World J Surg DOI 10.1007/s00268-014-2448-8
Understanding the Burden and Outcome of Trauma Care Drives a New Trauma Systems Model G. L. Laing • D. L. Skinner • J. L. Bruce • C. Aldous • G. V. Oosthuizen • D. L. Clarke
Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background The Pietermaritzburg Metropolitan Trauma Service (PMTS) attempts to provide care for a whole city and hence is referred to as a service rather than a center. As part of a multifaceted quality improvement program, the PMTS has developed and implemented a robust electronic surgical registry (ESR). This review of the first year’s data from the ESR forms part of a situational analysis to assess the burden of trauma managed by the service and the quality of care delivered within the constraints of the available resources. Methods Formal ethical approval was obtained prior to design and development of this study, and appropriate commercial software was sourced. The exercise of data capture was integrated into the process of service delivery and was accomplished at the endpoint of patient care. 12 months after implementation of the registry, the data were extracted and audited. Results A total of 2,733 patients were admitted over the 12 month study period. The average patient age was 28.3 years. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. The average monthly admission rate was 228 patients, with a peak of 354 admissions over the December period. The mean injury severity score (ISS) was 12 [interquartile range (IQR) 6.7–23.2]. A quarter G. L. Laing (&) D. L. Skinner J. L. Bruce C. Aldous G. V. Oosthuizen D. L. Clarke Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of General Surgery, University of Kwa-Zulu Natal Nelson R Mandela School of Medicine, Post-Net Suite 156, Private Bag X9118, Pietermaritzburg 3200, South Africa e-mail: [email protected] D. L. Clarke e-mail: [email protected]
(24.8 %) of all new emergency admissions had an ISS [ 15. The average duration of stay for patients was 5.12 days (IQR 2.3–13.2 days). Some 2,432 (92.1 %) patients survived, and 208 (7.9 %) died. A total of 333 (13 %) patients required admission to either the intensive care unit (ICU) or the high dependency unit. From the city mortuary data a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred within Pietermaritzburg hospitals other than Greys and Edendale. The total trauma-related mortality for the entire city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths. Conclusions The PMTS treats a significant volume and spectrum of trauma. Despite significant resource limitations, we have managed to implement a functional and sustainable trauma service across multiple hospitals. We believe the major resource deficits limiting our service could be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care came out of a need to work within our resource constraints, and it differs from the traditional model. Within the aforementioned limits, our data suggest that this model of delivering care is feasible, practical, and successful. Considering the universal burden of trauma and the all-toocommon imbalance between resource demand and supply among many health-care institutions, it is our hope that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.
Introduction Over two decades ago, Muckart compared trauma in KwaZulu Natal (KZN) to an epidemic and proposed a concerted
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systematic approach to the problem [1–3]. He believed that an ‘‘essential component of such a systematic approach would be a dedicated trauma center.’’ He went on to state that this should ‘‘include a multidisciplinary team available around the clock, lead by specialist trauma surgeons and supported by anesthetists, intensivists, and the appropriate sub-specialists. This team would ideally work within an environment affording the ready availability of surgical facilities where diagnosis, resuscitation, and definitive intervention would proceed smoothly’’ [1]. Since this time there has been a growing awareness of the need to strengthen trauma systems globally, and to improve the quality of care of the injured patient [4–10]. Much emphasis has been placed on the central role of the dedicated trauma center as the driver of quality trauma care [9, 10]. The Pietermaritzburg Metropolitan Trauma Service (PMTS) was established in 2006 with the intention of providing comprehensive trauma care to the city of Pietermaritzburg and the whole of western KZN Province. For a number of logistical reasons, the PMTS could not adopt the concept of a trauma center located in a single hospital. We therefore opted to attempt to provide care across the metropolitan complex. Hence the PMTS is a service and not a center. Trauma patients in Pietermaritzburg are directed to one of the two hospitals within the city, depending on their geographical location at the time of injury. This model of delivering trauma care is somewhat unique, and while philosophically attractive presents challenges in terms of implementation of safe and pragmatic management algorithms. Setting The PMTS aims to provide resources and expertise, as well as strategic and political leadership in trauma care to the city of Pietermaritzburg and the western rural health-districts of KZN. Pietermaritzburg is the capital of KZN and is the largest city in the western part of the province. It has a population of 1,001,000 people and is served by a tertiary hospital (Greys), a regional hospital (Edendale), and a district hospital (Northdale). There are three private hospitals in the city. Western KZN is a predominantly rural province with a population of two million people, and consists of four health districts. These include the Sisonke, Amajuba, Uthukela, and Umzinyathi districts. There are two other regional hospitals in Western KZN and 19 district hospitals.
with an interest in trauma surgery. All trainees and junior staff work under the supervision of the specialist staff. At an operational level, the staff is subdivided into three teams, one based at Greys Hospital and two at Edendale Hospital. Both hospitals have 24 h availability of a computed tomography (CT) scanner, and have support from a radiology service. Each hospital provides a single emergency operative slate, which caters for the competitive needs of all surgical specialities. The complex has 10 high dependency unit (HDU) beds (3 adult and 7 pediatric) and 19 intensive care unit (ICU) beds (12 adult and 7 pediatric), which are shared by all the surgical disciplines. Intensive care unit patients are managed with the Department of Critical Care in a ‘‘closed unit’’ fashion. The Pietermaritzburg Trauma Registry Since 2006 there has been a strategically driven multifaceted quality improvement program within the PMTS. This program has attempted to use a number of theoretical concepts from industry and public health, such as strategic planning, error theory, and health system models, to drive improvements in the quality of care of trauma patients in Pietermaritzburg and western KZN. One of the key drivers of any quality improvement program in health care is a functional and robust electronic registry [11–13]. The PMTS implemented such a comprehensive electronic surgical registry (ESR) in January 2012 [14]. A standardized paper-based check-box style admission document was used for the admission of all trauma patients. The data were then extracted from this document and entered directly into the trauma registry at the time of discharge. Data regarding operative access and procedures, complications, and outcomes were retrieved from inpatient records. A number of quality control processes were put in place. Data were analyzed and validated by the system administrator on a weekly basis. Omitted data sets were identified and where possible completed from the discharge summary or patient records. Registry data were manually checked on a weekly basis against morning hand-over reports, and on a threemonthly basis against hospital and city mortuary records. The present study is a situational analysis in which the first 12 months of data were reviewed. Through this process we attempted to compare the annual service load as recorded on the registry with the resources available to manage the volume of trauma.
Resources
Methodology
The PMTS has six specialist surgeons: three sub-specialist trauma surgeons, two surgeons enrolled in sub-specialist trauma fellowship training, and another general surgeon
In January 2013 the data from the trauma registry for the previous 12 months were collated and reviewed by the lead author (G.L.L.). The collected data included demographic
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details, admission vital signs, and categorization of anatomical injuries. Injury Severity Scores were tabulated and collected, as were data pertaining to operative interventions, complications, and outcomes. To ascertain the contribution of trauma to the overall surgical workload at Greys Hospital, the total number of admissions for general surgery, pediatric surgery, and trauma were compared over a three-month period.
Results A total of 2,733 patients were admitted over the study period. This included 2,659 (97.3 %) new emergency admissions and 74 (2.7 %) readmissions or transfers. The average patient age was 28.3 years (IQR 23.6–46.3 years). The ethnic breakdown was as follows: 2,653 patients (97.1 %) were black, 36 patients (1.3 %) were of mixed race, 23 patients (0.8 %) were white, and 21 patients (0.8 %) were Indian. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. Of the female patients, 12 were pregnant. The average monthly admission rate was 228 patients with a peak of 354 admissions over the month of December. Table 1 summarizes the monthly admission figures. Mechanism Analysis of the mechanism of injury revealed that 1,450 (54.5 %) patients sustained blunt trauma, 1,081 (40.7 %) penetrating trauma, 88 (3.3 %) bite wounds, 10 (0.4 %) electrocution injury, and 30 (1.1 %) a combination of blunt and penetrating trauma. In the blunt trauma group 666 (47 %) were victims of either a motor vehicle collision (MVC) or a pedestrian vehicle collision (PVC), 471 (32 %) patients were victims of assault, and 92 (6 %) were victims Table 1 Monthly trauma admission numbers
Monthly admissions
Total number
January
228
February
212
March
221
April
223
May
136
June
178
July
227
August September
of a community beating. Tables 2, 3, 4, 5 illustrate the mechanisms of injury. The weapons used are illustrated in Table 6. Table 2 Mechanism of injury Mechanism of injury
Total number
Percentage (%)
Blunt trauma
1,450
54.5
Penetrating trauma
1,081
40.7
Bites
88
3.3
Combination
30
1.1
Electrocution
10
0.4
Table 3 Subtypes of blunt trauma injuries Mechanism of injury
Total number
Blunt trauma
1,450
Assault
583
MVC
406
PVC
239
Fall from height
55
Fall from moving vehicle
48
Accidental fall
46
Collapse of building structure
21
Hanging injury Fall from bicycle
12 11
Motorcycle accident
10
Animal injury
10
Sport injury
6
Other
3
MVC motor vehicle collision; PVC pedestrian vehicle collision
Table 4 Subtypes of penetrating injuries Mechanism of injury
Total number (n)
Penetrating trauma
1,081
Stab wound
858
Gunshot wound
202
Impalement
14
Animal injury
4
Other
3
Table 5 Subtypes of bite injuries
Mechanism of injury
Total number (n)
235
Bites
88
245
Snake
64
October
230
Dog
11
November December
244 354
Human
12
Other
1
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World J Surg Table 6 Classification of weapons used in cases of assault
Weapons
1,212
Air-rifle
4
Table 10 Classification of thoracic injuries Thorax injuries
Total number (n)
Axe
11
Soft tissue injury
870
Glass bottle
90
Skeletal fracture
186
Rock
53
Airway injury
2
Bush-knife
48
Vascular injury
12
Hammer
8
Cardiac injury
27
Rifle
14
Lung parenchymal injury
500
Handgun
113
GIT injury
1
Knife
603
Nerve tissue injury
7
Metal rod
44
Screwdriver
19
Spear
7
Table 11 Classification of abdominal injuries
Whip
40
Abdomen injuries
Wooden rod
158
Table 7 Classification of head injuries
Total number (n)
Soft tissue injury
678
Lumbar spine fracture
20
Diaphragm injury
52
Vascular injury
5 1
Head injuries
Total number (n)
Esophageal injury
Soft tissue injury
1,007
Gastric injury
50
Skeletal injury
351
Duodenum injury
17
Diffuse brain injury
92
Small bowel injury
77
353
Large bowel injury
64
57
Rectal injury
6
Solid organ injury Biliary injury
191 8
Focal brain injury Neurology
Table 8 Classification of maxillofacial injuries Maxillofacial injuries
Total number (n)
Soft tissue injury
347
Skeletal injury
174
Table 9 Classification of neck injuries Neck injuries
Total number (n)
Soft tissue injury
242
Cervical spine injury
42
Airway injury
10
Vascular injury
27
GIT injury
14
Nerve tissue injury
15
GIT gastrointestinal tract
Spectrum The 2,566 new emergency admissions included 1,561 (60.8 %) cases of injury to an isolated anatomical region (isolated trauma) and 1,005 (39.2 %) cases of injury to two or more anatomical regions (polytrauma). Of the 1,561
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Urogenital injury
4
Nerve tissue injury
2
Table 12 Classification of pelvic injuries Pelvis injuries
Total number (n)
Soft tissue injury
70
Pelvic fracture
57
cases of isolated trauma, head injuries comprised 535 cases (34.3 %); thoracic injuries, 328 cases (21 %); abdominal injuries, 262 cases (16.8 %); extremity injuries, 207 cases (13.3 %); neck injuries, 126 cases (8.1 %); maxillofacial injuries, 91 cases (5.8 %); pelvic injuries, 11 cases (0.7 %); and perineal injury, 1 case (0.06 %). The average ISS was 12 (IQR 6.7–23.2). A quarter (24.8 %) of all new emergency admissions had ISS scores in excess of 15. A comprehensive tabulation of injuries is illustrated in Tables 7, 8, 9, 10, 11, 12, 13, 14. Operative procedures A total of 812 operative procedures were performed. This included 592 index operative cases and 220 re-
World J Surg Table 13 Classification of perineal injuries Perineum injuries
Total number (n)
Genital injury
12
Anal injury
6
Table 14 Classification of extremity injuries Extremity injuries
Total number (n)
Soft tissue injury
633
Skeletal fracture
288
Table 16 Classification of metropolitan mortalities by mechanism of injury Mechanism of injury
On-scene death
Hospital death
Total
Penetrating
141
75
216
Stab
94
39
133
GSW
47
36
83
Blunt
149
205
354
Total
290
280
570
GSW gunshot wound
Vascular injury
49
Nerve tissue injury
13
Table 15 Classification of operative procedures by anatomical region Operative procedures
Total number (n)
Percentage (%)
Maxillofacial
34
5.2
Neck
29
4.4
Thorax
78
11.9
Abdomen
334
50.8
Pelvis
6
0.9
Perinuem
9
1.4
Extremity
167
25.4
laparotomies and revision operations. Forty neurosurgical procedures were performed on patients subsequently referred to the referral neurosurgical unit in Durban. The total number of operative cases performed within the PMTS included 17 operative procedures to the head, 31 maxillofacial procedures, 29 neck explorations, 74 thoracotomies, 269 laparotomies, 6 pelvic procedures, 9 perineal procedures, and 157 extremity operative procedures. Table 15 summarizes the operative data. Outcomes The average duration of stay (DOS) for patients under the care of the PMTS was 5.12 days (IQR 2.3–13.2 days). Some 2,432 (92.12 %) patients survived, and 208 (7.88 %) died. A total of 333 (13 %) patients required admission to either the ICU or HDU. From the city mortuary data, a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred at hospitals other than Greys and Edendale, within the metropolitan area. The total annual trauma-related mortality for the city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths, and penetrating trauma the remainder.
Fig. 1 Comparative 3-monthly emergency admissions between general, trauma, and pediatric surgery
Table 16 illustrates the classification of trauma-related deaths. Comparison to the overall surgical burden Trauma-related surgical cases comprised 42.9 % of all emergency surgical admissions. General surgical emergencies contributed 40.3 %, and pediatric surgical emergencies represented 16.8 % (Fig. 1). The average waiting time for emergency trauma laparotomies was available for 140 patients within the ESR. For that group, the average time between admission and initiation of emergency laparotomy was 248 min (IQR 156.9–473.1 min) (Fig. 2).
Discussion The PMTS manages a significant volume and spectrum of trauma. The ratio of blunt to penetrating trauma is almost 1:1, and this is different from the situation in the developed world, where blunt injury predominates [1–3]. This observation is not new and reflects high levels of interpersonal and intentional injury, which has been a distinctive feature of the pattern of trauma and injury in South Africa for several decades. There was a disturbing trend for
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World J Surg Fig. 2 Spectrum of waiting time to emergency trauma laparotomy
the incidence of gunshot wounds (GSW) to rise dramatically and overshadow the incidence of stab wounds (SW) reported from both Johannesburg and Durban. In 2001, GSW victims at the Johannesburg Trauma Unit outnumbered SW victims by a factor of three (664 vs. 205) [1–3]. This trend is reversed in our series, where SWs outnumbered GSWs by a factor of four (858 vs. 202). GSW seem to have stabilized at around 20 % of all penetrating injuries in our environment. GSW remain more lethal than SWs, as evidenced by the fact that there is a 40 % mortality associated with GSWs compared to 15 % for SWs [15]. It was previously reported that of all GSW-related deaths, a mean of 77 % of victims die at the scene, and the remaining 23 % die in the hospital. In our series, however, 55 % of GSW victims went directly to the mortuary. Blunt trauma is an increasing problem for the PMTS [16]. Once again the problem of interpersonal violence is apparent, as 40 % of blunt trauma is secondary to assault. The phenomenon of the community assault is quite prevalent in our environment. These patients sustain multiple injuries and are at risk for the development of aerobic crush syndrome and acute kidney injury (AKI). The biggest contributor to the remaining 60 % is the combination of MVCs and PVCs. There has been an increase in the number of MVC and PVC victims in this series. Victims of MVCs now outnumber PVC victims by a factor of two. This may reflect the increasing urbanization and acquisition of motor vehicles in the country, as well as the continued use of minibus taxis as a means of mass transportation. A total of 48 patients fell off the back of a moving vehicle, and this almost certainly reflects the widespread use of flatbed trucks to transport passengers.
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This may well be a good target for legislative activism aimed at reducing MVC-related injury. The anatomical distribution of injury reflects the high incidence of penetrating trauma, which is more likely than blunt trauma to be confined to a specific anatomical area. Of the 1,561 cases of isolated trauma, the head (34.3 %) thorax (21 %), and abdomen (16.8 %) accounted for most of the injuries. The largest target area in the human body is the torso; therefore the thorax and abdomen will receive most injuries. However, in cases of interpersonal violence at close range, the head is also a prominent target. The widespread use of body armor in the military has tended to reduce the incidence of torso and head injury. This is not the case in civilian trauma. Our mortality rate for admitted trauma patients was 8 %; however, the overall mortality rate for trauma within Pietermaritzburg is just over 20 %. The ratio of on-scene to inhospital deaths is 1:1. This implies that we have an immature trauma system with a large number of phase one and phase two deaths [1]. Phase one deaths are not amenable to therapeutic intervention and must be addressed by prevention strategies. Phase two deaths are due to airway obstruction, tension pneumothorax, and massive hemorrhage. Improved retrieval systems may allow for earlier intervention, which may prevent this category of trauma death. However, 70 deaths occurred in health care facilities other than those covered by the PMTS. This suggests that the emergency medical rescue services (EMRS) are delivering severely injured patients to inappropriate facilities. This is an ongoing problem and requires a quality improvement initiative to ensure that severely injured patients are taken to the most appropriate institution.
World J Surg
Traumatic brain injury (TBI) is a major burden for the service [17]. Approximately 4 % of patients with TBI required transfer and operative intervention at the neurosurgical unit in Durban. The cohort with moderate TBI (GCS 9–13) require neuroprotective therapy and ideally should be admitted to an ICU for 48 h of neuroprotective support and close monitoring. Less than 5 % of this group were admitted to the ICU. This implies a significant unmet need for ICU beds in Pietermaritzburg. This unmet need is reflected by the fact that although a quarter of our patients had an ISS in excess of 15, only 13 % were admitted to the ICU/HDU. An ISS score in excess of 15 is generally regarded as indicating major trauma. The long delay between admission and laparotomy (mean: 248 min) reflects the fact that the PMTS shares the emergency operating rooms with other competing disciplines, which also require access to this precious resource [16]. The longer the delay to surgical control of major bleeding or source control of sepsis, the greater the overall morbidity and mortality. The reasons for these delays may well be multifactorial; however, the lack of ready access to an operating room is certainly a major contributor to this delay [18]. The PMTS treats a significant volume of trauma with limited resources. There are a number of deficits in the system. There are insufficient facilities to adequately treat TBI. A dedicated neurosurgical service is needed in Pietermaritzburg. That our trauma system is immature is evidenced by the fact that 70 deaths were reported from health facilities not covered by the PMTS. This implies that the EMRS are delivering severely injured patients to inappropriate facilities within the metropolitan complex. The number of ICU and HDU beds in the complex is insufficient to treat the volume of trauma patients seen by the PMTS. Ready access to an operating room is not guaranteed for acute trauma patients, and this may be partly responsible for long delays to definitive surgical treatment. Despite these resource limitations, we have achieved an acceptable mortality rate (8 %) for patients managed within our service. This suggests that our current model of care is appropriate for our environment.
Conclusions The implementation of an ESR has allowed us to quantify the burden and outcomes of trauma within our hospital complex. The PMTS treats a significant volume and spectrum of trauma with a significant limitation of available resources. Although we have identified several deficits within the system, we have managed to implement a functional and sustainable trauma service across multiple
hospitals. We believe the major resource deficits limiting our service would be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care differs from the traditional model. Within the limits of our resources, our data suggest that this model of delivering care is a practical and feasible one. Considering the universal burden of trauma and the all-too-common imbalance between resource demand and supply amidst many health-care institutions, it is hoped that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.
References 1. Muckart DJ (1991) Trauma—the malignant epidemic. S Afr Med J 79:93–95 2. Clarke DL, Thomson SR, Madiba TE et al (2005) Selective conservatism in trauma management: a South Africa contribution. World J Surg 29:962–965. doi:10.1007/s00268-005-0131-9 3. Bowley DM, Khavandi A, Boffard KD et al (2002) The malignant epidemic—changing patterns of trauma. S Afr Med J 92:798–802 4. Goosen J, Veller M (2008) Trauma and emergency surgery: South African model. World J Surg 32:1622–1625. doi:10.1007/ s00268-008-9573-1 5. Mock C, Joshipura M, Goosen J et al (2006) Overview of the essential trauma care project. World J Surg 30:919–929. doi:10. 1007/s00268-005-0764-8 6. Mock C, Joshipura M, Goosen J et al (2005) Strengthening trauma systems globally: the essential trauma care project. J Trauma 59:1243–1246 7. Joshipura M, Mock C, Goosen J et al (2004) Essential trauma care: strengthening trauma systems around the world. Injury 35:841–845 8. Mock C, Joshipura M, Goosen J (2004) Global strengthening of care for the injured. Bull World Health Organ 82:241 9. Hardcastle TC, Steyn E, Boffard K, Trauma Society of South Africa et al (2011) Guidelines for the assessment of trauma centers for South Africa. S Afr Med J 101:189–194 10. Hardcastle TC, Finlayson M, van Heerden M et al (2012) The prehospital burden of disease due to trauma in Kwa-Zulu Natal: the need for afrocentric trauma systems. World J Surg 37:1513–1525. doi:10.1007/s00268-012-1852-1 11. Nwomeh BC, Lowell W, Kable R et al (2006) History and development of trauma registry: lessons from developed to developing countries. World J Emerg Surg 1:32 12. O’Reilly GM, Cameron PA, Joshipura M (2012) Global trauma registry mapping: a scoping review. Injury 43:1148–1153 13. Juillard CJ, Mock C, Goosen J et al (2009) Establishing the evidence for trauma quality improvement: a collaborative WHOIATSIC review. World J Surg 33:1075–1086. doi:10.1007/ s00268-009-9959-8 14. Laing GL, Bruce JL, Aldous C et al (2014) The design, construction and implementation of a computerized trauma registry in a developing South African metropolitan trauma service. Injury 45:3–8 15. Clarke DL, Quazi MA, Reddy K et al (2011) Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa. J Thorac Cardiovasc Surg 142:563–568
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World J Surg 16. Howes N, Walker T, Allorto NL et al (2012) Laparotomy for blunt abdominal trauma in a civilian trauma service. S Afr J Surg 50:30–32 17. Alexander T, Fuller G, Hargovan P et al (2009) An audit of the quality of care of traumatic brain injury at a busy regional hospital in South Africa. S Afr J Surg 47(120–122):124–126
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18. Kong VY, Bulajic B, Allorto NL et al (2012) Acute appendicitis in a developing country. World J Surg 36:2068–2073. doi:10. 1007/s00268-012-1626-9
Understanding the Burden and Outcome of Trauma Care Drives a New Trauma Systems Model G. L. Laing • D. L. Skinner • J. L. Bruce • C. Aldous • G. V. Oosthuizen • D. L. Clarke
Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background The Pietermaritzburg Metropolitan Trauma Service (PMTS) attempts to provide care for a whole city and hence is referred to as a service rather than a center. As part of a multifaceted quality improvement program, the PMTS has developed and implemented a robust electronic surgical registry (ESR). This review of the first year’s data from the ESR forms part of a situational analysis to assess the burden of trauma managed by the service and the quality of care delivered within the constraints of the available resources. Methods Formal ethical approval was obtained prior to design and development of this study, and appropriate commercial software was sourced. The exercise of data capture was integrated into the process of service delivery and was accomplished at the endpoint of patient care. 12 months after implementation of the registry, the data were extracted and audited. Results A total of 2,733 patients were admitted over the 12 month study period. The average patient age was 28.3 years. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. The average monthly admission rate was 228 patients, with a peak of 354 admissions over the December period. The mean injury severity score (ISS) was 12 [interquartile range (IQR) 6.7–23.2]. A quarter G. L. Laing (&) D. L. Skinner J. L. Bruce C. Aldous G. V. Oosthuizen D. L. Clarke Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of General Surgery, University of Kwa-Zulu Natal Nelson R Mandela School of Medicine, Post-Net Suite 156, Private Bag X9118, Pietermaritzburg 3200, South Africa e-mail: [email protected] D. L. Clarke e-mail: [email protected]
(24.8 %) of all new emergency admissions had an ISS [ 15. The average duration of stay for patients was 5.12 days (IQR 2.3–13.2 days). Some 2,432 (92.1 %) patients survived, and 208 (7.9 %) died. A total of 333 (13 %) patients required admission to either the intensive care unit (ICU) or the high dependency unit. From the city mortuary data a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred within Pietermaritzburg hospitals other than Greys and Edendale. The total trauma-related mortality for the entire city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths. Conclusions The PMTS treats a significant volume and spectrum of trauma. Despite significant resource limitations, we have managed to implement a functional and sustainable trauma service across multiple hospitals. We believe the major resource deficits limiting our service could be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care came out of a need to work within our resource constraints, and it differs from the traditional model. Within the aforementioned limits, our data suggest that this model of delivering care is feasible, practical, and successful. Considering the universal burden of trauma and the all-toocommon imbalance between resource demand and supply among many health-care institutions, it is our hope that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.
Introduction Over two decades ago, Muckart compared trauma in KwaZulu Natal (KZN) to an epidemic and proposed a concerted
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World J Surg
systematic approach to the problem [1–3]. He believed that an ‘‘essential component of such a systematic approach would be a dedicated trauma center.’’ He went on to state that this should ‘‘include a multidisciplinary team available around the clock, lead by specialist trauma surgeons and supported by anesthetists, intensivists, and the appropriate sub-specialists. This team would ideally work within an environment affording the ready availability of surgical facilities where diagnosis, resuscitation, and definitive intervention would proceed smoothly’’ [1]. Since this time there has been a growing awareness of the need to strengthen trauma systems globally, and to improve the quality of care of the injured patient [4–10]. Much emphasis has been placed on the central role of the dedicated trauma center as the driver of quality trauma care [9, 10]. The Pietermaritzburg Metropolitan Trauma Service (PMTS) was established in 2006 with the intention of providing comprehensive trauma care to the city of Pietermaritzburg and the whole of western KZN Province. For a number of logistical reasons, the PMTS could not adopt the concept of a trauma center located in a single hospital. We therefore opted to attempt to provide care across the metropolitan complex. Hence the PMTS is a service and not a center. Trauma patients in Pietermaritzburg are directed to one of the two hospitals within the city, depending on their geographical location at the time of injury. This model of delivering trauma care is somewhat unique, and while philosophically attractive presents challenges in terms of implementation of safe and pragmatic management algorithms. Setting The PMTS aims to provide resources and expertise, as well as strategic and political leadership in trauma care to the city of Pietermaritzburg and the western rural health-districts of KZN. Pietermaritzburg is the capital of KZN and is the largest city in the western part of the province. It has a population of 1,001,000 people and is served by a tertiary hospital (Greys), a regional hospital (Edendale), and a district hospital (Northdale). There are three private hospitals in the city. Western KZN is a predominantly rural province with a population of two million people, and consists of four health districts. These include the Sisonke, Amajuba, Uthukela, and Umzinyathi districts. There are two other regional hospitals in Western KZN and 19 district hospitals.
with an interest in trauma surgery. All trainees and junior staff work under the supervision of the specialist staff. At an operational level, the staff is subdivided into three teams, one based at Greys Hospital and two at Edendale Hospital. Both hospitals have 24 h availability of a computed tomography (CT) scanner, and have support from a radiology service. Each hospital provides a single emergency operative slate, which caters for the competitive needs of all surgical specialities. The complex has 10 high dependency unit (HDU) beds (3 adult and 7 pediatric) and 19 intensive care unit (ICU) beds (12 adult and 7 pediatric), which are shared by all the surgical disciplines. Intensive care unit patients are managed with the Department of Critical Care in a ‘‘closed unit’’ fashion. The Pietermaritzburg Trauma Registry Since 2006 there has been a strategically driven multifaceted quality improvement program within the PMTS. This program has attempted to use a number of theoretical concepts from industry and public health, such as strategic planning, error theory, and health system models, to drive improvements in the quality of care of trauma patients in Pietermaritzburg and western KZN. One of the key drivers of any quality improvement program in health care is a functional and robust electronic registry [11–13]. The PMTS implemented such a comprehensive electronic surgical registry (ESR) in January 2012 [14]. A standardized paper-based check-box style admission document was used for the admission of all trauma patients. The data were then extracted from this document and entered directly into the trauma registry at the time of discharge. Data regarding operative access and procedures, complications, and outcomes were retrieved from inpatient records. A number of quality control processes were put in place. Data were analyzed and validated by the system administrator on a weekly basis. Omitted data sets were identified and where possible completed from the discharge summary or patient records. Registry data were manually checked on a weekly basis against morning hand-over reports, and on a threemonthly basis against hospital and city mortuary records. The present study is a situational analysis in which the first 12 months of data were reviewed. Through this process we attempted to compare the annual service load as recorded on the registry with the resources available to manage the volume of trauma.
Resources
Methodology
The PMTS has six specialist surgeons: three sub-specialist trauma surgeons, two surgeons enrolled in sub-specialist trauma fellowship training, and another general surgeon
In January 2013 the data from the trauma registry for the previous 12 months were collated and reviewed by the lead author (G.L.L.). The collected data included demographic
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details, admission vital signs, and categorization of anatomical injuries. Injury Severity Scores were tabulated and collected, as were data pertaining to operative interventions, complications, and outcomes. To ascertain the contribution of trauma to the overall surgical workload at Greys Hospital, the total number of admissions for general surgery, pediatric surgery, and trauma were compared over a three-month period.
Results A total of 2,733 patients were admitted over the study period. This included 2,659 (97.3 %) new emergency admissions and 74 (2.7 %) readmissions or transfers. The average patient age was 28.3 years (IQR 23.6–46.3 years). The ethnic breakdown was as follows: 2,653 patients (97.1 %) were black, 36 patients (1.3 %) were of mixed race, 23 patients (0.8 %) were white, and 21 patients (0.8 %) were Indian. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. Of the female patients, 12 were pregnant. The average monthly admission rate was 228 patients with a peak of 354 admissions over the month of December. Table 1 summarizes the monthly admission figures. Mechanism Analysis of the mechanism of injury revealed that 1,450 (54.5 %) patients sustained blunt trauma, 1,081 (40.7 %) penetrating trauma, 88 (3.3 %) bite wounds, 10 (0.4 %) electrocution injury, and 30 (1.1 %) a combination of blunt and penetrating trauma. In the blunt trauma group 666 (47 %) were victims of either a motor vehicle collision (MVC) or a pedestrian vehicle collision (PVC), 471 (32 %) patients were victims of assault, and 92 (6 %) were victims Table 1 Monthly trauma admission numbers
Monthly admissions
Total number
January
228
February
212
March
221
April
223
May
136
June
178
July
227
August September
of a community beating. Tables 2, 3, 4, 5 illustrate the mechanisms of injury. The weapons used are illustrated in Table 6. Table 2 Mechanism of injury Mechanism of injury
Total number
Percentage (%)
Blunt trauma
1,450
54.5
Penetrating trauma
1,081
40.7
Bites
88
3.3
Combination
30
1.1
Electrocution
10
0.4
Table 3 Subtypes of blunt trauma injuries Mechanism of injury
Total number
Blunt trauma
1,450
Assault
583
MVC
406
PVC
239
Fall from height
55
Fall from moving vehicle
48
Accidental fall
46
Collapse of building structure
21
Hanging injury Fall from bicycle
12 11
Motorcycle accident
10
Animal injury
10
Sport injury
6
Other
3
MVC motor vehicle collision; PVC pedestrian vehicle collision
Table 4 Subtypes of penetrating injuries Mechanism of injury
Total number (n)
Penetrating trauma
1,081
Stab wound
858
Gunshot wound
202
Impalement
14
Animal injury
4
Other
3
Table 5 Subtypes of bite injuries
Mechanism of injury
Total number (n)
235
Bites
88
245
Snake
64
October
230
Dog
11
November December
244 354
Human
12
Other
1
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World J Surg Table 6 Classification of weapons used in cases of assault
Weapons
1,212
Air-rifle
4
Table 10 Classification of thoracic injuries Thorax injuries
Total number (n)
Axe
11
Soft tissue injury
870
Glass bottle
90
Skeletal fracture
186
Rock
53
Airway injury
2
Bush-knife
48
Vascular injury
12
Hammer
8
Cardiac injury
27
Rifle
14
Lung parenchymal injury
500
Handgun
113
GIT injury
1
Knife
603
Nerve tissue injury
7
Metal rod
44
Screwdriver
19
Spear
7
Table 11 Classification of abdominal injuries
Whip
40
Abdomen injuries
Wooden rod
158
Table 7 Classification of head injuries
Total number (n)
Soft tissue injury
678
Lumbar spine fracture
20
Diaphragm injury
52
Vascular injury
5 1
Head injuries
Total number (n)
Esophageal injury
Soft tissue injury
1,007
Gastric injury
50
Skeletal injury
351
Duodenum injury
17
Diffuse brain injury
92
Small bowel injury
77
353
Large bowel injury
64
57
Rectal injury
6
Solid organ injury Biliary injury
191 8
Focal brain injury Neurology
Table 8 Classification of maxillofacial injuries Maxillofacial injuries
Total number (n)
Soft tissue injury
347
Skeletal injury
174
Table 9 Classification of neck injuries Neck injuries
Total number (n)
Soft tissue injury
242
Cervical spine injury
42
Airway injury
10
Vascular injury
27
GIT injury
14
Nerve tissue injury
15
GIT gastrointestinal tract
Spectrum The 2,566 new emergency admissions included 1,561 (60.8 %) cases of injury to an isolated anatomical region (isolated trauma) and 1,005 (39.2 %) cases of injury to two or more anatomical regions (polytrauma). Of the 1,561
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Urogenital injury
4
Nerve tissue injury
2
Table 12 Classification of pelvic injuries Pelvis injuries
Total number (n)
Soft tissue injury
70
Pelvic fracture
57
cases of isolated trauma, head injuries comprised 535 cases (34.3 %); thoracic injuries, 328 cases (21 %); abdominal injuries, 262 cases (16.8 %); extremity injuries, 207 cases (13.3 %); neck injuries, 126 cases (8.1 %); maxillofacial injuries, 91 cases (5.8 %); pelvic injuries, 11 cases (0.7 %); and perineal injury, 1 case (0.06 %). The average ISS was 12 (IQR 6.7–23.2). A quarter (24.8 %) of all new emergency admissions had ISS scores in excess of 15. A comprehensive tabulation of injuries is illustrated in Tables 7, 8, 9, 10, 11, 12, 13, 14. Operative procedures A total of 812 operative procedures were performed. This included 592 index operative cases and 220 re-
World J Surg Table 13 Classification of perineal injuries Perineum injuries
Total number (n)
Genital injury
12
Anal injury
6
Table 14 Classification of extremity injuries Extremity injuries
Total number (n)
Soft tissue injury
633
Skeletal fracture
288
Table 16 Classification of metropolitan mortalities by mechanism of injury Mechanism of injury
On-scene death
Hospital death
Total
Penetrating
141
75
216
Stab
94
39
133
GSW
47
36
83
Blunt
149
205
354
Total
290
280
570
GSW gunshot wound
Vascular injury
49
Nerve tissue injury
13
Table 15 Classification of operative procedures by anatomical region Operative procedures
Total number (n)
Percentage (%)
Maxillofacial
34
5.2
Neck
29
4.4
Thorax
78
11.9
Abdomen
334
50.8
Pelvis
6
0.9
Perinuem
9
1.4
Extremity
167
25.4
laparotomies and revision operations. Forty neurosurgical procedures were performed on patients subsequently referred to the referral neurosurgical unit in Durban. The total number of operative cases performed within the PMTS included 17 operative procedures to the head, 31 maxillofacial procedures, 29 neck explorations, 74 thoracotomies, 269 laparotomies, 6 pelvic procedures, 9 perineal procedures, and 157 extremity operative procedures. Table 15 summarizes the operative data. Outcomes The average duration of stay (DOS) for patients under the care of the PMTS was 5.12 days (IQR 2.3–13.2 days). Some 2,432 (92.12 %) patients survived, and 208 (7.88 %) died. A total of 333 (13 %) patients required admission to either the ICU or HDU. From the city mortuary data, a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred at hospitals other than Greys and Edendale, within the metropolitan area. The total annual trauma-related mortality for the city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths, and penetrating trauma the remainder.
Fig. 1 Comparative 3-monthly emergency admissions between general, trauma, and pediatric surgery
Table 16 illustrates the classification of trauma-related deaths. Comparison to the overall surgical burden Trauma-related surgical cases comprised 42.9 % of all emergency surgical admissions. General surgical emergencies contributed 40.3 %, and pediatric surgical emergencies represented 16.8 % (Fig. 1). The average waiting time for emergency trauma laparotomies was available for 140 patients within the ESR. For that group, the average time between admission and initiation of emergency laparotomy was 248 min (IQR 156.9–473.1 min) (Fig. 2).
Discussion The PMTS manages a significant volume and spectrum of trauma. The ratio of blunt to penetrating trauma is almost 1:1, and this is different from the situation in the developed world, where blunt injury predominates [1–3]. This observation is not new and reflects high levels of interpersonal and intentional injury, which has been a distinctive feature of the pattern of trauma and injury in South Africa for several decades. There was a disturbing trend for
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World J Surg Fig. 2 Spectrum of waiting time to emergency trauma laparotomy
the incidence of gunshot wounds (GSW) to rise dramatically and overshadow the incidence of stab wounds (SW) reported from both Johannesburg and Durban. In 2001, GSW victims at the Johannesburg Trauma Unit outnumbered SW victims by a factor of three (664 vs. 205) [1–3]. This trend is reversed in our series, where SWs outnumbered GSWs by a factor of four (858 vs. 202). GSW seem to have stabilized at around 20 % of all penetrating injuries in our environment. GSW remain more lethal than SWs, as evidenced by the fact that there is a 40 % mortality associated with GSWs compared to 15 % for SWs [15]. It was previously reported that of all GSW-related deaths, a mean of 77 % of victims die at the scene, and the remaining 23 % die in the hospital. In our series, however, 55 % of GSW victims went directly to the mortuary. Blunt trauma is an increasing problem for the PMTS [16]. Once again the problem of interpersonal violence is apparent, as 40 % of blunt trauma is secondary to assault. The phenomenon of the community assault is quite prevalent in our environment. These patients sustain multiple injuries and are at risk for the development of aerobic crush syndrome and acute kidney injury (AKI). The biggest contributor to the remaining 60 % is the combination of MVCs and PVCs. There has been an increase in the number of MVC and PVC victims in this series. Victims of MVCs now outnumber PVC victims by a factor of two. This may reflect the increasing urbanization and acquisition of motor vehicles in the country, as well as the continued use of minibus taxis as a means of mass transportation. A total of 48 patients fell off the back of a moving vehicle, and this almost certainly reflects the widespread use of flatbed trucks to transport passengers.
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This may well be a good target for legislative activism aimed at reducing MVC-related injury. The anatomical distribution of injury reflects the high incidence of penetrating trauma, which is more likely than blunt trauma to be confined to a specific anatomical area. Of the 1,561 cases of isolated trauma, the head (34.3 %) thorax (21 %), and abdomen (16.8 %) accounted for most of the injuries. The largest target area in the human body is the torso; therefore the thorax and abdomen will receive most injuries. However, in cases of interpersonal violence at close range, the head is also a prominent target. The widespread use of body armor in the military has tended to reduce the incidence of torso and head injury. This is not the case in civilian trauma. Our mortality rate for admitted trauma patients was 8 %; however, the overall mortality rate for trauma within Pietermaritzburg is just over 20 %. The ratio of on-scene to inhospital deaths is 1:1. This implies that we have an immature trauma system with a large number of phase one and phase two deaths [1]. Phase one deaths are not amenable to therapeutic intervention and must be addressed by prevention strategies. Phase two deaths are due to airway obstruction, tension pneumothorax, and massive hemorrhage. Improved retrieval systems may allow for earlier intervention, which may prevent this category of trauma death. However, 70 deaths occurred in health care facilities other than those covered by the PMTS. This suggests that the emergency medical rescue services (EMRS) are delivering severely injured patients to inappropriate facilities. This is an ongoing problem and requires a quality improvement initiative to ensure that severely injured patients are taken to the most appropriate institution.
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Traumatic brain injury (TBI) is a major burden for the service [17]. Approximately 4 % of patients with TBI required transfer and operative intervention at the neurosurgical unit in Durban. The cohort with moderate TBI (GCS 9–13) require neuroprotective therapy and ideally should be admitted to an ICU for 48 h of neuroprotective support and close monitoring. Less than 5 % of this group were admitted to the ICU. This implies a significant unmet need for ICU beds in Pietermaritzburg. This unmet need is reflected by the fact that although a quarter of our patients had an ISS in excess of 15, only 13 % were admitted to the ICU/HDU. An ISS score in excess of 15 is generally regarded as indicating major trauma. The long delay between admission and laparotomy (mean: 248 min) reflects the fact that the PMTS shares the emergency operating rooms with other competing disciplines, which also require access to this precious resource [16]. The longer the delay to surgical control of major bleeding or source control of sepsis, the greater the overall morbidity and mortality. The reasons for these delays may well be multifactorial; however, the lack of ready access to an operating room is certainly a major contributor to this delay [18]. The PMTS treats a significant volume of trauma with limited resources. There are a number of deficits in the system. There are insufficient facilities to adequately treat TBI. A dedicated neurosurgical service is needed in Pietermaritzburg. That our trauma system is immature is evidenced by the fact that 70 deaths were reported from health facilities not covered by the PMTS. This implies that the EMRS are delivering severely injured patients to inappropriate facilities within the metropolitan complex. The number of ICU and HDU beds in the complex is insufficient to treat the volume of trauma patients seen by the PMTS. Ready access to an operating room is not guaranteed for acute trauma patients, and this may be partly responsible for long delays to definitive surgical treatment. Despite these resource limitations, we have achieved an acceptable mortality rate (8 %) for patients managed within our service. This suggests that our current model of care is appropriate for our environment.
Conclusions The implementation of an ESR has allowed us to quantify the burden and outcomes of trauma within our hospital complex. The PMTS treats a significant volume and spectrum of trauma with a significant limitation of available resources. Although we have identified several deficits within the system, we have managed to implement a functional and sustainable trauma service across multiple
hospitals. We believe the major resource deficits limiting our service would be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care differs from the traditional model. Within the limits of our resources, our data suggest that this model of delivering care is a practical and feasible one. Considering the universal burden of trauma and the all-too-common imbalance between resource demand and supply amidst many health-care institutions, it is hoped that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.
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