Collecting injury surveillance data in low- and middle-income countries: the Cape Town Trauma Registry pilot

Barriers to Surgical Outcomes Research in Low- and Middle-Income Countries: A Scoping Review

INTRODUCTION

Systematic collection and analysis of surgical outcomes data is a cornerstone of surgical quality improvement. Unfortunately, there remains a dearth of surgical outcomes data from low- and middle-income countries (LMICs). To improve surgical outcomes in LMICs, it is essential to have the ability to collect, analyze, and report risk-adjusted postoperative morbidity and mortality data. This study aimed to review the barriers and challenges to developing perioperative registries in LMIC settings.

METHODS

We conducted a scoping review of all published literature on barriers to conducting surgical outcomes research in LMICs using PubMed, Embase, Scopus, and GoogleScholar. Keywords included 'surgery', 'outcomes research', 'registries', 'barriers', and synonymous Medical Subject Headings derivatives. Articles found were subsequently reference-mined. All relevant original research and reviews published between 2000 and 2021 were included. The performance of routine information system management framework was used to organize identified barriers into technical, organizational, or behavioral factors.

RESULTS

Twelve articles were identified in our search. Ten articles focused specifically on the creation, success, and obstacles faced during the implementation of trauma registries. Technical factors reported by 50% of the articles included limited access to a digital platform for data entry, lack of standardization of forms, and complexity of said forms. 91.7% articles mentioned organizational factors, including the availability of resources, financial constraints, human resources, and lack of consistent electricity. Behavioral factors highlighted by 66.6% of the studies included lack of team commitment, job constraints, and clinical burden, which contributed to poor compliance and dwindling data collection over time.

CONCLUSIONS

There is a paucity of published literature on barriers to developing and maintaining perioperative registries in LMICs. There is an immediate need to study and understand barriers and facilitators to the continuous collection of surgical outcomes in LMICs.

Fatal drowning in Indonesia: understanding knowledge gaps through a scoping review

Little is known about unintentional drowning deaths in Indonesia, the world's fourth most populous and largest archipelagic country. This study aimed to describe the epidemiology and risk factors of unintentional drowning in Indonesia and explore existing health promotion and drowning prevention approaches in Indonesia within a socio-ecological health promotion framework. A scoping review, guided by PRISMA-ScR, was conducted to locate peer-reviewed studies and government reports/policy documents published until May 2023, in English or Indonesian language, using MEDLINE (Ovid), CINAHL, Informit, PsycINFO (ProQuest), Scopus, SafetyLit, BioMed Central and Google Scholar, Indonesian journal databases (Sinta, Garuda) and government agencies websites around the terms: drown, swim, flood, hurricane, cyclone, disaster, water rescue and maritime/boat safety. This review identified 32 papers. However, a paucity of information on unintentional drowning rates, risk factors and prevention in Indonesia was noted. The unavailability of a coordinated national drowning data collection system in Indonesia, from which national and subnational subcategory data can be collected, underlines the possibility of under-representation of drowning mortality. The association between various exposures and drowning incidents has not been fully investigated. An over-reliance on individual-focused, behaviour-based, preventive measures was observed. These findings highlight the need for improving drowning surveillance to ensure the availability and reliability of drowning data; and strengthening research to understand the risk factors for drowning and delivery of drowning prevention programs. Further policy development and research focusing on health promotion approaches that reflect a socio-ecological approach to drowning prevention in Indonesia is imperative.

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation across country income levels: a scoping review

OBJECTIVE

Trauma is a leading cause of mortality and morbidity globally, disproportionately affecting low/middle-income countries (LMICs). Understanding the factors determining implementation success for in-hospital Trauma Quality Improvement Programs (TQIPs) is critical to reducing the global trauma burden. We synthesised topical literature to identify key facilitators and barriers to in-hospital TQIP implementation across country income levels.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Web of Science and Global Index Medicus databases were searched from June 2009 to January 2022.

ELIGIBILITY CRITERIA

Published literature involving any study design, written in English and evaluating any implemented in-hospital quality improvement programme in trauma populations worldwide. Literature that was non-English, unpublished and involved non-hospital TQIPs was excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers completed a three-stage screening process using Covidence, with any discrepancies resolved through a third reviewer. Content analysis using the Consolidated Framework for Implementation Research identified facilitator and barrier themes for in-hospital TQIP implementation.

RESULTS

Twenty-eight studies met the eligibility criteria from 3923 studies identified. The most discussed in-hospital TQIPs in included literature were trauma registries. Facilitators and barriers were similar across all country income levels. The main facilitator themes identified were the prioritisation of staff education and training, strengthening stakeholder dialogue and providing standardised best-practice guidelines. The key barrier theme identified in LMICs was poor data quality, while high-income countries (HICs) had reduced communication across professional hierarchies.

CONCLUSIONS

Stakeholder prioritisation of in-hospital TQIPs, along with increased knowledge and consensus of trauma care best practices, are essential efforts to reduce the global trauma burden. The primary focus of future studies on in-hospital TQIPs in LMICs should target improving registry data quality, while interventions in HICs should target strengthening communication channels between healthcare professionals.

Understanding the barriers and facilitators to trauma registry development in resource-constrained settings: A survey of trauma registry stewards and researchers

BACKGROUND

The implementation of trauma registries has proven a highly effective means of injury control. However, many low and middle-income countries lack trauma registries. Those that have trauma registries vary widely in terms of both implementation and structure. We sought to identify the most common barriers that stand in the way of sustainable trauma registry implementation, and the types of strategies that have proven successful in overcoming these barriers.

METHODS

We conducted a questionnaire of trauma registry stewards and researchers in LMICs.

RESULTS

Twenty-two individuals responded to the questionnaire representing trauma registry experiences across thirteen LMICs. The most common barriers to trauma registry implementation identified included staffing, funding, and stakeholder engagement. Many different strategies for addressing these barriers were discussed. Those mentioned by multiple respondents included the need for a trauma registry champion, fostering strong stakeholder relationships, and improving efficiency of data collection.

CONCLUSIONS

Though trauma registry implementation and structure may differ from place to place, there are many shared barriers and facilitators that can be learned from. Identifying these common experiences can help create a repository of knowledge that can better serve those looking to implement their own trauma registries in similar settings.

Comparison of the Pediatric Resuscitation and Trauma Outcome (PRESTO) Model and Pediatric Trauma Scoring Systems in a Middle-Income Country

BACKGROUND

The pediatric resuscitation and trauma outcome (PRESTO) model was developed to aid comparisons of risk-adjusted mortality after injury in low- and middle-income countries (LMICs). We sought to validate PRESTO using data from a middle-income country (MIC) trauma registry and compare its performance to the Pediatric Trauma Score (PTS), Revised Trauma Score, and pediatric age-adjusted shock index (SIPA).

METHODS

We included children (age < 15 years) admitted to a single trauma center in South Africa from December 2012 to January 2019. We excluded patients missing variables necessary for the PRESTO model-age, systolic blood pressure, pulse, oxygen saturation, neurologic status, and airway support. Trauma scores were assigned retrospectively. PRESTO's previously high-income country (HIC)-validated optimal threshold was compared to MIC-validated threshold using area under the receiver operating characteristic curves (AUROC). Prediction of in-hospital death using trauma scoring systems was compared using ROC analysis.

RESULTS

Of 1160 injured children, 988 (85%) had complete data for calculation of PRESTO. Median age was 7 (IQR: 4, 11), and 67% were male. Mortality was 2% (n = 23). Mean predicted mortality was 0.5% (range 0-25.7%, AUROC 0.93). Using the HIC-validated threshold, PRESTO had a sensitivity of 26.1% and a specificity of 99.7%. The MIC threshold showed a sensitivity of 82.6% and specificity of 89.4%. The MIC threshold yielded superior discrimination (AUROC 0.86 [CI 0.78, 0.94]) compared to the previously established HIC threshold (0.63 [CI 0.54, 0.72], p < 0.0001). PRESTO showed superior prediction of in-hospital death compared to PTS and SIPA (all p < 0.01).

CONCLUSION

PRESTO can be applied in MIC settings and discriminates between children at risk for in-hospital death following trauma. Further research should clarify optimal decision thresholds for quality improvement and benchmarking in LMIC settings.

Maximizing the potential of trauma registries in low-income and middle-income countries

Injury is a major global health issue, resulting in millions of deaths every year. For decades, trauma registries have been used in wealthier countries for injury surveillance and clinical governance, but their adoption has lagged in low-income and middle-income countries (LMICs). Paradoxically, LMICs face a disproportionately high burden of injury with few resources available to address this pandemic. Despite these resource constraints, several hospitals and regions in LMICs have managed to develop trauma registries to collect information related to the injury event, process of care, and outcome of the injured patient. While the implementation of these trauma registries is a positive step forward in addressing the injury burden in LMICs, numerous challenges still stand in the way of maximizing the potential of trauma registries to inform injury prevention, mitigation, and improve quality of trauma care. This paper outlines several of these challenges and identifies potential solutions that can be adopted to improve the functionality of trauma registries in resource-poor contexts. Increased recognition and support for trauma registry development and improvement in LMICs is critical to reducing the burden of injury in these settings.

Leveraging Existing Tools in Electronic Health Record Systems to Automate Clinical Registry Compilation

Clinical registries have proven beneficial by providing a resource to address research questions, monitor care, and identify suitable subjects for clinical studies. Despite a well-organized registry, population is often low because of the human capital required. The increasing prevalence of electronic medical health records provides the opportunity to integrate registry compilation into routine patient encounters. Here we describe how one tool existing within the Epic Medical Record software suite, Smart Phrases, can be adapted to automate population of a hearing loss patient registry. The usage rate of Smart Phrases was high and resulted in a significant reduction in the time burden associated with registry population. Use of Smart Phrases could become an important factor in the design of future registries that allow broad uptake and convenient data input.

Assessment of the Efficacy and Safety of a Novel, Low-Cost, Junctional Tourniquet in a Porcine Model of Hemorrhagic Shock

INTRODUCTION

Commercially available junctional tourniquets (JTQs) have several drawbacks. We developed a low-cost, compact, easy to apply JTQ. The aim of this study was to assess the tourniquets' safety and efficacy in a swine model of controlled hemorrhage.

MATERIALS AND METHODS

Five pigs were subjected to controlled bleeding of 35% of their blood volume. Subsequently, the JTQ was applied to the inguinal area for 180 minutes. Afterwards, the tourniquet was removed for additional 60 minutes of follow up. During the study, blood flow to both hind limbs and blood samples for tissue damage markers were repeatedly assessed. Following sacrifice, injury to both inguinal areas was evaluated microscopically and macroscopically.

RESULTS

Angiography demonstrated complete occlusion of femoral artery flow, which was restored following removal of the tourniquet. No gross signs of tissue damage were noticed. Histological analysis revealed mild necrosis and infiltration of inflammatory cells. Blood tests showed a mild increase in potassium and lactic acid levels throughout the protocol.

CONCLUSIONS

The tourniquet achieved effective arterial occlusion with minimal tissue damage, similar to reports of other JTQs. Subjected to further human trials, the tourniquet might be a suitable candidate for widespread frontline deployment because of its versatility, compactness, and affordable design.

Identification of the essential components of quality in the data collection process for public health information systems

This study identifies essential components in the data collection process for public health information systems based on appraisal and synthesis of the reported factors affecting this process in the literature. Extant process assessment instruments and studies of public health data collection from electronic databases and the relevant institutional websites were reviewed and analyzed following a five-stage framework. Four dimensions covering 12 factors and 149 indicators were identified. The first dimension, data collection management, includes data collection system and quality assurance. The second dimension, data collector, is described by staffing pattern, skill or competence, communication and attitude toward data collection. The third, information system, is assessed by function and technology support, integration of different data collection systems, and device. The fourth dimension, data collection environment, comprises training, leadership, and funding. With empirical testing and contextual analysis, these essential components can be further used to develop a framework for measuring the quality of the data collection process for public health information systems.

A multicenter observational study on the distribution of orthopaedic fracture types across 17 low- and middle-income countries

Objectives:

To describe the regional distribution of fractures sustained by women and health care system characteristics across 17 low- and middle-income countries (LMICs).

Methods:

The INternational ORthopaedic MUlticentre Study in fracture care (INORMUS) is an observational study collecting data on patients in LMICs who sustained a fracture or musculoskeletal injury. As a planned analysis for the INORMUS study, we explored differences in fracture locations and demographics reported among 9878 female patients who sustained a fracture within 17 LMICs in 5 regions (China, Africa, India, Other Asia, and Latin America).

Results:

Half of our study population (49.6%) was ≥60 years of age. Across all regions, 58.3% of patients possessed health insurance. Latin America possessed the highest proportion (88.8%) of health insurance, while in Africa, patients possessed the lowest (18.0%). Falls from standing were the most prevalent mechanism of injury (51.7%) followed by falls from height (12.8%) and motorcycle-related road traffic injuries (9.7%). The majority of the fractures (65.6%) occurred in patients aged 50 and older. Hip fractures were the most common fracture (26.8%), followed by tibia/fibula (12.6%) and spine fractures (9.7%). Open fractures accounted for 7.6% of fractures and were most commonly tibia/fibula fractures (35.1%). Despite these severe injuries, less than one-third (28.8%) of patients were transported for care after sustaining a fracture by ambulance. Regionally, a majority of female patients in Africa were working age and suffered tibia/fibula (21.6%) and femur fractures (14.0%). Patients in the regional category Other Asia, suffered the highest frequencies of open fractures (9.6% low grade, 7.1% high grade), and disproportionately from motorcycle road traffic injuries (29.9%).

Conclusion:

Across all regions, the most significant source of fracture burden was in the elderly, and included common fragility fractures, such as hip fractures. Notable regional deviations in fracture distributions were observed within Africa, and Other Asia. Across all studied LMICs, ambulance usage was low, and health insurance coverage was particularly low in Africa and India.

Global and regional child deaths due to injuries: an assessment of the evidence

Background

Injuries result in substantial number of deaths among children globally. The burden across many settings is largely unknown. We estimated global and regional child deaths due to injuries from publicly available evidence.

Methods

We searched for community-based studies and nationally representative data reporting on child injury deaths published after year 1990 from CINAHL, EMBASE, IndMed, LILACS, Global Health, MEDLINE, SCOPUS, and Web of Science. Specific and all-cause mortality due to injuries were extracted for three age groups (0-11 months, 1-4 years, and 0-4 years). We conducted random-effects meta-analysis on extracted crude estimates, and developed a meta-regression model to determine the number of deaths due to injuries among children aged 0-4 years globally and across the World Health Organization (WHO) regions.

Results

Twenty-nine studies from 16 countries met the selection criteria. A total of 230 data-points on 15 causes of injury deaths were retrieved from all studies. Eighteen studies were rated as high quality, although heterogeneity was high (I² = 99.7%, P < 0.001) reflecting variable data sources and study designs. For children aged 0-11 months, the pooled crude injury mortality rate was 29.6 (95% confidence interval (CI) = 21.1-38.1) per 100 000 child population, with asphyxiation being the leading cause of death (neonatal) at 189.1 (95% CI = 142.7-235.4) per 100 000 followed by suffocation (post-neonatal) at 18.7 (95% CI = 11.8-25.7) per 100 000. Among children aged 1-4 years, the pooled crude injury mortality rate was 32.7 (95% CI = 27.3-38.1) per 100 000, with traffic injuries and drowning the leading causes of deaths at 10.8 (95% CI = 8.9-12.8) and 8.8 (95% CI = 7.5-10.2) per 100 000, respectively. Among children under five years, the pooled injury mortality rate was 37.7 (95% CI = 32.7-42.7) per 100 000, with traffic injuries and drowning also the leading causes of deaths at 10.3 (95% CI = 8.8-11.8) and 8.9 (95% CI = 7.8-9.9) per 100 000 respectively. When crude mortality changes over age, WHO regions, and study period were accounted for in our model, we estimated that in 2015 there were 522 167 (95% CI = 395 823-648 630) deaths among children aged 0-4 years, with South East Asia (SEARO) recording the highest number of deaths at 195 084 (95% CI = 159476-230502), closely followed by the Africa region (AFRO) with 176523 (95% CI = 115 040-237 831) deaths. Globally, traffic injuries and drowning were the leading causes of under-five injury fatalities in 2015 with 142 661 (22.0/100 000) and 123 270 (19.0/100 000) child deaths, respectively. The exception being burns in AFRO with 57 784 deaths (38.6/100 000).

Conclusions

Varying study designs, case definitions, and particularly limited country representation from Africa and South-East Asia (where we reported higher estimates), imply a need for more studies for better population representative estimates. This study may have however provided improved understanding on child injury death profiles needed to guide further research, policy reforms and relevant strategies globally.

Factors contributing to successful trauma registry implementation in low- and middle-income countries: A systematic review

BACKGROUND

Trauma registries (TR) provide invaluable data, informing resource allocation and quality improvement. The purpose of this systematic review was to identify factors promoting and inhibiting successful TR implementation in low- and middle-income countries (LMICs).

METHODS

The protocol was registered a priori (CRD42017058586). With librarian oversight, a peer-reviewed search strategy was developed. Adhering to PRISMA guidelines, two independent reviewers performed first-screen and full-text screening. Studies describing implementation of a TR in LMICs or reviewed the experience of registry users/implementers were included. Extracted data, focusing on publication, institution, registry and data factors, was summarized using descriptive statistics and subjected to thematic qualitative analysis.

RESULTS

Out of 3842 screened references, 40 articles were included for analysis. Most registries were paper-based, implemented in single publicly-funded institutions within LMICs, benefited from funding, and were run by untrained house-staff with other clinical responsibilities. Constituent variables, injury scoring, outcome assessment, and quality assurance practices were very diverse. Principal obstacles to successful implementation were lack of funding, significant missing data, and insufficient resources.

CONCLUSIONS

This work may contribute to the planning of future efforts towards TR implementation in LMICs, where better injury data has the potential to alleviate the morbidity and mortality associated with trauma through advocacy and quality-improvement.

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center

Importance

Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity.

Objective

To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools.

Design, Setting, and Participants

This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013.

Main Outcomes and Measures

The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital.

Results

The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell's Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]).

Conclusions and Relevance

Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data.

Road traffic injury in sub-Saharan African countries: A systematic review and summary of observational studies

OBJECTIVE

The aim of this study is to evaluate, through a systematic review of hospital-based studies, the proportion of road traffic injuries and fatalities in sub-Saharan Africa (SSA).

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology guidelines, we searched the following electronic databases: PubMed, Embase, Africa-Wide Information, Global Health, and Web of Science. Articles were eligible if they measured proportion of road traffic injuries (RTIs) in SSA by using hospital-based studies. In addition, a reference and citation analysis was conducted as well as a data quality assessment.

RESULTS

Up to 2015, there were a total of 83 hospital-based epidemiologic studies, including 310,660 trauma patients and 99,751 RTI cases, in 13 SSA countries. The median proportion of RTIs among trauma patients was 32% (4 to 91%), of which the median proportion of death for the included articles was 5% (0.3 to 41%).

CONCLUSION

The number of studies evaluating RTI proportions and fatalities in SSA countries is increasing but without the exponential rise expected from World Health Organization calls for research during the Decade of Action for Road Traffic Injuries. Further research infrastructure including standardization of taxonomy, definitions, and data reporting measures, as well as funding, would allow for improved cross-country comparisons.

Population incidence of pedestrian traffic injury in high-income countries: A systematic review

BACKGROUND

Road traffic injuries are the fifth leading cause of years of life lost, with pedestrians comprising 39% of all road deaths. International recognition of this public health issue has led to a reduction in road traffic deaths in many high-income countries. However data on non-motorised road users such as pedestrians is incomplete. Additionally, non-fatal injuries are poorly documented. The aim of this study was to identify the incidence of pedestrian traffic injury reported from high-income countries.

METHODS

A systematic review of the literature was conducted using MEDLINE, Scopus, PubMed and the Cochrane library. Studies were eligible for inclusion if they reported the incidence of pedestrian injury in a defined population from a high-income country defined using the World Bank atlas method for the 2016 fiscal year. A meta-analysis was performed on the population incidence of pedestrian traffic injury by world region.

RESULTS

Seventeen studies were identified from eight high-income countries that satisfied the inclusion criteria. The pooled incidence of PTI in the European region was 68.8 per 100,000 population (95%CI 50-87.7, p<0.01) and 89.3 per 100,000 (95%CI 47.2-131.4, p<0.01) in the American region. The incidence of pedestrian traffic injury varied from 20 per 100,000 in Victoria, Australia to 203 per 100,000 in New York City, United States of America. Pedestrian mortality ranged from 0.9 to 14 per 100,000 population. Wide variation in population size, location and demographics was observed between studies.

CONCLUSIONS

This review concluded a high burden of pedestrian trauma in HICs with individual reports reporting from rates of 20 to 203 per 100,000 population. Recommended interventions directed at reducing the burden of pedestrian trauma were not universally present in the reported high-income countries. Implementation of such safety strategies and demonstration of improvement in pedestrian trauma rates and outcomes present directions for further research.

Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital

BACKGROUND

Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility-based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes.

METHODS

An electronic, tablet-based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in-patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in-patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes.

RESULTS

A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity.

CONCLUSION

The establishment of hospital-based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs.

Development of an mHealth trauma registry in the Middle East using an implementation science framework

BACKGROUND

Trauma registries (TRs) play a vital role in the assessment of trauma care, but are often underutilized in countries with a high burden of injuries.

OBJECTIVES

We investigated whether information and communications technology (ICT) such as mobile health (mHealth) could enable the design of a tablet-based application for healthcare professionals. This would be used to inform trauma care and acquire surveillance data for injury control and prevention in Oman. This paper focuses on documenting the implementation process in a healthcare setting.

METHODS

The study was conducted using an ICT implementation framework consisting of multistep assessment, development and pilot testing of an electronic tablet-based TR. The pilot study was conducted at two large hospitals in Oman, followed by detailed evaluation of the process, system and impact of implementation.

RESULTS

The registry was designed to provide comprehensive information on each trauma case from the location of injury until hospital discharge, with variables organized to cover 11 domains of demographic and clinical information. The pilot study demonstrated that the registry was user friendly and reliable, and the implementation framework was useful in planning for the Omani hospital setting. Data collection by trained and dedicated nurses proved to be more feasible, efficient and reliable than real-time data entry by care providers.

CONCLUSIONS

The initial results show the promising potential of a user-friendly, comprehensive electronic TR through the use of mHealth tools. The pilot test in two hospitals indicates that the registry can be used to create a multicenter trauma database.

Delivering a sustainable trauma management training programme tailored for low-resource settings in East, Central and Southern African countries using a cascading course model

BACKGROUND

Injuries cause five million deaths and 279 Disability Adjusted Life Years (DALYS) each year worldwide. The COSECSA Oxford Orthopaedic Link (COOL) is a multi-country partnership programme that has delivered training in trauma management to nine sub-Saharan countries across a wide-cadre of health-workers using a model of "primary" courses delivered by UK instructors, followed by "cascading" courses led by local faculty. This study examines the impact on knowledge and clinical confidence among health-workers, and compares the performance of "cascading" and "primary" courses delivered in low-resource settings.

METHODS

Data was collated from 1030 candidates (119 Clinical Officers, 540 Doctors, 260 Nurses and 111 Medical Students) trained over 28 courses (9 "primary" and 19 "cascading" courses) in nine sub-Saharan countries between 2012 and 2013. Knowledge and clinical confidence of candidates were assessed using pre- and post-course MCQs and confidence matrix rating of clinical scenarios. Changes were measured in relation to co-variants of gender, job roles and primary versus cascading courses. Multivariate regression modelling and cost analysis was performed to examine the impact of primary versus cascading courses on candidates' performance.

FINDINGS

There was a significant improvement in knowledge (58% to 77%, p<0.05) and clinical confidence (68% to 90%, p<0.05) post-course. "Non-doctors" demonstrated a greater improvement in knowledge (22%) and confidence (24%) following the course (p<0.05). The degree of improvement of MCQ scores differed significantly, with the cascading courses (21%) outperforming primary courses (15%) (p<0.002). This is further supported by multivariate regression modelling where cascading courses are a strong predictor for improvement in MCQ scores (Coef=4.83, p<0.05).

INTERPRETATION

Trauma management training of health-workers plays a pivotal role in tackling the ever-growing trauma burden in Africa. Our study suggests cascading PTC courses may be an effective model in delivering trauma training in low-resource settings, however further studies are required to determine its efficacy in improving clinical competence and retention of knowledge and skills in the long term.

The WHO injury surveillance guidelines: a systematic review of the non-fatal guidelines' utilization, efficacy and effectiveness

OBJECTIVES

To systematically assess the utilization, efficacy and effectiveness of the WHO Injury Surveillance Guidelines.

STUDY DESIGN

A systematic review of the literature.

METHODS

A comprehensive systematic search of peer reviewed and grey literature was conducted for relevant studies published between Jan 2002 and May 2013 reporting utilization of the Injury Surveillance Guidelines. Injury experts and government departments from low- and middle-income countries were contacted.

RESULTS

Forty-nine studies met the inclusion criteria. These were conducted in health facilities in five WHO regions, African Region (28%): Eastern Mediterranean and Western Pacific Regions, both 22%. The Guidelines were mostly used selectively: the minimum data set as a survey tool; process and system environment evaluation; categorizing injuries for data analysis; measuring injury severity and for data quality assessment or comparisons. Twenty-six studies used the Guidelines to collect overview injury data prospectively and/or retrospectively, or for Injury Surveillance System (ISS) feasibility studies, with four actually establishing an ISS or informing the establishment process. Few reported effects on injury policies and programs. Most studies used only the minimum dataset, limiting the level of detail for injury prevention. Other ISSs may have been established using the Guidelines, though no English language publications referencing this were found.

CONCLUSIONS

This review provides encouraging results that the Guidelines continue to be used, albeit mainly for short-term studies predominantly in low- and middle-income countries with very limited sustained ISS establishment and local injury prevention capacity building. It highlights the need to improve and expand the minimum dataset to at least include a meaningful narrative text and potentially to expand the mechanism codes to a second level of detail, as well as building local injury prevention capacity.

Young, male, road traffic victims: a systematic review of the published trauma registry literature from low and middle income countries

BACKGROUND

Trauma contributes significantly to the global burden of disease. We analysed published trauma registries to assess the demographics of those most affected in low and middle-income countries (LMICs).

METHODS

We performed a systematic review of published trauma registry studies according to PRISMA guidelines. We included published full-text articles from trauma registries in low and middle-income countries describing the demographics of trauma registry patients. Articles from military trauma registries, articles using data not principally derived from trauma registry data, articles describing patients of only one demographic (e.g. only paediatric patients), or only one mechanism of injury, trauma registry implementation papers without demographic data, review papers and conference proceedings were excluded.

RESULTS

The initial search retrieved 1868 abstracts of which 1324 remained after duplicate removal. After screening the abstracts, 78 full-text articles were scrutinised for their suitability for inclusion. Twenty three papers from 14 countries, including 103,327 patients, were deemed eligible and included for analysis. The median age of trauma victims in these articles was 27 years (IQR 25-29). The median percentage of trauma victims who were male was 75 (IQR 66-84). The median percentage of road traffic injuries (RTIs) as a percentage of total injuries caused by trauma was 46 (IQR 21-71).

CONCLUSIONS

Young, male, road traffic victims represent a large proportion of the LMIC trauma burden. This information can inform and be used by local and national governments to implement road safety measures and other strategies aimed at reducing the injury rate in young males.

Intentional injury and violence in Cape Town, South Africa: an epidemiological analysis of trauma admissions data

Background

Injury is a truly global health issue that has enormous societal and economic consequences in all countries. Interpersonal violence is now widely recognized as important global public health issues that can be addressed through evidence-based interventions. In South Africa, as in many low- and middle-income countries (LMIC), a lack of ongoing, systematic injury surveillance has limited the ability to characterize the burden of violence-related injury and to develop prevention programmes.

Objective

To describe the profile of trauma presenting to the trauma centre of Groote Schuur Hospital in Cape Town, South Africa – relating to interpersonal violence, using data collected from a newly implemented surveillance system. Particular emphasis was placed on temporal aspects of injury epidemiology, as well as age and sex differentiation.

Design

Data were collected prospectively using a standardized trauma admissions form for all patients presenting to the trauma centre. An epidemiological analysis was conducted on 16 months of data collected from June 2010 to October 2011.

Results

A total of 8445 patients were included in the analysis, in which the majority were violence-related. Specifically, 35% of records included violent trauma and, of those, 75% of victims were male. There was a clear temporal pattern: a greater proportion of intentional injuries occur during the night, while unintentional injury peaks late in the afternoon. In total, two-third of all intentional trauma is inflicted on the weekends, as is 60% of unintentional trauma. Where alcohol was recorded in the record, 72% of cases involved intentional injury. Sex was again a key factor as over 80% of all records involving alcohol or substance abuse were associated with males. The findings highlighted the association between violence, young males, substance use, and weekends.

Conclusions

This study provides the basis for evidence-based interventions to reduce the burden of intentional injury. Furthermore, it demonstrates the value of locally appropriate, ongoing, systematic public health surveillance in LMIC.

Development, implementation, and evaluation of a hybrid electronic medical record system specifically designed for a developing world surgical service

BACKGROUND

The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service. This HEMR system was designed to incorporate the function and benefits of an ESR, an electronic medical record (EMR) system, and a clinical decision support system (CDSS).

METHODS

Formal ethical approval to maintain the HEMR system was obtained. Appropriate software was sourced to develop the project. The data model was designed as a relational database. Following the design and construction process, the HEMR file was launched on a secure server. This provided the benefits of access security and automated backups. A systematic training program was implemented for client training. The exercise of data capture was integrated into the process of clinical workflow, taking place at multiple points in time. Data were captured at the times of admission, operative intervention, endoscopic intervention, adverse events (morbidity), and the end of patient care (discharge, transfer, or death).

RESULTS

A quarterly audit was performed 3 months after implementation of the HEMR system. The data were extracted and audited to assess their quality. A total of 1,114 patient entries were captured in the system. Compliance rates were in the order of 87-100 %, and client satisfaction rates were high.

CONCLUSIONS

It is possible to construct and implement a unique, simple, cost-effective HEMR system in a developing world surgical service. This information system is unique in that it combines the discrete functions of an EMR system with an ESR and a CDSS. We identified a number of potential limitations and developed interventions to ameliorate them. This HEMR system provides the necessary platform for ongoing quality improvement programs and clinical research.

The burden of trauma in four rural district hospitals in Malawi: a retrospective review of medical records

BACKGROUND

Few injury surveillance systems collect data in sub-Saharan Africa. This medical record review of four rural hospitals provides baseline data on the burden of trauma in Malawi.

METHODS

We reviewed all outpatient, inpatient, and mortuary records for one full year at four of the 28 district hospitals in Malawi: Dedza in central Malawi, Mangochi in the east, Nkhata Bay in the north, and Thyolo in the south. We used descriptive and comparative statistics to examine characteristics of patients and the data file.

RESULTS

During 2012, 18,735 trauma patients were treated at the four district hospitals. Trauma cases accounted for 3.5% of the 541,170 patient visits. In total, 60.8% of trauma patients were male; 39.1% were 0–14 years old and 50.4% were 15–49 years old. The logbooks were missing information about the primary type of injury for 44.9% of patients and about injury cause for 82.7%. Of the recorded trauma diagnoses, the most common injuries were soft tissue injuries, fractures, and sprains. The most commonly reported causes of injuries were animal bites (mostly dog bites), road traffic injuries, assaults, burns, and falls.

CONCLUSIONS

The development and implementation of improved methods for acquiring more complete, accurate, and useful trauma data in Malawi and other low-income countries requires addressing difficulties that might result in missing data. Increased injury surveillance is critical for improving trauma care and meeting the emerging global demand for burden of disease data.

Establishing hospital-based trauma registry systems: lessons from Kenya

OBJECTIVE

In the developing world, data about the burden of injury, injury outcomes, and complications of care are limited. Hospital-based trauma registries are a data source that can help define this burden. Under the trauma care component of the Bloomberg Global Road Safety Partnership, trauma registries have been implemented at three sites in Kenya. We describe the challenges and lessons learned from this effort.

METHODS

A paper-based trauma surveillance form was developed, in collaboration with local hospital partners, to collect data on all trauma patients presenting for care. The form includes demographic information, pre-hospital care given, and patient care and clinical information necessary to calculate estimated injury surveillance. The type of data collected was standardized across all three sites. Frequent reviews of the data collection process, quality, and completeness, in addition to regular meetings and conference calls, have allowed us to optimize the process to improve efficiency and make corrective actions where required.

RESULTS

Trauma registries have been implemented in three hospitals in Kenya, with potential for expansion to other hospitals and facilities caring for injured patients. The process of establishing registries was associated with both general and site-specific challenges. Problems were identified in planning, data collection, entry processes, and analysis. Problems were addressed when identified, resulting in improved data quality.

CONCLUSIONS

Trauma registries are a key data source for defining the burden of injury and developing quality improvement processes. Trauma registries were implemented at three sites in Kenya. Problems and challenges in data collection were identified and corrected. Through the registry data, gaps in care were identified and systemic changes made to improve the care of the injured.

The Uyo Trauma Registry-developed for sustainable audit of trauma care and cause in Nigeria

The Cape Town Trauma Registry (CTTR) was developed as a minimum data set for low-resource settings and was applied in a southern Nigerian tertiary hospital. Based on the outcome of the study, the CTTR was modified to produce the Uyo Trauma Registry. Using the CTTR, data was obtained prospectively from injured patients who presented to the Accident and Emergency Department of the University of Uyo Teaching Hospital over a 7 week period in June and July 2012. The final data set was determined based on the ease of capture of each item and its relative importance to injury surveillance. The goal for satisfactory data capture was chosen as ≥ 80%. The Uyo Trauma Registry has 19 patient-variable items and may be the first locally relevant hospital based injury surveillance tool in Nigeria. The Uyo Trauma Registry has provided the resource constrained setting in Nigeria with a simplified tool in order to sustainably obtain trauma data and thus engage in objective locally relevant efforts at injury prevention and improved care of the injured patient.

Development and pilot implementation of a locally developed Trauma Registry: lessons learnt in a low-income country

Background

Trauma registries (TRs) play an integral role in the assessment of trauma care quality. TRs are still uncommon in developing countries owing to awareness and cost. We present a case study of development and pilot implementation of “Karachi Trauma Registry” (KITR), using existing medical records at a tertiary-care hospital of Karachi, Pakistan to present results of initial data and describe its process of implementation.

Methods

KITR is a locally developed, customized, electronic trauma registry based on open source software designed by local software developers in Karachi. Data for KITR was collected from November 2010 to January 2011. All patients presenting to the Emergency Department (ED) of the Aga Khan University Hospital (AKUH) with a diagnosis of injury as defined in ICD-9 CM were included. There was no direct contact with patients or health care providers for data collection. Basic demographics, injury details, event detail, injury severity and outcome were recorded. Data was entered in the KITR and reports were generated.

Results

Complete data of 542 patients were entered and analysed. The mean age of patients was 27 years, and 72.5% were males. About 87% of patients had sustained blunt injury. Falls and motor vehicle crashes were the most common mechanisms of injury. Head and face, followed by the extremities, were the most frequently injured anatomical regions. The mean Injury Severity Score (ISS) was 4.99 and there were 8 deaths. The most common missing variables in the medical records were ethnicity, ED notification prior to transfer, and pre-hospital IV fluids. Average time to review each chart was 14.5 minutes and entry into the electronic registry required 15 minutes.

Conclusion

Using existing medical records, we were able to enter data on most variables including mechanism of injuries, burden of severe injuries and quality indicators such as length of stay in ED, injury to arrival delay, as well as generate injury severity and survival probability but missed information such as ethnicity, ED notification. To make the data collection process more effective, we propose provider based data collection or making a standardized data collection tool a part of medical records.

Assessing quality of existing data sources on road traffic injuries (RTIs) and their utility in informing injury prevention in the Western Cape Province, South Africa

OBJECTIVES

This study assessed whether the quality of the available road traffic injury (RTI) data was sufficient for determining the burden of RTIs in the Western Cape Province and for implementing and monitoring road safety interventions.

METHODOLOGY

Underreporting was assessed by comparing data reported by the South African Police Services (SAPS) in 2008 with data from 18 provincial mortuaries. Completeness of the driver death subset of all RTIs was assessed using the capture-recapture method.

RESULTS

The mortuary and police data sets comprised 1696 and 860 fatalities respectively for the year 2008. The corresponding provincial road traffic mortality rates were as follows: 32.2 deaths/100,000 population per year (95% confidence interval [CI]: 30.7-33.8) and 16.3 deaths/100,000 population per year (95% CI: 15.3-17.5). The police data set contained 820,960 crashes, involving 196,889 persons, indicating substantial duplication of crash events. There were varying proportions of missing data for demographic and other identifying variables, with age missing in nearly half of the cases in the police data set. The estimated total number of driver deaths/year was 588.6 (95% CI: 544.4-632.8), yielding estimated completeness of the mortuary and police data sets of 57.6 and 46.4 percent separately and 77.3 percent combined.

CONCLUSION

This study found extensive data quality problems, including missing data, duplication, and significant underreporting of traffic injury deaths in the police data. Not all assumptions underlying the use of capture-recapture method were met in this study; hence, the estimates provided by this analysis should be interpreted with caution. There is a need to address the problems highlighted by this study in order to improve data utility for informing road safety policies. Supplemental materials are available for this article. Go to the publisher's online edition of Traffic Injury Prevention to view the supplemental file.

A profile of injury in Fiji: findings from a population-based injury surveillance system (TRIP-10)

BACKGROUND

Over 90% of injury deaths occur in low-and middle-income countries. However, the epidemiological profile of injuries in Pacific Islands has received little attention. We used a population-based-trauma registry to investigate the characteristics of all injuries in Viti Levu, Fiji.

METHOD

The Fiji Injury Surveillance in Hospitals (FISH) database prospectively collected data on all injury-related deaths and primary admissions to hospital (≥ 12 hours stay) in Viti Levu during 12 months commencing October 2005.

RESULTS

The 2167 injury-related deaths and hospitalisations corresponded to an annual incidence rate of 333 per 100,000, with males accounting for twice as many cases as females. Almost 80% of injuries involved people aged less than 45 years, and 74% were deemed unintentional. There were 244 fatalities (71% died before admission) and 1994 hospitalisations corresponding to crude annual rates of 37.5 per 100,000 and 306 per 100,000 respectively. The leading cause of fatal injury was road traffic injury (29%) and the equivalent for injury admissions was falls (30%). The commonest type of injury resulting in death and admission to hospital was asphyxia and fractures respectively. Alcohol use was documented as a contributing factor in 13% of deaths and 12% of admissions. In general, indigenous Fijians had higher rates of injury admission, especially for interpersonal violence, while those of Indian ethnicity had higher rates of fatality, especially from suicide.

CONCLUSIONS

Injury is an important public health problem that disproportionately affects young males in Fiji, with a high proportion of deaths prior to hospital presentation. This study highlights key areas requiring priority attention to reduce the burden of potentially life-threatening injuries in Fiji.