A Trauma Registry (TR) and Trauma System Improvement Project (TSIP) for Bangladesh

 

The trauma registry has been an invaluable tool for informing the design of quality trauma care system, including planned resource allocation and injury surveillance over time. However, its implementation in lower middle in-come countries (LMICs) like Bangladesh faces many barriers and challenges. To test the feasibility of implementation of a trauma registry (TR) and trauma system improvement programme (TSIP) in Bangladesh, a pilot study was conducted in four public sector hospitals in districts with a high incidence of Road-traffic accidents (RTAs) (Bogra, Comilla, Jhenaidah and Tangail). Following the World Health Organisation (WHO) guidelines, the TR and TSIP were designed, contextualised and implemented simultaneously in the above hospitals from Oct. 2021– Feb. 2022. 

A few key findings ae summarised below:

·         Approximately 56 per cent of patients missed the golden hour (first 60 minutes of the occurrence of the accident/crush) of hospital arrival. In 44 per cent of RTAs, the time difference between the occurrence of road traffic injury (RTI) and screening by a health care provider was ≤60 minutes.

·         RTI victims with a household income of less than 15000 had a higher rate (15%) of late arrival at hospital ER, i.e., ≥ 3 hours.

·         80% of the RTA victims were males but females were admitted in the in-patient wards at a higher proportion (70%); the lower extremities (68%) of the body endured the most injuries and the most common injury being  abrasion (72%).

·         Motorists sustained a high proportion of lower extremity (76%), cut/open wound injuries (44%), and abrasion (76%) type injuries.

·         Eighty-one per cent of the cases were attended by nurses, followed by support staff (17%) and physicians (1%) when the patient arrived at the emergency room.

·         In 76% of cases, the vital signs were neither observed nor recorded. The practice of Glasgow Coma Scale (GCS) scoring of the road traffic accident (RTA) victims is low  (14%). Almost all patients receive non-operative management (95%) upon admission to a healthcare facility.

·         Clinical investigations were not requested or documented for more than half of the patients (53%); radiology/X-ray (37%) and CT scan (11%) were requested at a higher proportion compared to other investigations.

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In each hospital, steering committees (SC) and multi-disciplinary trauma teams (TT) were formed involving the hospital authorities and trauma care providers for smooth and informed implementation of the TSIP with the use of TR data. The members’ active participation facilitated and guided the implementation activities as per protocol.

·         The SC meetings and mortality and morbidity (M&M) conferences were organized quarterly (two rounds in each facility). M&M conferences provided the platform to discuss scope of trauma care improvement, under the current constraints, following the trauma case presentation.

·         The hospitals reported a shortage of human resources and basic amenities for trauma care which was a major constraint in all the facilities; the experience shows that TR implementation is more convenient in facilities with dedicated casualty department especially in the medical college hospitals at the tertiary level.

·         Appropriateness of registry design as per context, capacity development of the trauma care providers, organization of available resources, ensuring data quality and sustainability by securing a higher level of commitment and ownership, and mainstreaming TR/TSIP within the existing system is crucial for improving RTI related morbidity and mortality.

Excerpts from a forthcoming report of BRAC JPGSPH, funded by the World Bank