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Global Public Health
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Collecting injury surveillance data in
low- and middle-income countries: The
Cape Town Trauma Registry pilot
a
a
Nadine Schuurman , Jonathan Cinnamon , Richard Matzopoulos
b
, Vanessa Fawcett
c e
d
, Andrew Nicol & S. Morad Hameed
e
a
Department of Geography, Simon Fraser University, Burnaby, BC,
V5A 1S6, Canada
b
MRC/UNISA Crime, Violence, and Injury Lead Programme in
South Africa, Cape Town, South Africa
c
Vancouver Coastal Health, BC, Canada
d
Department of Surgery, University of Cape Town, Cape Town,
South Africa
e
Division of General Surgery, University of British Columbia,
Vancouver, BC, V5Z 1M9, Canada
Available online: 24 May 2011
To cite this article: Nadine Schuurman, Jonathan Cinnamon, Richard Matzopoulos, Vanessa
Fawcett, Andrew Nicol & S. Morad Hameed (2011): Collecting injury surveillance data in low- and
middle-income countries: The Cape Town Trauma Registry pilot, Global Public Health, 6:8, 874-889
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Global Public Health
Vol. 6, No. 8, December 2011, 874889
Collecting injury surveillance data in low- and middle-income countries:
The Cape Town Trauma Registry pilot
Downloaded by [Simon Fraser University] at 12:16 02 December 2011
Nadine Schuurmana*, Jonathan Cinnamona, Richard Matzopoulosb,
Vanessa Fawcettc,e, Andrew Nicold and S. Morad Hameede
a
Department of Geography, Simon Fraser University, Burnaby, BC V5A 1S6, Canada; bMRC/
UNISA Crime, Violence, and Injury Lead Programme in South Africa, Cape Town, South
Africa; cVancouver Coastal Health, BC, Canada; dDepartment of Surgery, University of Cape
Town, Cape Town, South Africa; eDivision of General Surgery, University of British Columbia,
Vancouver, BC V5Z 1M9, Canada
(Received 26 October 2009; final version received 3 July 2010)
Injury is a major public health issue, responsible for 5 million deaths each year,
equivalent to the total mortality caused by HIV, malaria and tuberculosis
combined. The World Health Organisation estimates that of the total worldwide
deaths due to injury, more than 90% occur in low- and middle-income countries
(LMIC). Despite the burden of injury sustained by LMIC, there are few
continuing injury surveillance systems for collection and analysis of injury data.
We describe a hospital-based trauma surveillance instrument for collection of a
minimum data-set for calculating common injury scoring metrics including the
Abbreviated Injury Scale and the Injury Severity Score. The Cape Town Trauma
Registry (CTTR) is designed for injury surveillance in low-resource settings.
A pilot at Groote Schuur Hospital in Cape Town was conducted for one month to
demonstrate the feasibility of systematic data collection and analysis, and to
explore challenges of implementing a trauma registry in a LMIC. Key
characteristics of the CTTR include: ability to calculate injury severity, key
minimal data elements, expansion to include quality indicators and minimal drain
on human resources based on few fields. The CTTR provides a strategy to
describe the distribution and consequences of injury in a high trauma volume,
low-resource environment.
Keywords: injury surveillance; burden of injury; low- and middle-income
countries; South Africa; injury prevention; geographic information systems;
injury data
Background
Injury as a public health issue in low- and middle-income countries (LMIC)
Injury is a major public health issue, responsible for 5 million deaths each year
worldwide, equivalent to the total mortality caused by HIV, malaria and tuberculosis
combined (World Health Organisation 2008a). Although the problem is truly global,
the World Health Organisation (WHO) estimates that, of the total worldwide deaths
due to injury, more than 90% occur in low- and middle-income countries (LMIC;
Peden et al. 2002). Furthermore, for every death from injury, there are many more
*Corresponding author. Email: nadine@sfu.ca
ISSN 1744-1692 print/ISSN 1744-1706 online
# 2011 Taylor & Francis
http://dx.doi.org/10.1080/17441692.2010.516268
http://www.tandfonline.com
Downloaded by [Simon Fraser University] at 12:16 02 December 2011
Global Public Health
875
injuries that result in hospitalisation (Krug et al. 2000), and many that are
unaccounted for altogether. In LMIC, injury is overlooked as a major public health
concern in favour of more visible issues, despite the massive number of lives lost and
the large contribution to patient disability and morbidity (Mock et al. 2004, Hofman
et al. 2005). For example, many thousands of children and adolescents saved from
nutritional and infectious diseases are killed or disabled through injuries sustained in
subsequent years (Sommers 2006). Fortunately, injury in children and youth is
beginning to be viewed as a major public health concern globally (World Health
Organisation 2008b, Hyder et al. 2009); however, improved awareness is needed
worldwide regarding the toll of injury in all age groups.
Injury is a large public health burden common to many LMIC. Hyder and
Aggarwal (2009) describe the much greater toll of injury observed in the LMIC of
Eastern Europe and Eurasia, compared with the high-income countries of Western
Europe. Similar issues have been highlighted in LMIC in Asia (Consunji and Hyder
2004), and Latin America (Perel et al. 2006). African countries are particularly
burdened by high rates of injury (Lopez et al. 2006). South Africa is a middle-income
country that is encumbered with a diverse burden of disease, including infectious
diseases, chronic and degenerative diseases, malnutrition and childbirth-related
conditions and a disproportionately large burden of trauma (Brysiewicz 2001,
Goosen et al. 2003). Interpersonal violence and road-traffic collisions are the leading
causes of injury in South Africa (Brooks et al. 1999, Goosen et al. 2003, Meel 2004).
In 2005, 39% of all injury-related deaths resulted from interpersonal violence
(Prinsloo 2007). Despite the reduction in political conflict in the post-apartheid era,
interpersonal violence has continued to plague South Africa (Norman et al. 2007),
and has actually increased in the past 20 years (Bowley et al. 2002). South Africa has
the dubious distinction of being one of the few places where rates of intentional
injury exceed the rates of unintentional injury (Norman et al. 2007). The murder rate
in South Africa is 56 per 100,000; this rate is over five times that in the USA (10.6 per
100,000; Brooks and Barker 2003).
Road-traffic fatality rates in South Africa are also among the highest in the world
and in 2000 were estimated at double the global average (Norman et al. 2007). In
2001, pedestrian deaths accounted for more than half of all road-traffic fatalities in
South Africa (Sukhai and van Niekerk 2002). Surveillance data from South Africa’s
four largest cities (Cape Town, Durban, Pretoria and Johannesburg) between 2001
and 2005 revealed that deaths were clustered in the 2044-year age category and that
more than half of the pedestrian deaths occurred when the drivers were under the
influence of alcohol (Mabunda et al. 2008).
The value of injury surveillance and control
Injury prevention relies on the availability of up-to-date and detailed information
that is acquired through injury surveillance. It is imperative that data on injury are
collected and analysed so that public health officials can gain a better understanding
of the magnitude and characteristics of the problem, as a key step towards injury
control (Krug et al. 2000). Injury surveillance systems are relatively well developed in
resource-rich settings; however, they are poorly equipped or non-existent in many
LMIC (Mock et al. 2004). There is growing interest in developing injury surveillance
systems in LMIC. For example, recent studies have documented the development of
876 N. Schuurman et al.
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injury surveillance systems in Colombia (Gutierrez-Martinez et al. 2007), Thailand
(Santikarn et al. 1999), Sri Lanka (Jayatilleke et al. 2007), Ghana (London et al.
2002), Malawi (Samuel et al. 2009), Ethiopia (Kebede et al. 2008) and Nicaragua
(Tercero 2007). This study describes the results of a pilot data capture study and
feasibility analysis at a hospital in Cape Town, South Africa, as the first step towards
the development of an injury surveillance system, the CTTR.
The pilot described in this study is the first of three pilot data collection projects
designed to successively cover a greater geographical extent of Cape Town. Pilot 2
will begin in February 2010 and will run for 3 months. It will integrate patient
charting with the injury surveillance data. Pilot 3, expected to begin in January 2011,
will include eight major trauma treatment hospitals in Cape Town.
Injury surveillance in sub-Saharan Africa
Few trauma registries exist in sub-Saharan Africa and those that are operating are
often poorly developed and maintained (Nwomeh et al. 2006). As such, little or no
data are collected on injury in these settings, and as a result, its causes and social
implications are largely unknown (Mock et al. 2004). South Africa has a system for
capturing injury mortality, the National Injury Mortality Surveillance System
(NIMSS), which was established by a research consortium, and which uses mortuary
data to populate a database of injury-related deaths (Matzopoulos 2005). This
system, however, does not capture the full spectrum of the burden of injury in that
country, particularly the massive public health issue of injury morbidity. This was
deemed too expensive and logistically challenging for the consortium to establish and
maintain without considerable financial and logistical support (Matzopoulos et al.
1999).
Streamlined hospital-based data collection is an effective method of collecting
injury data in resource-poor settings, contributing greatly to our understanding of
both injury morbidity and mortality (Schultz et al. 2007). A minimum data-set
(MDS) that captures just the relevant information, coded to a recognised standard,
may be the best approach for collection of public health data in locations where
resources, expertise and time are limited (Tierney et al. 2006). Tierney et al. (2006)
describe a MDS used to collect data on HIV in order to manage and monitor
patients. Zavala and colleagues (2007, 2008) describe a multinational injury
surveillance pilot study at hospitals in Democratic Republic of the Congo, Kenya,
Nigeria, Uganda and Zambia. Phase 1 of this study was designed to uncover the
necessary administration, supervision and human resources necessary for a
functioning surveillance system.
Kobusingye and Lett (2000) described the establishment of hospital-based trauma
registries at two hospitals in Uganda, as a first step towards the creation of a
comprehensive injury surveillance system for the country. In addition to the
development and testing of a MDS for data collection, a new injury severity
instrument was devised (the Kampala Trauma Score KTS) as a simplified method
to assess injury severity. Based on the success of the implementation, the authors
concluded that trauma registries and a simplified injury severity metric are feasible and
valuable in sub-Saharan Africa. Whilst these tools were demonstrated to be important
innovations for collecting injury data in low-resource environments, the concept has
yet to take hold in many regions. The purpose of the present study was to develop
Global Public Health
877
injury data collection protocols appropriate to low-resource environments, building on
previous developments in the field such as those described previously.
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Methods
Groote Schuur Hospital (GSH) is a large, publicly funded tertiary hospital that
shares the trauma patient load for the Cape Town metropolitan area with Tygerberg
Hospital the other major adult definitive care centre. In addition, there are a
number of secondary hospitals that treat injuries. An estimated 11,00012,000
patients are registered at GSH Trauma Unit annually. GSH is one of two definitive
trauma centres in Cape Town. However, Cape Town does not have an inclusive
trauma system, which means many severe injuries will be treated in hospitals with
ICU capacity, rather than in definitive trauma centres. Unpublished data from a
caseload assessment showed that GSH only saw 15,000 of a total of 108,000 patients
presenting to secondary and tertiary hospitals in the city (Matzopoulos 2005). These
data do not, however, differentiate severe injury from general caseload. Whilst GSH
treats approximately 11,000 patients annually, the hospital sees a greater proportion
of severe injury than most local hospitals, excepting Tygerberg and the Red Cross
Children’s Hospital.
Assessment of need
A needs and feasibility assessment was conducted with the staff and directors of the
trauma unit at GSH prior to engaging in designing a data collection protocol. The
needs assessment was designed to respond to local hospital-based requirements,
dictates of trauma registrars in North America and Europe and examination of the
surveillance literature. Chief among the priorities that emerged from the needs
assessment was the requirement that the KTS, Abbreviated Injury Scale (AIS) and
Injury Severity Score (ISS) could be calculated. The form itself was developed
through a series of consultations with trauma registrars with the goal of achieving
compliance with major parameters of international surveillance. In addition,
iterative on-site revisions were made to comply with local data flow needs.
GSH was one of the hospitals that participated in the National Trauma Data Bank
project in South Africa (Verticalapps 2008). The Head of the Trauma Centre at GSH
estimates that 8000 of 24,000 injury patient records were entered during a two-year
trial period at GSH. The current system was determined to be ineffective at capturing
the trauma population, as information was not gathered for a large proportion of the
patients seen in the unit. The purpose of the CTTR is to streamline that data entry
process so that it becomes an integral part of the workflow and is thus accomplished
despite institutional and cultural barrier to injury surveillance data collection.
Creation of the Cape Town Trauma Registry (CTTR) injury surveillance data
collection instrument
It was envisioned that the Cape Town Trauma Registry (CTTR) could potentially
provide a valuable record of all patients who presented to the trauma unit at GSH. It
is common to exclude patients from a registry based on a number of criteria,
including injury severity and length of stay; however, there is little concurrence
878 N. Schuurman et al.
between registries on their choice of criteria. Bergeron et al. (2006) suggest that the
choice of exclusion criteria can seriously affect the composition of the observed
population and, therefore, the severity of injuries and the utilisation of resources. For
the purposes of the CTTR, all registered patients were included. The paper form used
to collect CTTR data points was designed to capture relevant demographic,
geographic, incident and clinical data as parsimoniously as possible. Ethics approval
was received from GSH as well as Simon Fraser University.
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Case report form
Important resources for the foundation of the CTTR included the study of hospitalbased trauma data collection in Uganda by Kobusingye and Lett (2000), the
multinational, multi-phase injury surveillance study by Zavala and colleagues (2007,
2008), and the guidelines for injury surveillance system design published by the
WHO (Holder et al. 2001).
The CTTR case report form is shown in Figure 1. The first generation of the
CTTR form was designed based on the WHO guidelines and the template used in
the Kampala study; however, it was modified several times to permit a future
environmental scan to determine ecological factors associated with increased risk of
injury. The CTTR form was designed to fit on one page for eventual ease of use by
the trauma team. The following information was recorded: patient demographic
details, spatial and temporal information, injury mechanism and type, patient vital
signs, diagnostic and treatment information and patient outcome.
Data capture
A data capture pilot study at GSH was conducted for the month of October 2008 to
demonstrate the utility and feasibility of systematic data collection and analysis, and
to explore challenges involved in implementing the CTTR in a low-resource
environment. Two researchers were responsible for capturing the data and creating
the improved registry. Multiple sources were consulted by the researchers to populate
the CTTR form. Sources of data included where applicable: patient history and
physical forms, nursing notes, ambulance forms, and diagnostic and treatment forms.
The sources and steps involved in data collection are illustrated in Figure 2.
Geographic location data specifying the injury location appropriate for mapping
were obtained from the ambulance or history and physical forms on the patient’s
folder if recorded by the health-care team.
Preliminary analysis of pilot data
A large data-set was created from the successful data capture pilot study.
A preliminary analysis of the data-set was undertaken to demonstrate the utility of
hospital-based data collection and analysis. A map showing the spatial distribution of
injury locations in Cape Town was created. Locations were aggregated to a post code
area and mapped using ArcGIS 9.2 (Esri 2006) to illustrate the spatial implications of
trauma in Cape Town. Post code areas with fewer than five records were restricted for
privacy reasons. Patient street address was available for most patients although it was
not recorded for reasons of privacy.
Global Public Health
GSH TRAUMA DATA FORM
Neurological status:
Alert
Unresponsive
[Put patient sticker here]
879
Responds to verbal stimuli
Responds to painful stimuli
Diagnostic:
Xray C-spine Xray chest Xray pelvis
Xray upper extremity
Xray lower extremity
CT Abdo
CT Chest
CT Head
CT spine LODOX
ECG
Angiogram
Ultrasound
Other:
Race:
Black
White
Coloured
Procedures:
Other
Intubation
Occupation:
Sm. business owner
Vendor
Driver
Student/pupil
Labourer
Educator
General Assistant
Other:
Unemployed
CivilServant
Administration
Operation:
Referral:
Home details: Address:
Suture
Splint/cast
Thoracotomy
Chest drain
CPR/defib. Other
No
No
Yes (specify)
Yes (specify)
Suburb:
Patient disposition:
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Incident location: Address:
Suburb:
Setting:
Home
Work
Road
School
Bar/rest/shop
Shebeen Sport/Rec. Other
Treated and released
Admitted to trauma dept
Admitted to ICU
Died in trauma dept
Transferred to other hospital:
Referred to OPD
Admitted to other dept
Left against med. advice
DOA
Injuries and Description:
Injury date:
/
Arrival date:
/
/
Assess date:
Time
/
/
List and describe all injuries in detail, providing as much information
as possible. If the patient has not been injured, write NIL below.
Time
/
Time
Arrival method:
Own transport
Ambulance
Referring Hospital:
Injury:
Blunt
Penetrating
Other
Injury mechanism:
MVA-Unknown
MVA-Bicycle
Fall-same level
Gunshot
Punch, kick
Other (specify)
MVA-Pedestrian
MVA-Motorcycle
Fall-from height
Stab, Cut
Blunt object
MVA-Passenger
MVA-Driver
Burn
Animal bite
Unknown
Intent:
Unintentional
Undetermined
Intentional- Assaulted
acquaintance
by: stranger
Intentional- Self inflicted
family
intimate partner
Co-morbidities/Past medical history:
No
Yes (specify)
Substance use:
Alcohol
Drugs (specify)
BP:
Respiration rate:
Casualty Doctor name:
Pulse:
GCS:
Eyes:
Figure 1.
Verbal:
Motor:
Total:
Signature:
CTTR data capture form.
Results
Using the described data collection protocol, nearly 800 trauma patient records were
obtained for the month of October 2008. This represents between 80 and 90% of the
total patient volume at GSH Trauma in a typical month. Most of the patients not
880 N. Schuurman et al.
Trauma patient
registration room
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Patient accounts
Trauma wards
C5 and/or C12
Other wards, e.g.
Ortho, Neuro, ICU
ENT, Plastics, etc.
No
Patient form
complete?
Yes
Patient record
complete
Figure 2. Data capture flowchart.
Multiple sources and locations were consulted to complete a patient record. All patients are
registered in the master patient list located in the patient registration room. A record of the
discharged patients could be collected from their folder located in the accounts department.
Data for patients remaining on the trauma ward or other wards were collected on location.
These patients were frequently revisited to complete the patient record, before it could be
entered into the CTTR database.
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Global Public Health
881
recorded were missed because of an immediate discharge to an outpatient
department with non-serious injuries. Table 1 illustrates the fields of the CTTR
and rates of capture for the one-month pilot. Note that the CTTR had a significantly
higher rate of capture for the majority of fields than what was previously captured on
clinical records. It is also significant, for instance, that the question of whether the
patient had used drugs or alcohol was captured just 15% of the time, as confirmatory
tests were not conducted. Another poorly captured field was the past medical
history/co-morbidities of the patient, which was recorded for just 16% of the patients.
Also, the setting where the incident occurred and the patient’s respiratory rate on
arrival were recorded just over 50% of the time. The poor rate of capture necessitated
the exclusion of these fields from further analysis.
Preliminary comments from clinical personnel trialling the forms were positive
and centred on the idea that the new form allowed for faster and more simplified
collection of information from the patient than the multiple, disparate forms of data
collection previously in use. In contrast to the CTTR form, an average of just 500
patient records had been captured every month and just seven fields of interest were
recorded using the current data collection system in use at GSH, as shown in Table 1.
Many important fields were not recorded using that system, including: type of injury
sustained, patient home location, date and time of injury, arrival method, injury
intent and patient vital sign information.
The ability to calculate common ISS is a critical requirement of injury
surveillance. Following the data collection period, analysts at Vancouver General
Hospital were able to confirm that AIS and ISS could both be calculated from the
minimal data-set in the CTTR. In addition, the KTS could also be calculated.
Injury patterns
Determination of injury patterns for the data was also possible. Table 2 highlights the
mechanism of injury for 785 patients presenting to GSH Trauma, broken down by
age and sex. Of 785 patients recorded in the CTTR for October 2008, 588 (75%) were
male. A majority of patients (60%) were in the 2039 age category. Just 12% of
patients were under 20, while only 8% were 60 or over. Whilst there are many juvenile
injuries in Cape Town, most children 12 and under are treated at Red Cross
Children’s Hospital. Stab/cut was the most common mechanism of injury, and it
represented 22% of the total, followed by blunt object with 16%. Pedestrian incidents
were the most common cause of motor-vehicle-related injuries, accounting for 42%
(73/173) of all traffic incidents.
Spatial distribution of injury
Figure 3 illustrates the spatial distribution of injury incidents for patients presenting
to GSH Trauma Unit, for the month of October 2008. Locations where injuries were
sustained were aggregated to post code areas to provide a simple visualisation of
areas with a high number of incidents. Generally, high-incident areas exist
immediately proximal to GSH in the post code area 7925, which includes the
suburbs of Woodstock, Observatory and Salt River. The pattern of high-incident
areas extends south-east of the city centre adjacent to the N2 motorway. These highincident post code areas are home to many of the poorest, most densely populated
882 N. Schuurman et al.
Table 1.
Capture rates for data fields collected on the CTTR form.
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Field
Sex
Age
Language
Race
Occupation
Home post code
Home suburb
Injury post code
Injury suburb
Setting
Injury date
Injury time
Arrival date
Arrival time
Assessment date
Assessment time
Arrival method
Basic injury type
Injury mechanism
Intent
Co-morbidities
Substance use
Blood pressure
Respiratory rate
Pulse
GCS
Neurological status
Patient disposition
Injuries
CTTR capture (%)
GSH capture (%)
100
99
93
77
75
83
92
75
77
58
98
74
98
90
98
63
93
94
93
92
16
15
95
56
95
87
93
99
89
99
98
N/R
99
N/R
N/R
N/R
N/R
72
N/R
N/R
N/R
100
N/R
N/R
N/R
N/R
N/R
93
N/R
N/R
N/R
N/R
N/R
N/R
N/R
N/R
45
N/R
township communities, including Athlone, Guguletu, Nyanga and Khayelitsha. Raw
counts of injury were used for two reasons: (1) much of the population in some
suburbs is migratory and reliable census data do not exist; and (2) absolute
population counts are more important than rates because they allow design of an
appropriate trauma system.
Discussion
This paper has presented the results of a pilot study that aimed to determine the
feasibility and utility of a hospital-based trauma registry in a medium-income
country, as a preliminary step towards comprehensive injury surveillance in LMIC.
A highly inclusive data capture exercise at GSH in Cape Town, South Africa was
piloted over the month of October 2008. The study results include the ability to
summarise injury patterns as well as the spatial distribution of injury. Notable is the
profound overlap between socio-economically depressed areas and high injury
counts. Whilst this is predictable, the scientific evidence renders it more compelling.
Global Public Health
Table 2.
Mechanism of injury by age and sex.
Female
Injury mechanism
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883
Animal bite
Blunt object
Fall from height
Fall same level
Gunshot
Human bite
Punch/kick
Sprain/strain
Stab/cut
Traffic bicycle
Traffic driver
Traffic motorcycle
Traffic passenger
Traffic pedestrian
Traffic unknown
Unknown
Other
Total
Male
B20 2039 4059 60 Total B20 2039 4059 60 Total Total
0
2
0
2
0
0
1
0
2
0
0
1
1
15
3
18
2
0
6
2
11
0
4
1
0
3
6
8
0
0
1
2
7
0
2
2
1
3
0
23
1
0
0
0
0
0
0
0
2
24
9
51
3
0
8
4
20
0
6
4
1
13
2
7
11
1
5
1
18
3
0
5
4
69
15
18
35
2
17
2
112
1
18
10
3
18
4
12
4
1
10
2
20
2
3
2
0
2
3
11
0
0
1
0
1
0
1
3
8
101
24
48
50
4
33
5
151
6
22
20
10
125
33
99
53
4
41
9
171
6
28
24
3
4
0
1
0
16
18
12
0
10
3
106
7
4
0
3
0
45
0
0
0
1
0
29
28
20
0
15
3
197
1
6
0
4
2
80
8
23
3
22
3
362
2
20
0
14
0
117
0
4
0
3
1
30
11
53
3
43
6
588
39
73
3
58
9
785
In addition, the CTTR does allow scoring of AIS and ISS, thus making it a useful
addition to global injury surveillance efforts.
Success of the Cape Town Trauma Registry (CTTR)
The high rate of capture for the majority of the fields suggests that allowing for some
modifications and linking with other records, the CTTR could fulfil multiple
functions, from a record of patient admission to a data registry for injury
surveillance and control.
The cost of infrastructure and personnel is a serious limitation to the
implementation of trauma registries in settings with severely constrained health
budgets (Nwomeh et al. 2006). It is not expected that extensive personnel or financial
resources will be needed to maintain or refine the CTTR in the future.
The value of locally appropriate trauma registries
Trauma registries have multiple uses, including: trauma programme evaluation,
quality improvement, medical care monitoring, resource tracking, outcome analysis
and injury prevention (Watts 1995, Moore and Clark 2008). Current evidence of
trauma centre volume statistics and level of trauma care delivery are very useful for
resource allocation and quality improvement (Bergeron et al. 2006, Moore and Clark
2008). Injury control in Africa could be vastly improved if trauma registries were
implemented which collate data on the full spectrum of injury morbidity and
884 N. Schuurman et al.
mortality (Nwomeh et al. 2006). Surveillance of injury mortality is of some use to
injury control, however, prospectively kept trauma registries that are able to track
injury mortality and morbidity may be more valuable for injury control efforts.
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Applications of epidemiological and spatial data analysis
Perhaps the most valuable function of the CTTR system is its role as a database that
can be used for injury prevention and control. There is a serious need for injury
prevention in Cape Town and the Western Cape Province. There is no specific health
programme to address injury in Cape Town despite the fact that deaths due to injury
are among the greatest contributors to premature mortality (Groenewald et al. 2008).
Injury is one of the top five pressing health conditions in the Western Cape, along
with tuberculosis, HIV/AIDS, paediatric respiratory and gastric infections and
chronic diseases (Cummins 2002). Western Cape has the lowest overall mortality rate
of all the nine South African provinces; however, the injury-related death rate is the
highest of all provinces (Bradshaw et al. 2006). In fact, traumatic injury is the leading
cause of death in the province, responsible for 23% of total mortality (163/100,000;
Cummins 2002). The burden of injury varies greatly within the Cape Town
Municipality. For example, in Khayelitsha and Nyanga, two of the township
communities highlighted in our spatial analysis, injury mortality rates for males are
as high as 333 and 357 per 100,000, respectively (Groenewald et al. 2003). Bradshaw
et al. (2006) outline the factors that may contribute to differential burden of injury
between different areas in South Africa, including: different patterns of wealth and
development, geographic and environmental factors and access to health and other
basic services. Alcohol abuse and road safety are two important areas of concern that
require urgent intervention, particularly in the poorer areas of Cape Town
(Groenewald et al. 2003). For example, future data collection might include testing
for alcohol relatedness of injuries in order to determine policy effectiveness of liquor
control regulations being tested in the Western Cape (Republic of South AfricaProvince of Western Cape 2008). Prevention programming that targets these at-risk
areas and populations will likely contribute to injury control in the Western Cape and
South Africa in general. The CTTR system presents an important step towards
achieving this goal.
Analysis of the data captured during the pilot study was useful in demonstrating
the utility of a trauma registry for epidemiological analysis. The disproportionate
burden in males and in those aged 2039 may be of some interest to injury
prevention planners. Also, the high number of injuries resulting from pedestrian
motor-vehicle incidents is of some concern. In addition to the use of the data for
epidemiological analysis, the volume statistics may be of use to the trauma unit at
GSH for resource allocation purposes.
Geography is closely interrelated to the health of individuals and populations
(Dummer 2008). For injury prevention, spatial analysis can help unlock explanatory
social and environmental factors that may be associated with the risk of injury
(Cusimano et al. 2007). Spatial analyses could greatly contribute to injury
epidemiology research in LMIC. In India, for example, a spatial analysis revealed
geographic clustering of motorcycle crashes, which led to an examination of the
crash site and the subsequent discovery of a malfunctioning traffic light (Bagaria and
Bagaria 2007). Despite the potential benefit, the few injury data sources that are
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available in these countries often do not include detailed location information. As
such, spatial data collection was a key focus for the development of the CTTR. Our
preliminary spatial analysis highlighted the large number of incidents taking place in
the poorer township areas of Cape Town. The map in Figure 3 provides a generalised
overview of the spatial implications of injury and more detailed analyses can be made
with the data collected for the CTTR. Global Positioning Systems (GPS) may hold
the key to fine-grain spatial analyses of injury and implementation of these systems
into the Emergency Medical Services (EMS) in Cape Town and other cities will be a
great leap towards understanding the detailed spatial implications of injury.
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Limitations and future directions
The initiation of the CTTR was based on a 30-day trial data collection period; this
was not sufficient time to uncover the full range of issues related to hospital-based
injury data collection. In this case, however, the pilot was the first phase of three
planned efforts. Pilot 1 was designed to determine whether a MDS could be collected
given the hospital’s current data resources, and whether injury scoring could be
achieved based on the trial data. Despite the limited trial period, feasibility of the
collection of each of the MDS fields was established. In addition, experienced
analysts at a large Vancouver Level 1 trauma hospital were successfully able to
Figure 3. Injury location by post code area for GSH trauma patients.
The suburb areas in the vicinity of GSH and the township communities along the N2
motorway corridor are high-incident areas for injuries sustained by GSH trauma patients.
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886 N. Schuurman et al.
calculate AIS and ISS from the approximately 800 patient records. The two planned
future pilot studies will augment these initial findings from Pilot 1 in an effort to
develop a sustainable data registry for GSH, and eventually for the other hospitals of
Cape Town. Upon completion of the final pilot study, the surveillance system can be
evaluated according to a framework such as the one recently proposed by Mitchell
et al. (2009). This injury surveillance system framework has been designed to
conduct evaluations in three key areas: data quality, system operation and practical
capability.
Injured patients who do not seek formal medical care are not included in a
hospital-based trauma registry despite contributing to the overall injury burden. This
is a limitation to the CTTR, and indeed to many trauma registries (Moore and Clark
2008). To better capture the complete trauma population in a catchment, other
methods are often needed including household surveys and police records (Tercero
2007). Also, to fully capture the complete trauma population in a given city or
region, implementation of a trauma registry is necessary at all of its trauma centres
(whether designated or de facto). Linking the CTTR with trauma registries at the
network of hospitals in Cape Town would provide a more complete analysis of the
Cape Town trauma population, and could provide insight into the city’s trauma
system (Matzopoulos et al. 1999). Ultimately, what is needed is a comprehensive,
centralised registry made up of all hospital-based trauma registries in a country. The
development of a global infrastructure to collate and manage injury data from
multiple countries may provide the ultimate solution. Jayatilleke et al. (2007) describe
the potential for a web-based system to achieve this goal.
Completion of trauma data forms by busy clinicians is another concern in
hospitals with limited personnel resources. This was a concern at GSH and, whilst
increased surveillance compliance was observed through the course of the study,
there continue to be a number of negative pressures on compliance. These include
clinician time stresses, lack of an injury surveillance culture, poor prospects for longterm sustainability (thus affecting present compliance) and highly constrained job
definitions amongst nursing staff. Future research should seek to understand optimal
methods of improving data form completion.
Conclusions
Injury is a major public health issue in South Africa and around the world. Evidencebased injury control based on rigorous data collection is urgently needed. Trauma
registries have provided the foundation for important advances in injury prevention
and acute trauma care in well-resourced trauma systems. Implementation of such
registries in LMIC represents a promising frontier in global efforts to reduce the
burden of injury. The CTTR, a trauma unit-based injury database, is one strategy to
describe the distribution and consequences of injury in a high trauma volume, lowresource environment. The key characteristics of the CTTR include: ability to
calculate common ISS, inclusion of key minimal data elements to permit generalised
spatial and epidemiological analysis for the purposes of prevention and education;
future easy expansion to include quality indicators; and minimal drain on human
resources based on few fields. In addition, the CTTR was introduced as part of a
structured rollout as it is the first of three planned pilots. This strategy permits
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887
gradual accommodation on the part of the host hospital as well as permitting the
team to identify and accommodate local conditions that bear on feasibility.
In the long run, epidemiologic and spatial analyses of hospital data may
complement existing analyses of mortuary data and create new opportunities for the
design of injury prevention efforts and the optimisation of trauma systems. We
envisage that this research will be extended to more poorly resourced countries and
provide the basis for injury surveillance and subsequent intervention.
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Acknowledgements
Support for this research was provided by the Social Science and Humanities Research
Council (SSHRC) and the Michael Smith Foundation for Health Research (MSFHR).
Research support for Schuurman was also provided by career awards from the Canadian
Institutes of Health Research (CIHR) and MSFHR. Cinnamon was supported by a SSHRC
doctoral scholarship. We are grateful to the British Columbia Trauma Registry (BCTR) and to
Groote Schuur Hospital. Finally, we are grateful to the two reviewers who made many
suggestions that ultimately enhanced this paper.
References
Bagaria, V. and Bagaria, S., 2007. A geographic information system to study trauma
epidemiology in India. Journal of Trauma Management & Outcomes, 1 (1), 3.
Bergeron, E., et al., 2006. Paying the price of excluding patients from a trauma registry.
Journal of Trauma, 60 (2), 300304.
Bowley, D.M.G., et al., 2002. Penetrating vascular trauma in Johannesburg, South Africa.
Surgical Clinics of North America, 82 (1), 221235.
Bradshaw, D., et al., 2006. South African national burden of disease study, 2000: estimates of
provincial mortality. Cape Town: South Africa Medical Research Council, Burden of
Disease Research Unit.
Brooks, A. and Barker, P., 2003. Missile and explosive wounds. Surgery, 21 (8), 190192.
Brooks, A., Macnab, C., and Boffard, K., 1999. South Africa. Trauma Quarterly, 14 (3), 301
310.
Brysiewicz, P., 2001. Trauma in South Africa. International Journal of Trauma Nursing, 7 (4),
129132.
Consunji, R.J. and Hyder, A.A., 2004. The burden of injuries in the Philippines: implications
for national research policy. Accident Analysis & Prevention, 36 (6), 11111117.
Cummins, P., 2002. Access to health care in the Western Cape. The Lancet, 360 (Suppl. 1),
s49s50.
Cusimano, M.D., et al., 2007. Geomatics in injury prevention: the science, the potential and
the limitations. Injury Prevention, 13 (1), 5156.
Dummer, T.J.P., 2008. Health geography: supporting public health policy and planning.
Canadian Medical Association Journal, 178 (9), 11771180.
Esri, 2006. ArcGIS 9.2. 9.2 ed. Redlands, CA.
Goosen, J., et al., 2003. Trauma care systems in South Africa. Injury, 34 (9), 704708.
Groenewald, P., et al., 2008. Cause of death and premature mortality in Cape Town, 20012006.
Cape Town: South African Medical Research Council.
Groenewald, P., et al., 2003. Cape Town mortality, 2001 part I: cause of death and premature
mortality. Cape Town: South African Medical Research Council.
Gutierrez-Martinez, M.I., et al., 2007. The evaluation of a surveillance system for violent and
non-intentional injury mortality in Colombian cities. International Journal of Injury Control
and Safety Promotion, 14 (2), 7784.
Hofman, K., et al., 2005. Addressing the growing burden of trauma and injury in low- and
middle-income countries. American Journal of Public Health, 95 (1), 1317.
Holder, Y., et al., 2001. Injury surveillance guidelines. Geneva: World Health Organisation.
Downloaded by [Simon Fraser University] at 12:16 02 December 2011
888 N. Schuurman et al.
Hyder, A.A. and Aggarwal, A., 2009. The increasing burden of injuries in Eastern
Europe and Eurasia: making the case for safety investments. Health Policy, 89 (1),
113.
Hyder, A.A., et al., 2009. Global childhood unintentional injury surveillance in four cities in
developing countries: a pilot study. Bulletin of the World Health Organization, 87 (5), 345
352.
Jayatilleke, A.U., et al., 2007. Web based injury surveillance system (WBISS) for road traffic
injuries. In: A.U. Jayatilleke, C.A. Marasinghe, S. Nakahara, S.T. Nandasara, A. Jayatilleke,
and M. Jimba, eds. Proceedings of the IEEE seventh international conference on computer
and information technology, 1619 October 2007, Aizu-Wakamatsu, Japan: IEEE, 1111
1115.
Kebede, T., et al., 2008. Injury surveillance in six hospitals of Addis Ababa, Ethiopia.
Ethiopian Medical Journal, 46 (4), 383390.
Kobusingye, O.C. and Lett, R.R., 2000. Hospital-based trauma registries in Uganda. Journal
of Trauma, 48 (3), 498502.
Krug, E.G., Sharma, G.K., and Lozano, R., 2000. The global burden of injuries. American
Journal of Public Health, 90 (4), 523526.
London, J., et al., 2002. Using mortuary statistics in the development of an injury surveillance
system in Ghana. Bulletin of the World Health Organization, 80 (5), 357364.
Lopez, A.D., et al., 2006. Global and regional burden of disease and risk factors, 2001:
systematic analysis of population health data. The Lancet, 367 (9524), 17471757.
Mabunda, M.M., Swart, L.-A., and Seedat, M., 2008. Magnitude and categories of pedestrian
fatalities in South Africa. Accident Analysis & Prevention, 40 (2), 586593.
Matzopoulos, R., 2005. A profile of fatal injuries in South Africa: 6th annual report of the
national injury mortality surveillance system 2004. Cape Town: Medical Research Council UNISA Crime, Violence, and Injury Lead Programme.
Matzopoulos, R.G., Prinsloo, M.R., and Bopape, J.L., 1999. Estimating the South African
trauma caseload as a basis for injury surveillance. Cape Town: South African Medical
Research Council.
Meel, B., 2004. Pre-hospital and hospital traumatic deaths in the former homeland of
Transkei, South Africa. Journal of Clinical Forensic Medicine, 11 (1), 611.
Mitchell, R., Williamson, A., and O’connor, R., 2009. The development of an evaluation
framework for injury surveillance systems. BMC Public Health, 9 (1), 260.
Mock, C.N., et al., 2004. Strengthening the prevention and care of injuries worldwide. The
Lancet, 363 (9427), 21722179.
Moore, L. and Clark, D.E., 2008. The value of trauma registries. Injury, 39 (6), 686695.
Norman, R., et al., 2007. The high burden of injuries in South Africa. Bulletin of the World
Health Organization, 85 (9), 695702.
Nwomeh, B., et al., 2006. History and development of trauma registry: lessons from developed
to developing countries. World Journal of Emergency Surgery, 1 (1), 32.
Peden, M., Mcgee, K., and Krug, E.G., 2002. Injury: a leading cause of the global burden of
disease, 2000. Geneva: World Health Organisation.
Perel, P., et al., 2006. Noncommunicable diseases and injuries in Latin America and the
Caribbean: time for action. PLOS Medicine, 3 (9), 344.
Prinsloo, M., ed. 2007. A profile of fatal injuries in South Africa: 7th annual report of the
national injury mortality surveillance system 2005. Cape Town: Medical Research Council UNISA Crime, Violence, and Injury Lead Programme.
Republic of South Africa-Province of Western Cape, 2008. Western Cape Liquor Act 2008 (Act
4 of 2008). Cape Town: Western Cape Provincial Parliament.
Samuel, J.C., et al., 2009. Epidemiology of injuries at a tertiary care center in Malawi. World
Journal of Surgery, 33 (9), 18361841.
Santikarn, C., et al., 1999. The establishment of injury surveillance in Thailand. International
Journal for Consumer and Product Safety, 6 (3), 133143.
Schultz, C.R., et al., 2007. Development of a hospital-based trauma registry in Haiti: an
approach for improving injury surveillance in developing and resource-poor settings.
Journal of Trauma, 63 (5), 11431154.
Downloaded by [Simon Fraser University] at 12:16 02 December 2011
Global Public Health
889
Sommers, M.S., 2006. Injury as a global phenomenon of concern in nursing science. Journal of
Nursing Scholarship, 38 (4), 314320.
Sukhai, A. and van Niekerk, A., 2002. Transport-related deaths. Cape Town: Medical Research
Council-UNISA Crime, Violence and Injury Lead Programme.
Tercero, F., 2007. Measuring injury magnitude and patterns in a low-income country: experiences
from Nicaragua. Thesis (PhD). Karolinska Insitutet.
Tierney, W.M., et al., 2006. Viewpoint: a pragmatic approach to constructing a minimum data
set for care of patients with HIV in developing countries. Journal of the American Medical
Informatics Association, 13 (3), 253260.
Verticalapps, 2008. TraumaBank. Gauteng, South Africa: Verticalapps.
Watts, D.D., 1995. How to determine institutional needs and requirements for a trauma
registry. International Journal of Trauma Nursing, 1 (4), 9498.
World Health Organisation, 2008a. 10 facts on injury and violence [online]. Available from:
http://www.who.int/features/factfiles/injuries/en/index.html [Accessed 10 October 2008].
World Health Organisation, 2008b. World report on child injury prevention. Geneva: World
Health Organisation.
Zavala, D.E., et al., 2007. A multinational injury surveillance system pilot project in Africa.
Journal of Public Health Policy, 28 (4), 432441.
Zavala, D.E., et al., 2008. Implementing a hospital based injury surveillance system in Africa:
lessons learned. Medicine, Conflict. and Survival, 24 (4), 260272.