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

WHO Statistics on Number of Vehicles and Road Deaths

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

Objectives of the Trauma Registry

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

RTIs at KNH, 2011

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

Injury Surveillance System: Core + Supplementary Data

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

THE END

THANK YOU