Development and pilot implementation of a standardised trauma documentation form to inform a national trauma registry in a low-resource setting: lessons from Tanzania

Review of a large trauma registry in Addis Ababa, Ethiopia: insights into prehospital care and provider training for trauma quality improvement

Background

Injury is a major cause of death and disability in Ethiopia. ALERT Hospital, one of only three designated trauma centers in the country, has employed a basic trauma registry since its inception in 2016; however, these data had not been used. In joint efforts with the Federal Ministry of Health, we aimed to understand patient injury characteristics and predictors of mortality, to inform priorities in resource and training investments.

Methods

Data from 12 816 consecutive patients in the first 3 years of the trauma registry were reviewed retrospectively. Modified Early Warning Score was used at triage to indicate injury severity (red=critically injured, green=minor injury). No physiologic data for calculating Injury Severity Scores or in-hospital intervention data were available. Triage groups were compared and multivariate logistic regression conducted to determine predictors of in-emergency department (ED) mortality.

Results

Most patients presented with minor injuries with 64.7% triaged as 'yellow' and 16.4% triaged as 'green', and most (75.9%) referred from another facility. Of those who were critically injured, only 31.0% arrived by ambulance. Most injuries were soft tissue (51.1%) and fractures (23.0%); when stratified by triage category, most critical ('red') patients had sustained head injuries (52.7%). Arrival by ambulance (OR 2.20, p=0.017) and head injury (OR 3.11, p<0.001) were independent predictors of death in the ED.

Conclusion

This study of injured patients presenting to an Ethiopian trauma center is one of the largest to date, highlighting the need for more accessible and streamlined prehospital trauma care. Opportunities for improvement include staff training in initial trauma management and implementation of a more comprehensive trauma registry containing physiologic, intervention, and outcomes data to support a robust quality improvement program. Efforts by the Federal Ministry of Health are ongoing to support these improvements in care.

Level of Evidence

Level 3, observational study.

Clinical emergency care quality indicators in Africa: a scoping review and data summary

OBJECTIVES

Emergency care services are rapidly expanding in Africa; however, development must focus on quality. The African Federation of Emergency Medicine consensus conference (AFEM-CC)-based quality indicators were published in 2018. This study sought to increase knowledge of quality through identifying all publications from Africa containing data relevant to the AFEM-CC process clinical and outcome quality indicators.

DESIGN

We conducted searches for general quality of emergency care in Africa and for each of 28 AFEM-CC process clinical and five outcome clinical quality indicators individually in the medical and grey literature.

DATA SOURCES

PubMed (1964-2 January 2022), Embase (1947-2 January 2022) and CINAHL (1982-3 January 2022) and various forms of grey literature were queried.

ELIGIBILITY CRITERIA

Studies published in English, addressing the African emergency care population as a whole or large subsegment of this population (eg, trauma, paediatrics), and matching AFEM-CC process quality indicator parameters exactly were included. Studies with similar, but not exact match, data were collected separately as 'AFEM-CC quality indicators near match'.

DATA EXTRACTION AND SYNTHESIS

Document screening was done in duplicate by two authors, using Covidence, and conflicts were adjudicated by a third. Simple descriptive statistics were calculated.

RESULTS

One thousand three hundred and fourteen documents were reviewed, 314 in full text. 41 studies met a priori criteria and were included, yielding 59 unique quality indicator data points. Documentation and assessment quality indicators accounted for 64% of data points identified, clinical care for 25% and outcomes for 10%. An additional 53 'AFEM-CC quality indicators near match' publications were identified (38 new publications and 15 previously identified studies that contained additional 'near match' data), yielding 87 data points.

CONCLUSIONS

Data relevant to African emergency care facility-based quality indicators are highly limited. Future publications on emergency care in Africa should be aware of, and conform with, AFEM-CC quality indicators to strengthen understanding of quality.

Burden of Road Traffic Injuries in Tanzania: One-Year Prospective Study of Consecutive Patients in 13 Multilevel Health Facilities

BACKGROUND

Road traffic injuries (RTIs) pose a severe public health crisis in Sub-Saharan Africa (SSA) and specifically in Tanzania, where the mortality due to RTIs is nearly double the global rate. There is a paucity of RTI data in Tanzania to inform evidence-based interventions to reduce the incidence and improve care outcomes. A trauma registry was implemented at 13 health facilities of diverse administrative levels in Tanzania. In this study, we characterize the burden of RTIs seen at these health facilities.

METHODS

This was a one-year prospective descriptive study utilizing trauma registry data from 13 multilevel health facilities in Tanzania from 1 October 2019 to 30 September 2020. We provide descriptive statistics on patient demographics; location; share of injury; nature, type, and circumstances of RTI; injury severity; disposition; and outcomes.

RESULTS

Among 18,553 trauma patients seen in 13 health facilities, 7,416 (40%) had RTIs. The overall median age was 28 years (IQR 22-38 years), and 79.3% were male. Most road traffic crashes (RTC) occurred in urban settings (68.7%), involving motorcycles (68.3%). Motorcyclists (32.9%) were the most affected road users; only 37% of motorcyclists wore helmets at the time of the crash. The majority (88.2%) of patients arrived directly from the site, and 49.0% used motorized (two- or three-) wheelers to travel to the health facility. Patients were more likely to be admitted to the ward, taken to operating theatre, died at emergency unit (EU), or referred versus being discharged if they had intracranial injuries (27.8% vs. 3.7%; p < 0.0001), fracture of the lower leg (18.9% vs. 6.4%; p < 0.0001), or femur fracture (12.9% vs. 0.4%; p < 0.0001). Overall, 36.1% of patients were admitted, 10.6% transferred to other facilities, and mortality was 2%.

CONCLUSIONS

RTCs are the main cause of trauma in this setting, affecting mostly working-age males. These RTCs result in severe injuries requiring hospital admission or referral for almost half of the victims. Motorcyclists are the most affected group, in alignment with prior studies. These findings demonstrate the burden of RTCs as a public health concern in Tanzania and the need for targeted interventions with a focus on motorcyclists.