Amber Mehmood

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.

Trauma care in Oman: A call for action

Many Arab countries have undergone the epidemiologic transition of diseases with increasing economic development and a proportionately decreasing prevalence of communicable diseases. With this transition, injuries have emerged as a major cause of mortality and morbidity in the Gulf Cooperation Council countries in addition to diseases of affluence. Injuries are the number one cause of years of life lost and disability-adjusted life-years in the Sultanate of Oman. The burden of injuries, which affects mostly young Omani males, has a unique geographic distribution that is in contrast to the trauma care capabilities of the country. The concentration of health care resources in the northern part of the country makes it difficult for the majority of Omanis who live elsewhere to access high-quality and time-sensitive care. A broader multisectorial national injury prevention strategy should be evidence based and must strengthen human resources, service delivery, and information systems to improve care of the injured and loss of life. This paper provides a unique overview of the Omani health system with the goal of examining its trauma care capabilities and injury control policies.

How vital are the vital signs? a multi-center observational study from emergency departments of Pakistan

BackgroundVital signs play a critical role in prioritizing patients in emergency departments (EDs), and are the foundation of most triage methods and disposition decisions. This study was conducted to determine the frequency of vital signs documentation anytime during emergency department treatment and to explore if abnormal vital signs were associated with the likelihood of admission for a set of common presenting complaints.MethodsData were collected over a four-month period from the EDs of seven urban tertiary care hospitals in Pakistan. The variables included age, sex, hospital type (government run vs. private), presenting complaint, ED vital signs, and final disposition. Patients who were >12 years of age were included in the analysis. The data were analyzed to describe the proportion of patients with documented vitals signs, which was then crossed-tabulated with top the ten presenting complaints to identify high-acuity patients and correlation with their admission status.ResultsA total of 274,436 patients were captured in the Pakistan National Emergency Department Surveillance (Pak-NEDS), out of which 259,288 patients were included in our study. Vital signs information was available for 90,569 (34.9%) patients and the most commonly recorded vitals sign was pulse (25.7%). Important information such as level of consciousness was missing in the majority of patients with head injuries. Based on available information, only 13.3% with chest pain, 12.8% with fever and 12.8% patients with diarrhea could be classified as high-acuity. In addition, hospital admission rates were two- to four-times higher among patients with abnormal vital signs, compared with those with normal vital signs.ConclusionMost patients seen in the EDs in Pakistan did not have any documented vital signs during their visit. Where available, the presence of abnormal vital signs were associated with higher chances of admission to the hospital for the most common presenting symptoms.

Exploring injury severity measures and in-hospital mortality: A multi-hospital study in Kenya

INTRODUCTION Low- and middle-income countries (LMICs) have a disproportionately high burden of injuries. Most injury severity measures were developed in high-income settings and there have been limited studies on their application and validity in low-resource settings. In this study, we compared the performance of seven injury severity measures: estimated Injury Severity Score (eISS), Glasgow Coma Score (GCS), Mechanism, GCS, Age, Pressure score (MGAP), GCS, Age, Pressure score (GAP), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Kampala Trauma Score (KTS), in predicting in-hospital mortality in a multi-hospital cohort of adult patients in Kenya. METHODS This study was performed using data from trauma registries implemented in four public hospitals in Kenya. Estimated ISS, MGAP, GAP, RTS, TRISS and KTS were computed according to algorithms described in the literature. All seven measures were compared for discrimination by computing area under curve (AUC) for the receiver operating characteristics (ROC), model fit information using Akaike information criterion (AIC), and model calibration curves. Sensitivity analysis was conducted to include all trauma patients during the study period who had missing information on any of the injury severity measure(s) through multiple imputations. RESULTS A total of 16,548 patients were included in the study. Complete data analysis included 14,762 (90.2%) patients for the seven injury severity measures. TRISS (complete case AUC: 0.889, 95% CI: 0.866-0.907) and KTS (complete case AUC: 0.873, 95% CI: 0.852-0.892) demonstrated similarly better discrimination measured by AUC on in-hospital deaths overall in both complete case analysis and multiple imputations. Estimated ISS had lower AUC (0.764, 95% CI: 0.736-0.787) than some injury severity measures. Calibration plots showed eISS and RTS had lower calibration than models from other injury severity measures. CONCLUSIONS This multi-hospital study in Kenya found statistical significant higher performance of KTS and TRISS than other injury severity measures. The KTS, is however, an easier score to compute as compared to the TRISS and has stable good performance across several hospital settings and robust to missing values. It is therefore a practical and robust option for use in low-resource settings, and is applicable to settings similar to Kenya.

Development of an mHealth trauma registry in the Middle East using an implementation science framework.

ABSTRACT Background: Trauma registries (TRs) play a vital role in the assessment of trauma care, but are often underutilized in countries with a high burden of injuries. Objectives: We investigated whether information and communications technology (ICT) such as mobile health (mHealth) could enable the design of a tablet-based application for healthcare professionals. This would be used to inform trauma care and acquire surveillance data for injury control and prevention in Oman. This paper focuses on documenting the implementation process in a healthcare setting. Methods: The study was conducted using an ICT implementation framework consisting of multistep assessment, development and pilot testing of an electronic tablet-based TR. The pilot study was conducted at two large hospitals in Oman, followed by detailed evaluation of the process, system and impact of implementation. Results: The registry was designed to provide comprehensive information on each trauma case from the location of injury until hospital discharge, with variables organized to cover 11 domains of demographic and clinical information. The pilot study demonstrated that the registry was user friendly and reliable, and the implementation framework was useful in planning for the Omani hospital setting. Data collection by trained and dedicated nurses proved to be more feasible, efficient and reliable than real-time data entry by care providers. Conclusions: The initial results show the promising potential of a user-friendly, comprehensive electronic TR through the use of mHealth tools. The pilot test in two hospitals indicates that the registry can be used to create a multicenter trauma database.

Work related injuries in Qatar: a framework for prevention and control

Work related injuries (WRIs) are a growing public health concern that remains under-recognized, inadequately addressed and largely unmeasured in low and middle-income countries (LMIC’s). However, even in high-income countries, such as those in Gulf Cooperating Council (GCC) like Qatar, there are challenges in assuring the health and safety of its labor population. Countries in the GCC have been rapidly developing as a result of the economic boom from the petrochemical industry during the early seventies. Economic prosperity has propelled the migration of workers from less developed countries to make up for the human resource deficiency to develop its infrastructure, service and hospitality industries. Although these countries have gradually made huge gains in health, economy and human development index, including improvements in life expectancy, education, and standard of living, there remains a high incidence of work-related injuries especially in jobs in the construction and petrochemical sector. Currently, there is scarcity of literature on work-related injuries, especially empirical studies documenting the burden, characteristics and risk factors of work injuries and the work injured population, which includes large numbers of migrant workers in many GCC countries. This paper will focus on the current understanding of WRIs in those countries and identify the gaps in current approaches to workplace injury prevention, outlining current status of WRI prevention efforts in Qatar, and propose a framework of concerted action by multi-sectoral engagement.

Traumatic brain injury in Uganda: exploring the use of a hospital based registry for measuring burden and outcomes

ObjectiveLack of data on traumatic brain injuries (TBI) hinders the appreciation of the true magnitude of the TBI burden. This paper describes a scientific approach for hospital based systematic data collection in a low-income country. The registry is based on the evaluation framework for injury surveillance systems which comprises a four-step approach: (1) identifying characteristics that assess a surveillance system, (2) review of the identified variables based on adopted specific, measurable, assignable, realistic, and time-related criteria, (3) assessment of the proposed variables and system characteristics by an expert panel, and (4) development and application of a rating system.ResultsThe electronic hospital-based TBI registry is designed through a collaborative approach to capture comprehensive, yet context specific, information on each TBI case, from the time of injury until death or discharge from the hospital. It includes patients’ demographics, pre-hospital and hospital assessment and care, TBI causes, injury severity, and patient outcomes. The registry in Uganda will open the opportunity to replicate the process in other similar context and contribute to a better understanding of TBI in these settings, and feed into the global agenda of reducing deaths and disabilities from TBI in low-and middle-income countries.

PW 1038 Causes and outcomes of unintentional traumatic brain injury in uganda

Traumatic brain injury (TBI) is an important cause of morbidity and mortality especially in low-and-middle income countries (LMICs). The study objective was to assess causes and outcomes of intentional TBI among patients presenting to a tertiary-care hospital in Uganda. The study site was Mulago National Referral Hospital, Kampala, Uganda. Data was collected from May 2016-July 2017. Patients of all age groups presenting to emergency department of the hospital with suspected or documented TBI were enrolled. Patient demographics, TBI causes and outcomes were recorded. TBI was grouped into mild (13–15), moderate (9–12) and severe (≤8) categories based on Glasgow Coma Scale (GCS). Ethical approval was taken from Johns Hopkins School of Public Health and Makerere University. Out of 3749 patients with known intent, 30.3% (n=1135) had intentional TBI. Majority were males (84.5%); mean age was 28.5±14.5 years. Assault (97.1%) was the main cause, however, there were 33 (2.9%) cases of self-harm. Common assault methods were use of bodily force (33.7%), iron bar (24.2%) and hammer (12%). Gun was used in 3 cases. About 60.9% of these victims were breadwinners. 62.8% were in mild GCS category, 22.4% in moderate and 14.9% were in severe category. About 42.6% of the patients were admitted to ward, 37.1% were sent home. There were 30 deaths; 29 were assault victims and 1 of self-harm. Intentional TBI is common among young males in Kampala with assault being the main cause of TBI. TBI resulting from assault among young males in Kampala is an important cause of mortality and morbidity. This has consequences for LMICs like Uganda which has a young population contributing to a broad population pyramid. There is need for further exploration of intentional injuries among youth in the country and to develop programs to engage youth in productive activities for contribution towards country’s economic development.

SM 03-1640 Harnessing the potential of mobile technologies: mhealth applications for injury surveillance and control

The rapid proliferation of mobile technologies in low- and middle-income countries (LMICs) has generated considerable eagerness among researchers, donors, and implementers to employ these advances for improving the effectiveness and efficiency of public health programs. While mHealth innovations present promise for the field of injury prevention and control, their use in LMICs has largely been as part of pilot programs. In order to scale up the use of these innovations to improve reach, efficiency and effectiveness of injury prevention, control, and surveillance programs, we ought to examine the empirical evidence supporting their value in terms of diversity, performance. This 90-minute session will aim to highlight the use of mHealth approaches for different purposes in LMICs, such as data collection to understand risk factors for road safety, interventions for home-based child injuries, and hospital-based surveillance/registries. The presenters will share their experience with respect to the development, implementation, user satisfaction, strengths and challenges in resource-limited environments. The presentations will be followed by a moderated interactive discussion to highlight key lessons for the field and further opportunities to harness the potential of digital technology for injury prevention and control in LMICs. Program: Welcome and Overview of Nexus of Injury Research and mHealth Innovations: Dr. Adnan Hyder (10 min); Talks include ‘Establishing mHealth based trauma registries in LMICs: Implementation challenges’ by Dr. Amber Mehmood; (2) Roadside observational study of road safety risk factors using tablet-based data collection in Accra, Ghana’ by Francis Afukaar; (3) ‘mCHILD: A cell-phone based tool for the prevention of child injuries in the home environment’ by Dr. Abdulgafoor M. Bachani. Moderated panel discussion on ‘What are the future opportunities for large-scale mHealth based injury research?’

PW 1797 Digitizing data collection for roadside observational studies: the process and experience

The diversity of mobile-health (mHealth) applications has generated immense interest among researchers to test innovative ideas. To facilitate real time data collection in a roadside environment, mHealth tools were developed for population-level observational studies on three road safety risk factors: speed, helmet and seatbelt use. The digitization was employed to improve efficiency of the process through rapid aggregation and analysis, to enhance the quality of data through standardization, and to monitor adherence to protocols. The process involved: (1) selecting proper mobile data capture software application and a device; (2) setting up the server; (3) developing data collection forms; (4) deploying and pre-testing the forms; and (5) pilot-testing in the field. We selected KoBoToolbox software as it supports specific features of the data collection forms (capture of repeated vehicle-specific information). We use KoBoCollect app on Android tablets from where completed forms are sent to the secure cloud server. KoBoCollect forms were developed based on paper forms using XLM language. Digitizing has several advantages: KoBo supports data of all types (text, images, GPS); such features of the KoBo form as hints, constraints, required decrease the errors during data entry; XLM forms are easily customized and offer multilingual support; cloud server enables multi-location data collection; touch-screen Android tablets and simple KoBo app are easily adopted by users without special IT skills. mHealth-based apps enable access to ready-to-use data on hundreds-of-thousands of roadside observations in a short period of time. This eliminates the efforts of double data entry and data cleaning and thus proves to be cost-effective. On a larger scale, these benefits translate into improved quality and accuracy of data and overall efficiency of the process. This is especially important for the field of road safety where robust data essential for monitoring trends, developing effective interventions and assessing the progress, is required.