Isaac Botchey

Vascular access modifies the protective effect of obesity on survival in hemodialysis patients.

BACKGROUND The protective effect of obesity on the survival of patients undergoing hemodialysis (HD) for end-stage renal disease (ESRD), described as the obesity paradox, has been established previously. Survival benefits also have been ascribed to permanent modes of HD access (fistula/graft) compared with catheter at first HD. The purpose of this study is to evaluate the impact of incident HD access type on the obesity paradox. METHODS A retrospective study of all patients with ESRD in the US Renal Database System who initiated HD between 2006 and 2010 was carried out. Multivariate logistic, Cox regression, and propensity score matched analyses were used to evaluate the association between body mass index (BMI), modes of HD access (fistula/graft vs catheter), and mortality. RESULTS There were 501,920 dialysis initiates studied; 83% via catheter, 14% via fistula, and 3% via grafts. Mortality was lesser for patients initiating hemodialysis with permanent forms of access compared with catheter (adjusted odds ratio 0.68, 95% confidence interval 0.67-0.69, P < .001). High body mass index (BMI) was associated with lower mortality. Patients with high BMI were more likely to initiate hemodialysis via permanent modes of access compared with patients with normal BMI. CONCLUSION The highly popularized protective effect of increased BMI on survival in HD patients is significantly influenced by the method of hemodialysis access. There is greater use of permanent access among patients with high BMI compared with patients with normal BMI. There remains a critical need to increase permanent access utilization at incident hemodialysis so as to improve survival irrespective of BMI status.

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.

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.

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.

PW 1644 Emergency medical systems in low- and middle-income countries: the need, the experience, and the way forward

Low- and middle-income countries (LMICs) are now facing a triple burden of injuries, communicable, and non-communicable diseases. LMICs generally, and poor people in individual countries are particularly at the risk of higher burden of injury and adverse outcomes from a variety of acute and life-threatening conditions. The odds of dying due to injuries is six-times higher in the absence of a well-organized and coordinated Emergency Medical System (EMS). Research has demonstrated that EMS could significantly reduce morbidity and mortality from road traffic injuries, acute cardiovascular diseases, sepsis and obstetrical complications. Despite the high burden and increased risk of death from injuries, the availability and quality of EMS in LMICs are extremely variable. This session will highlight the state of EMS in three different LMICs, describing the needs, challenges and priorities in the format of case studies. This two-hour symposium aims to put forward a compelling narrative of the cross cutting role of EMS in strengthening emergency and trauma care to inform and promote current and future strengthening of EMS in LMICs. 10 min Welcome and Overview of Emergency Medical Services in LMICs: Dr. Adnan Hyder 25 min ‘It’s hard to get an ambulance’- Findings of an assessment of the Emergency Medical System in Kampala, Uganda using Health systems framework: Dr. Amber Mehmood, JH-IIRU 25 min Towards a better emergency care: Evolution of Emergency Medical Services Policy in Kenya: Dr. Isaac Botchey, JH-IIRU 25 min Overview of Emergency Medical Services in Pakistan: A comparison of public and private run services: Dr. Razzak Junaid, Department of Emergency Medicine, Johns Hopkins 20 min Steps forward: Are there any ‘best models’ for Emergency Medical Services in low-resource settings? Dr. Olive Kobusingye Makerere University School of Public Health 15 min Discussion/Question and answer session. Dr. Adnan Hyder.

PW 2269 Characteristics and determinants of speeding in the city of accra, ghana: implications for road safety monitoring and evaluation

Background Road Traffic Injuries (RTI) is the 19th leading cause of disability-adjusted life years in Ghana, and this burden translates into 1.68% of total disability-adjusted life years. Speeding has been identified as a major risk factor for RTI in Ghana. Despite the public health significance of road traffic injuries in the Greater Accra region, little information is known about the determinants of speeding in the city. The overall objective of this study was to assess the characteristics and determinants of speeding in the city of Accra. Methods Five rounds of speed observational studies were obtained from six randomly selected locations representative of the city of Accra. Descriptive statistics and multivariable logistic regression models were used to determine the characteristics and risk factors for speeding. Results Out of the 86 619 vehicles observed, 73.3% were observed to be driving above the posted speed limit. Disaggregated by the day of the week, the speeding rate was higher on weekends than weekdays in all rounds (74.3% vs 72.8%). When disaggregated by vehicle ownership, there were significant differences in the prevalence of speeding. The highest prevalence was observed among private, government and taxi ownership. The mean speed for all vehicles was 67.1 km/hr. and 84.3 km/hr. respectively on roads with a posted speed limit of 50 km/hr. and 80 km/hr. Predictors of posting above the speed limit were traveling on weekends, SUV/4WD vehicles and traveling on a road with a speed limit of 50 km/hr. Vehicles were less likely to post above the speed limit if there was the presence of law enforcement, a road with a posted limit of 80 km/hr., and large trucks vehicles. Conclusion There is an urgent need for a comprehensive multi-sectoral intervention strategy to address speeding in Accra. Such interventions should focus on enforcement, road design, and social marketing campaigns.

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.

869 Road traffic injuries in kenya: a hospital-based surveillance study

Background Road Traffic Injuries (RTIs) are a leading cause of disability and mortality worldwide with a disproportionate burden in Low-and Middle-Income Countries (LMICs). RTIs account for 3.6 percent of the global mortality burden [1]. Additionally, the risk of death from injuries in LMICs is six times more likely than in High Income Countries (HICs)[2]. RTIs are estimated to be the fifth leading cause of disability-adjusted life-years (DALYs) lost by 2030 worldwide[3]. Data defining the burden of injury, risk factors and outcomes of RTIs in LMICs are limited. Our study analyses RTIs seen in the casualty departments at four regional referral hospitals in Kenya. Methods Electronic-based trauma registries were developed at four regional hospitals in Kenya: Kenyatta National, Thika, Meru and Machakos. Information on mechanism of injury, injury severity, patient outcomes, and patterns of care (pre-hospital and hospital-based) was collected prospectively between January 2014 to September 2015. Results A total of 6429 patients were enrolled. Patients were predominantly male (78.5%), young (median age 27.6 years) and arrived mainly by car/taxi (49.4%), mini bus (18.9%) or an ambulance (16.2%). Injuries were common amongst pedestrians (40.8%) and passengers (36.7%). Seatbelts were used by 7.2% of passengers. Body regions most commonly injured were the extremities (54%) and head (22.7%). The overall mortality rate was 2.2%. Predictors of RTI deaths were moderate head injury [GCS 9–12] (OR 6.4, 95% CI: 4.0–10.1), severe head injury [GCS ≤ 8] (OR 71.5, 95% CI: 49.7–102.8), moderate ISS [ISS 9–15] (OR 3.6, 95% CI: 2.5–5.1) and severe ISS [ISS > 15] (OR 9.4,95% CI: 5.7–15.2). Conclusions RTIs contribute significantly to the burden of disease in Kenya. A renewed focus on addressing this burden through the development of a trauma care system is necessary. Trauma registries can be used as a plausible tool to identify priority areas for quality improvement and injury prevention.

31 Developing and evaluating trauma care systems in low- and middle-income countries (LMICs): experiences in africa

Background Injuries kill more than 5 million people around the world each year. More than 90% of these deaths occur in low- and middle-income countries (LMICs), and road traffic injury (RTI) is the most common mechanism of fatal injury, with an estimated 1.24 million deaths per yea. RTI fatality rates are two to three times higher in LMICs than in high-income countries (HICs), due to a variety of factors including differences in road construction, vehicle conditions, and the existence and enforcement of laws regulating safety behaviours. An additional factor is the lack or poor quality of trauma care systems in many LMICs. As a consequence, fatality rates for the moderately and severely injured are more than 50% higher in LMIC than in the United States, and an estimated 1.73 million lives could be saved each year if trauma care capabilities could be brought to par with those of HICs. Moderator Dr. Adnan A. Hyder, Johns Hopkins International Injury Research Unit (JH-IIRU, USA) Welcome and overview of trauma in low- and middle-income countries – Dr. Adnan A. Hyder, Johns Hopkins International Injury Research Unit, USA Talk 1: Efforts to improve the care of the injured in Kenya – successes and struggles – Dr. Isaac Botchey, Johns Hopkins International Injury Research Unit, USA Abstract: Kenya is a LMIC in East Africa with a population of 40 million people. Injury is the second leading cause of death after HIV/AIDS in Kenya and the number of people injured is on the rise. There is a lack of coordinated, integrated pre-hospital, hospital and rehabilitative care in Kenya. The Bloomberg Philanthropies Global Road Safety Program (BPGRSP) was a five-year, ten-country effort to reduce the mortality associated with RTIs. The goal of the Johns Hopkins International Injury Research Unit’s (IIRU) trauma care activities in Kenya was to improve the care of the injured through a systematic, multi-faceted, evidence-based approach. A literature review and a trauma system profile was performed based on which a nine point plan was set to achieve our objective. The nine-point plan was centred on stakeholder engagement, trauma registry development and implementation; pre-hospital and hospital care training as well as strengthening of trauma-care legislation. Talk 2: Role of trauma registries to improve quality of care in developing countries – case studies from three different settings – Dr. Amber Mehmood, Johns Hopkins International Injury Research Unit, USA Abstract: Trauma registries play an important role in performance improvement and hospital-based injury surveillance. Case studies from Pakistan, Kenya and Kampala are presented with details about inclusion, exclusion criteria, data collection platform, implementation model, funding sources and stakeholder engagement. All three registries used electronic platforms, however implementation strategies differed. Dedicated trauma registry personnel results in reliable capture of cases, complete follow up of patients and better quality of data but has higher cost of operation. Trauma registries not only helped in measuring hospital injury burden but also helped documenting the care processes with potentially impactful solutions. Implementation of trauma registries may cause both direct and indirect positive impact on trauma care in the hospital regardless of method of implementation. Long term and sustainable impact could only be seen with strong support from key hospital administrators. Talk 3: Developing an internet-based traumatic brain injury registry in Uganda – Dr. Olive Kobusingye, Makerere University School of Public Health, Uganda Abstract: The primary aim of this review was to define core variables for an internet-based data registry focused on TBI in Uganda. A comprehensive review was conducted. Six databases including PubMed/Medline, Embase, Scopus, Cochrane Reviews, System for Information on Grey Literature and Global Health Ovid were searched for literature pertaining to TBI in the African region and TBI registries in low-and middle-income countries. Thirty-five articles were identified as relevant to the focus of inquiry. The majority of the articles were from Nigeria, followed by South Africa and Tunisia. Few included definition used to define TBI. The most commonly collected core variables were demographics, injury event, initial assessment, emergency department care, in-patient care and outcome at hospital discharge. Discussant: Steps forward: what are the best “systems” to care for the injured in low-resource settings -- Dr. Junaid Razzak, Johns Hopkins International Injury Research Unit, USA Q&A -- Dr. Adnan A. Hyder, Johns Hopkins International Injury Research Unit, USA

785 Development of a national EMS policy for Kenya: opportunities for action

Background Emergency Medical Services (EMS) are a community’s gateway to acute and emergency medical care for members of the public facing time-sensitive, critical illness and injury.1 A functional EMS is an effective, frontline intervention to reduce the disproportionately high morbidity and mortality in Low- and-Middle Income Countries (LMICs).1–3 The World Health Organisation and the African Federation for Emergency Medicine have promoted the formation of locally appropriate EMS systems in LMICs.1–4 Description of the problem Under article 43 of the Constitution of Kenya “a person shall not be denied emergency medical treatment.” However, recent events including floods and the Westgate terrorism attack have revealed a low-functioning system for care of the injured in Kenya. There is extensive variability in the level of care provided at the pre-hospital setting due to the absence of national standards in training of personnel, available equipment and infrastructure. Furthermore, emergency rooms in the public health facilities are often poorly resourced to deliver definitive emergency care. Results In 2012 and 2013, Johns Hopkins International Injury Research Unit, CDC-Kenya and the Ministry of Health brought together local EMS stakeholders to form a consortium. Members were tasked with creating a locally appropriate EMS Policy. In 2015, a comprehensive policy that recognises pre-hospital care as a component of the healthcare system was developed. It establishes a regulatory body for EMS, defines minimum training and equipment standards and mandates data reporting for quality improvement. Conclusions The development of a locally appropriate EMS policy requires consensus and extensive stakeholder engagement. The implementation of this policy will provide the opportunity for definitive emergency care as stipulated in the national constitution and serve as a model for EMS development in LMICs. References Kobusingye OC et al. Emergency medical systems in Low-and middle-income countries: recommendations for action. Bulletin of the World Health Organization 2005;83:626–31 Razzak JA and Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bulletin of the World Health Organization 2002;80:900–905 Henry JA and Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta-analysis. Journal of trauma and Acute Care Surgery 2012;73:261–268 Calvello E et al. Emergency care in sub-Saharan Africa: Results of a consensus conference. African Journal of Emergency Medicine 2013;3:42–8