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MAINSTREAMING TRAUMA RESEARCH AT THE KNH
The Trauma Registry Project
Saidi Hassan BSc,MBChB, FCS(ECSA), FACS
Njoga Njihia BSc,MBChB
Fatima Paruk MD, MPH
Introduction
• Trauma accounts for 14% of total burden of disease globally (WHO 2003)
• Burden disproportionate
• Morbidity and mortality highest for developing countries
• Reducing in the West- prevention, acute care, rehab, systems
• Escalating in LMIC – prevention efforts no match
Introduction • Trauma registries are a key ingredient of trauma
systems
• NTDB a collation several million trauma records from over 405 trauma centers in the USA; > 700 data points
• In Africa, the large trauma burden remains unattended; worse outcomes
• Goal: KNH the foundation for a National Trauma Database
Trauma Registries in Africa
• Tikur Anbesa Hospital
• Injury Control Centre- Uganda
• South Africa
• ? Kenya
The Case for KNH: Pre-hospital deaths, Nairobi 2012
GenderTraffic(%) Assault(%) GSW(%) Fall(%) Burns(%) Suicide(%) Other(%)
Male.72(34) 42 (19.8) 61 (28.8) 3 (1.4) 10 (4.7) 13 (6.1) 11 (5.2)
Female 12(48) 5 (20) 0 (0) 1 (4) 4 (16) 2 (8) 12 (5.2)
Saidi, 2011
Violence injuries at KNH, 2011
• Intentional trauma, self-harm and unintentional injury comprised 24.4 % (n =402), 0.2% and 74.9% of 1639 trauma admissions
• 58.1 % younger than 30 years of age, male 91.9%
• Compared to other trauma:• Night event (78.6% versus 27.5%, (p < 001)
Saidi, 2011
Violence injuries at KNH, 2011
• Direct admissions (63.8% versus 45.1 %, p < 0.01)
• LOS > 2 weeks 36.7% vs 60.4% for other trauma.
• IPV 81.6%, GSW 16.7% (n = 67) of cases
• Inpatient mortality was 8.4%% (n 32).
Saidi, 2011
RTI Mortality, KNH, 2011Variable Alive Died P value OR (C/I)
Disposition Wards 841 41(4.6%) < 0.001 10.1(6.0-16.8)
ICU/OR 71 35 (33.0%)
Region of injury Head/neck 263 (85.4%) 45 (14.6%) < 0.001 3.2 (2.1 -4.9
Other 649 (95.4%) 31 (4.6%)
Surgical treatment Major procedure 452 (96.8%) 15 (3.2%) < 0.001 3.9 (2.2-7.0)
Nonsurgical care 446 (88.5%) 11.5%
Injury severity ISS < 15 806 (95.4%) 39 (4.6%) < 0.001 7.9 (4.8 – 12.9)-
ISS > 15 97 (72.4%) 37 (27.6%)
Admission status Direct from scene 383 (95.1%) 20 (4.9%) 0.001 2.5 (1.5-4.3)
Transfer-in 409 (88.5%) 53 (11.5%)
Age < 60 years 862 (92.9%) 66 (7.1%) 0.07 4. (0.9 – 6.5)
> 60 years 27 (84.4%) 5 (15.6%)
Gender Male 718 (92.1%) 62 (7.9%) 0.38 1.3 (0.7-2.4)
Female 185 (93.9%) 12 (6.1%)
Blood product Transfused 142 (82.6%) 30 (17.4%) < 0.001 2.6 (1.7-4.1)
Not transfused 641 (93.4%) 45 (6.6%)
Specific injury Head injuries 173 (84.6%) 31 (15.2%) < 0.001 2.6 (1.7-4.0)
Other injuries 732 (94.2%) 45 (5.8%)
Abdominal injury 18 (78.3%) 5 (21.7%) 0.011 2.9 (1.3-6.6)
Other injury 887 (92.6%) 71 (7.4%)
The Case for KNH: 72 Elderly trauma patients, 2011
• Mean 70.5, 4.5% of all trauma admissions
• Intent: accidental in 84.7% of cases
• Mechanisms: traffic (44.4%) and falls (41.7%)
• Females 41.7%, LL fractures (54.9%),
• ICU rate 6%, LOS 24 d
• Mortality 13.9% ; gender, HI predictors
Saidi, 2011
The Case for KNH: the motorcycle menace, 2011
• N = 205 ; 22.3% of vehicular admissions• 50% of riders and 20% of passengers used helmets• Injuries: extremity (60.7%) and head/neck (32.07%)• Mortality 9.0%; surgery 51.7% , LOS 24.3 d • Determinants:– ISS, ICU admission, non-surgical treatment, blood
transfusion, head injury, deranged vital signs, helmet use
• Significant HI, LOS, Mortality calls for efforts to embrace helmet laws for riders and passengers.
Saidi, 2011
Trauma Registry for KNH, 2011
• Data reviewed one-off surveys
• Need for sequential data capture to: – Improve efficiency of detecting defects in care
– Measure improvement in care delivery
– Monitoring process of trauma care
– Trend trauma epidemiology
– Enhance trauma research
– Inform resource allocation
• KNH - catchment 4 million
The Injury Surveillance System
What are the steps required to develop an injury surveillance system?
The Team
• The project PI
• PI assistant
• RS-10 team
• Clinical and academic nurse
• Medical officer
• ICT office
• KNH Senior Director, Surgical Services
• KNH A&E Coordinator
Summary features of KNH registry• Prospective data collection
• Expanded versus limited data element collection
• Dedicated, customized computer versus generic repository
• Data abstractors with medical background
• Linkage to performance improvement activities
• Large trauma census
Process – Initiating a Trauma RegistryDevelopment of the survey instrument: a single, paper based form Adaptation to individual hospital capability and interestsData collected:
Facility name, Hospital ID, Date/Time of Arrival in Facility, Time seen by HCW, DOB, Age, Sex
Education level/Occupation Care provided at scene of injury? By whom? What type (C-spine/IVF)Mode of arrival, transport time to hospital, referral statusDate/Time/Place/Activity at time of Injury Alcohol/Substance Abuse Mechanism of InjuryType of RTA, Road User
Clinical Data in Hospital-Based Registry
Clinical Data Collected Vitals: BP/HR/RRGCSInjury – Anatomical area affected, Pathology,
SeverityTreatment, including type of Operative
ManagementOperative and other complications, including
HAIDisposition/Date/Time of dischargeCost
Inclusion criteria
“one at significant risk for loss of life or limb, or significant permanent disfigurement or
disability from a blunt or penetrating injury, exposure to electromagnetic, chemical, or
radioactive energy, drowning, suffocation, or strangulation, or a deficit or excess of heat.”
Computer Hardware/Software• Microsoft Access front- and back-end
- Lightweight (data footprint of 2kb/patient)
- Allows file-system level and application-level security tiers for data security
- Easy to deploy
- Reporting capability easier
- Exportability to Excel and subsequently to SAS/SPSS/Stata
Computer Hardware/Software• Parallel-phased implementation
- Principle borrowed from experience with BRECC
- Allows easier identification of bottlenecks- Gives redundancy to backup of data- Acceptability- Enable internal and external audit in future
Sample Results• Overall M:F ratio = 81.5 : 18.5
• Mean age 27.48 years (SD, 14.85)
• Top 3 Causes of Injury (n=204)
• RTI (29.4%)
• Struck by object/person (21.1%)
• Stab/Cut (12.7%)
Challenges• Multiple data entries• Hospital data forms/intake form• Registry paper form• Electronic form
• Incomplete data, Incorrect data entry• Subjectivity between data collectors• Different data entry systems between hospital
systems – challenge for merging data• Link with hospital EMR• Lack of awareness within the KNH and UON
community
Successes
• Data on 266/535 patients for Nov - Jan
• Healthy team spirit
• Buy-in and Support from the administration – CEO, MAC, IRB, A & E
• Collaboration and mentorship/JHU
• Young team members embracing culture of research and publication
The next steps• Link to the hospital EMR system
• Data cleaning
• Train staff from medical record, A&E with a view to sustainability
• Strategic objective for KNH
• Presentations to the A & E, University, and KNH
• Continue collaboration for mentorship
• Share experience with the surgical fraternity
The next steps/ the trauma dream
• Larger scale national system based on KNH/Tenwek/Embu/Nakuru/Kijabe 2014
• Advocacy: Health ministries, SSK, KOA, National Road safety board, KRC, Universities for a lead agency on trauma/Injury control unit?
• Hospital support with trauma registry clerk for sustainable registry
Acknowledgements
• Dr. Joshua Owiti
• Mr. Ali Wangara
• Dr. Bernard Githae
• Dr. Ebrahim Hassan
• Dr. Kent Stevens
• Dr. Fatima Razuk