Nine-point plan to improve care of the injured patient: A case study from Kenya.

BACKGROUND: Injury rates in low- and middle-income countries are among the greatest in the world, with >90% of unintentional injury occurring in low- or middle-income countries. The risk of death from injuries is 6 times more in low- and middle-income countries than in high-income countries. This increased rate of injury is partly due to the lack of availability and access to timely and appropriate medical care for injured individuals. Kenya, like most low- and middle-income countries, has seen a 5-fold increase in injury fatalities throughout the past 4 decades, in large part related to the absence of a coordinated, integrated system of trauma care. METHODS: We aimed to assess the trauma-care system in Kenya and to develop and implement a plan to improve it. A trauma system profile was performed to understand the landscape for the care of the injured patient in Kenya. This process helped identify key gaps in care ranging from prehospital to hospital-based care. RESULTS: In response to this observation, a 9-point plan to improve trauma care in Kenya was developed and implemented in close collaboration with local stakeholders. The 9-point plan was centered on engagement of the stakeholders, generation of key data to guide and improve services, capacity development for prehospital and hospital care, and strengthening policy and legislation. CONCLUSION: There is an urgent need for coordinated strategies to provide appropriate and timely medical care to injured individuals in low- or middle-income countries to decrease the burden of injuries and related fatalities. Our work in Kenya shows that such an integrated system of trauma care could be achieved through a step-by-step integrated and multifaceted approach that emphasizes engagement of local stakeholders and evidence-based approaches to ensure effectiveness, efficiency, and sustainability of system-wide improvements. This plan and lessons learned in its development and implementation could be adaptable to other similar settings to improve the care of the injured patient in low- or middle-income countries.

Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital.

BACKGROUND: Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility-based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes. METHODS: An electronic, tablet-based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in-patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in-patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes. RESULTS: A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity. CONCLUSION: The establishment of hospital-based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs.

Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study.

BACKGROUND: Injury is a leading cause of disability and death worldwide, accounting for over 5 million deaths each year. The injury burden is higher in low- and middle-income countries where more than 90% of injury-related deaths occur. Despite this burden, the use of prospective trauma registries to describe injury epidemiology and outcomes is limited in low- and middle-income countries. Kenya lacks robust data to describe injury epidemiology and care. The objective of this study was to investigate the epidemiology and outcomes of injuries at 4 referral hospitals in Kenya using hospital-based trauma registries. METHODS: From January 2014 to May 2015, all injured patients presenting to the casualty departments of Kenyatta National, Thika Level 5, Machakos Level 5, and Meru Level 5 Hospitals were enrolled prospectively. Data collected included demographic characteristics, type of prehospital care received, prehospital time, injury pattern, and outcomes. RESULTS: A total of 14,237 patients were enrolled in our study. Patients were predominantly male (76.1%) and young (mean age 28 years). The most common mechanisms of injury were road traffic injuries (36.8%), falls (26.4%), and being struck/hit by a person or object (20.1%). Burn was the most common mechanism of injury in the age category under 5 years. Body regions commonly injured were lower extremity (35.1%), upper extremity (33.4%), and head (26.0%). The overall mortality rate was 2.4%. Significant predictors of mortality from multivariate analysis were Glasgow Coma Scale ≤12, estimated injury severity score ≥9, burns, and gunshot injuries. CONCLUSION: Hospital-based trauma registries can be important sources of data to study the epidemiology of injuries in low- and middle-income countries. Data from such trauma registries can highlight key needs and be used to design public health interventions and quality-of-care improvement programs.

Establishing hospital-based trauma registry systems: lessons from Kenya.

OBJECTIVE: In the developing world, data about the burden of injury, injury outcomes, and complications of care are limited. Hospital-based trauma registries are a data source that can help define this burden. Under the trauma care component of the Bloomberg Global Road Safety Partnership, trauma registries have been implemented at three sites in Kenya. We describe the challenges and lessons learned from this effort. METHODS: A paper-based trauma surveillance form was developed, in collaboration with local hospital partners, to collect data on all trauma patients presenting for care. The form includes demographic information, pre-hospital care given, and patient care and clinical information necessary to calculate estimated injury surveillance. The type of data collected was standardized across all three sites. Frequent reviews of the data collection process, quality, and completeness, in addition to regular meetings and conference calls, have allowed us to optimize the process to improve efficiency and make corrective actions where required. RESULTS: Trauma registries have been implemented in three hospitals in Kenya, with potential for expansion to other hospitals and facilities caring for injured patients. The process of establishing registries was associated with both general and site-specific challenges. Problems were identified in planning, data collection, entry processes, and analysis. Problems were addressed when identified, resulting in improved data quality. CONCLUSIONS: Trauma registries are a key data source for defining the burden of injury and developing quality improvement processes. Trauma registries were implemented at three sites in Kenya. Problems and challenges in data collection were identified and corrected. Through the registry data, gaps in care were identified and systemic changes made to improve the care of the injured.