because interested participants are usually well aware of the emergency model available in their city/country. The study should therefore be seen as a global survey, and in such studies, all countries are very seldom represented. Moreover, the results of such a screening study can neither be fully representative of the whole world nor a whole country. The 103 IADT members came from 42 different countries and 83 cities. Sometimes, a few participants reported from the same city, while in other times only one questionnaire was filled out for a whole country. Furthermore, the way information was collected about each system might not be accurate and influenced by subjective opinion. Obviously, it could have been more precise to collect information from official sources rather than personal opinions, but we preferred estimations of real-life performance, rather than the endorsed laws and regulations that might not be implemented in everyday life. Furthermore, using the members of IADT to record the current status in a city has the advantage that we are dealing with a group of participants who have interest and knowledge in TDI and they for sure know the emergency systems in their cities and the shortcomings of these systems, which was the intention of the study to investigate. The use of e-mail to distribute questionnaires has advantages and disadvantages, and this must be taken into consideration before drawing conclusions from the results. However, for a simple observational study to describe the present status in a number of cities/countries to stimulate interest in further research, the method may be appropriate. It is hoped that this will stimulate interest for more comprehensive studies in the future where a more developed survey instrument © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Global dental trauma emergency services should be used, using several rounds of questionnaires, extensive pretesting, and validation (53, 54). Such studies should also follow a careful standardized protocol for reporting and then followed by intervention in the emergency programmes. Moreover, measuring the status before and after such an intervention programme would be advantageous. In voluntary participation, we must protect the anonymity of the participant, who is going to reveal information that can be seen as sensitive. To protect the anonymity of individuals and clinics, we decided not to analyze other deeper levels than the city level. For the same reason, cities were not mentioned by name in the published results. We have also abstained from making any ranking list of the countries. Only the countries of the best scorers were mentioned in the results. The scoring system used in this study has many limitations, so we should be careful with drawing too far and wrong conclusions when interpreting the results. The purpose of the scoring system was only to identify whether there were places in the world with good models that others could learn from. And as seen from the results, there were actually some countries where all cities scored high, indicating an overall high national standard. We must also be aware of that points are given with no consideration to the relative weight of importance of each entity. Some features are perceived to be more important than others. This could result in systems that are lacking some crucial aspects, yet scoring a high score. On the other hand, in general, the more qualities a system had, the higher it scored. Nevertheless, in some of the countries that had an excellent-functioning model in one city still had other less perfect systems in others. This means that these systems were not implemented nationally, rather depended on local initiatives. With all the limitations of a study like this, one should be careful with drawing too far conclusions. However, if the results of this study can stimulate further research in this field, this study can lay a ground for more comprehensive well-developed study designs. We recommend local and regional initiatives for studies on the quality and availability of emergency services for traumatic dental injuries. Conclusions and recommendations
Dental emergency services are in many countries well functioning during office hours on weekdays with general dentists and specialists available. The major problem seems to be related to availability and competence outside office working hours, where many specialists are not available, although many TDI occur during this time. There is definitely room for critical improvement especially outside office working hours in many places worldwide. Emergency services should be organized using a list of telephone numbers to dentist oncall distributed to emergency telephone services and hospital emergency rooms. General dentists, experienced in emergency treatment, should be encouraged to be further educated and trained in primary management of TDI. Competent specialist should be available © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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for more complex injuries. National programmes for quality assurance of emergency services of TDI should be encouraged. Acknowledgements
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