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Limbe Regional Hospital Case Study

Demographic characteristics A total of 5,617 patients were seen at Limbe Regional Hospital ED over the study period with 88. 2% of these patients residing in the Limbe municipality (Table 1). The average age of patients was 26. 8 years [CI: 26. 4, 27. 2] with a median age of 26 years [IQR: 19, 34]. The peak age incidence of injury was 20 to 29 years (36. 5%) followed by patients aged 30-39 years (22. 4%) and 10-19 years (15. 3%) (Figure 1). About two-thirds of patients were male (67. 6%) (Table 1).

Students comprised the highest proportion of injured patients (25. %), followed by those working in transportation (15. 0%), and sales (13. 6%) (Figure 2). Nature of injury RTIs (55. 5%) were the leading cause of injury followed by assault (21. 9%) (Table 1). Of the patients who sustained RTIs, 53. 9% were passengers, 28. 3% drivers and 17. 8% were pedestrians. Among patients that suffered an RTI, 34. 7% involved a motorcycle alone, 22. 7% involved a car against a motorcycle, 14. 8% car alone, 11. 6% motorcycle against pedestrian, and 7. 0% car against pedestrian.

Analysis of mechanism of injury and sex revealed statistically significant differences in how men were injured compared to women (p<9) (93. 6%) (Table 1). GCS was recorded for 3,707 (66. 0%) of injured patients, of whom, 97. 8% were mildly injured. RTS was recorded for 467 patients (8. 3%). About 22 deaths occurred. Eighteen of the dead patients had a documented GCS, of which 17 were classified as severely injured. About 13 of the deceased patients were awarded an ISS, of which only four were classified as severe injuries while the remaining nine were considered to have mild injuries.

Completeness of data The Limbe trauma registry collected significantly more data for all variables compared to the retrospective administrative hospital logs at the same facility (Table 2). A similar pattern was observed when comparing the Central Hospital Yaounde trauma registry with their administrative data. However, the number of records collected annually in the Limbe trauma registry was inconsistent. The proportion of missing data for most variables typically ranged from 0. 5 -14. 9%, except for RTS, which was not documented in 57. 3% of cases.

The quality of data collection using the trauma registry generally improved over time and the lowest rate of missing data was seen in years 2010 and 2013 (Figure 3). Clinical and calculated variables, such as GCS, ISS, and RTS, were consistently difficult to collect across the years. The varying proportions of missing data for blood pressure and respiratory rate were parallel across years of data collection, both peaking at 30. 5% missing in 2011. Discussion Limbe Regional Hospital encounters a high trauma volume, chiefly related to traffic injuries and assault.

Patients were predominantly young (10 to 39 years old), male, and residents of Limbe municipality presenting with mild injuries at one or two anatomical locations. Most patients presented to the emergency department within an hour of being injured. These visits most often led to formal discharge. Using a trauma registry for data collection was associated with a higher level of data completeness for all variables, particularly blood pressure, respiratory rate, GCS, ISS, and patient transport time.

Study findings support existing literature showing that young males are more likely to be victims of trauma, a phenomenon that can cause significant social and economic hardship to families [8,30–33]. Such hardship could be a result of expensive out-of-pocket health care costs or the loss of household earnings incurred during the period of treatment, subsequent disability, or both [34]. From this perspective, trauma poses a considerable economic risk to entire households, warranting further research and investment focused on increasing access to adequate trauma care as well as effective injury prevention.

If universal health coverage is to be achieved, implementing sustainable schemes for financial risk protection of individuals that are at an increased risk for trauma must be a priority. Two-thirds of all injuries presenting to the hospital were RTIs. This is similar to findings in other sub-Saharan African countries, where RTI account for approximately 40-90% of all injuries [17,35]. Unsafe transportation options, poor road infrastructure, or ineffective and/or poorly enforced policies to ensure road safety may contribute to the high burden of RTIs in the region [36].

The occupations most often injured were students (25. 5%) followed by transportation workers (15. 0%) and salespersons (13. 6%). With these groups traveling regularly, this finding is presumably tied to RTIs as the leading cause of injury. Public education efforts to improve awareness and road safety should target these high-risk populations. About 67% of RTIs (37% of all injuries) were motorcycle-related, making motorcycle-associated injury the leading mechanism of injuries in this setting. Studies in other settings indicate similar rates of motorcycle-associated injuries [37–39].

Considering that motorcycles account for over 30% of public transportation in Cameroonian cities, there may be a need to explore safer transportation alternatives [40]. Municipal governments in Nigeria and Liberia, for instance, have banned the use of motorcycles for public transportation and have seen a subsequent reduction in RTI incidence [32,41,42]. Indonesia requires that public transportation vehicles have at least three wheels [43]. Ancillary measures may include proper road construction to enhance road safety for motorists and also pedestrians. Assault (21. %) and domestic accidents (13. 0%) were the second and third leading mechanism of injury, respectively.

The high rate of interpersonal violence is an interesting finding in the absence of civil unrest or documented communal clashes. This registry does not capture the exact mechanism of domestic accidents. Efforts to further explore the nature of these mechanisms of injury could inform interventions aimed at prevention or addressing underlying causality. The implementation of the trauma registry in Limbe led to improvement in the data collection and quality.

The amount and quality of data collected via the Limbe trauma registry suggest that adequate implementation requires continued commitment and oversight. Despite some fluctuations in the amount and quality of data collected, there was general improvement in the completeness of data collected for indicators over the course of the study period. This may suggest that data collection using the trauma registry became routine over time, contributing to more regular recordkeeping of specified indicators. Challenges persisted in the collection of calculated clinical indicators, such as GCS, ISS, and RTS.

However, given the logistical and technological requirements of various trauma-scoring systems, this may speak to the broader challenge of accurately applying these scores in resource-limited settings. Local stakeholder buy-in, adequate and motivated workforce, and secure funding are crucial elements that support the sustainability of a trauma registry. While some studies suggest that registries must be locally-driven to be sustainable, the role of international or external partners in funding, developing, implementing, and evaluating trauma registries is also key [44].

The use of electronic registries has the benefit of scalability, but may not be feasible in every setting. Where the capacity for electronic registries exists, platforms or software that are user-friendly and familiar to the local workforce, are advantageous. A trauma registry can serve as tool for developing and monitoring quality improvement interventions that involve reliable clinical documentation. In comparison with secondary data obtained from administrative records, the use of a trauma registry demonstrates a higher rate of documentation and completeness of data in all variables recorded [7,9].

This hints that trauma registries are not only feasible but can also improve the quality of clinical documentation in LMIC settings. The registry can also serve as a basis for the development of an electronic medical records system appropriate for this setting. Hospital-based data collection limits the sample population studied to injured persons seeking formal care at the facility. As a result, it is possible that the incidence and epidemiology of injury is different when examined at the community level.

While the proportion of missing data is typically low for indicators included in the Limbe Regional Hospital trauma registry, the variation in annual number of records highlights the possibility of inconsistencies in data collection or overall implementation of the registry. In terms of data collected, the failure of severity scores to correlate with patient outcomes suggests broader challenges of applying these scoring systems in this setting.

Though beyond the scope of this particular study, exploration of appropriate severity scoring systems for this context may enhance the utility of the trauma registry in clinical care provision. Conclusions This study shows that the implementation of a locally-developed trauma registry is feasible and sustainable, providing valuable, higher quality data to inform our understanding of injury as well as trauma care and systems in this setting. The high prevalence of motorcycle-related injuries raises concerns and the need for a proactive approach towards reducing the incidence of these injuries.

Improving road safety and infrastructure, provision of safer public transportation systems, and the formulation and implementation of policies to ensure road and passenger safety will be critical to reducing the risk and occurrence of trauma in the region. The availability of trauma registry data in LMICs will enhance the understanding of the local and global surgical disease burden. Such understanding will catalyze the prioritization of surgical care delivery in LMICs and facilitate the development and implementation of targeted capacity building and quality improvement interventions that are context-appropriate.

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