mainstreaming trauma research at the knh the trauma registry project saidi hassan bsc,mbchb,...

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