Caring for the Multiply - Injured:

Need to strengthen the Trauma Systems

Introduction to Trauma Registries

Amit Gupta
Professor, Trauma Surgery & Critical Care
 Greetings from AIIMS, New Delhi
09-11-2017
 JAI PRAKASH NARAIN APEX TRAUMA CENTER
AIIMS, New Delhi Estd. 2006

Level I - State of the art Trauma Research

Patient Care Design Systems
Trauma Education Role Model
Our aim is to provide state of the art, efficient and compassionate trauma care, from
resuscitation to rehabilitation, to all Acutely injured patients and those requiring its specialized
services. Develop patterns of teaching, training, research and preventive strategies related to
injury of highest standard.
09-11-2017
09-11-2017
 Road Safety - Killer Roads

4 Es
Engineering of Roads
Education of People
Enforcement of Laws
Emergency Medical Services

09-11-2017
 Injury Pyramid
Each Death ~ 30 Severely
Injured Patients
Will have considerable post injury
disability
Brain Injury, Spinal Injury,
Amputations
4 million

Each Death ~ 70 Non-Life

threatening and minor
Injuries
9 million
Transport related trauma Gururaj et al, NIMHANS, Bangalore

09-11-2017
 Silent Genocide
40 - 45%
Transport
related
Injuries

55 - 60%

Falls (pediatric/ old age group)

Work Place Trauma
Agricultural related trauma
Fire Arms, Intentional self harm
Assault, Fall of objects
Burns, Drowning
Natural Disasters
Terrorist Attacks
Possibility of NBC events
09-11-2017
 Very high mortality and morbidity (16
times) for the same Injury severity in India
as compared to western data
Primitive or no existence of TRAUMA SYSTEMS
Lack of dedicated Pre-hospital care
Absence of trained manpower in Pre-hospital; In-
hospital Acute trauma care and rehabilitation
Lack of Trauma related hospital data (registry) and
Trauma Quality improvement programs.

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09-11-2017
 Care of the severely Injured
Requires a broad framework of policies and
protocols in a given geographical area
Seamless transition between each phase of care,
integrating health resources
Team work between various agencies

Getting the right patient to the right

place at the right time for the right
care
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 Inclusive Trauma System or Trauma Care System

TRAUMA DATA COLLECTION

&
TRAUMA QUALITY IMPROVEMENT

09-11-2017
 National Trauma Policy Thrust Areas
Improvement in Health care Infrastructure at rural levels
Strengthen organizational aspect Establish Trauma Systems
Pre Hospital
Information Transfer and communications
Inter-facility Transfer
Protocol Development
TRAUMA CENTRES (26 Level I; 110 Level II; 260 Level III)
Trauma Education / Interest Generation
Pre-Hospital
Definitive Care
Rehabilitation
Evaluation and Research

09-11-2017
 Pre-hospital Care
Pre Hospital Care being
given by a private agency
with a common number
108
Adopted by 19 States and is
in different phases of EMS Body to govern and Audit
No Legislation/
Commissioning Sustainability??
ALS + BLS
Short Term Trained
personnel
Communications Center
with GPS enabled systems

09-11-2017
CAPACITY BUILDING Manpower Training
Manpower training through short term courses like:
ATLS (Doctors); ATCN (Nurses)
ATAM (Advanced Trauma Assessment & Mn. Course); NTMC (National Trauma
Management Course)
PHTLS, AUTLS
Empowering Bystanders: Trauma First Responder (TFR) &
AIIMS BECC
Rural Trauma Team Development Course
Long Term Capacity building:
M.Ch. (Trauma Surg. & Critical Care)
MS (Traumatology & Surgery MCI)
DM (Trauma Intensive Care)
Various Fellowships in Spinal Trauma/ Pelvic Trauma etc.
M.Sc. (Trauma & Emergency Nursing)
09-11-2017
 Other Activities
Rehabilitation Centers
4 Regional
35 State Level (One in Every State/ UT)
Activities for data collection and injury prevention
related research
National Injury Surveillance Center (RML Hospital)
Initiation of Nodal Trauma Registries Research Mode
(JPNATC/ AITSC/ ICMR)
Networking of Regional and formation National Trauma
Database
Public awareness activities for Injury Prevention
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 Multipronged Approach

09-11-2017
 TRAUMA SERVICES
Care of Injured Patient

ACUTE CARE

=
IN HOSPITAL IN HOSPITAL
DEFINITIVE
CARE

TRAUMA CENTRE
Acute Rehab.
(Physical and
Neuro)

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 Dedicated
Trauma
Service
& Surgeons
Teaching Community
and Outreach
and
Training
Public
interest
TRAUMA
CENTER
Trauma
Quality
Research and
Performance
Improvement
Trauma
Registry

09-11-2017
 TRAUMA CENTRE

IS AN
ORGANIZATIONAL CONCEPT
AND NOT AN
INFRASTRUCTURAL CONCEPT
09-11-2017
 Components of Trauma System

Structure
Physical Resources
Infrastructure
Equipment and
Technology

Structure
Human
Resources
Staffing and
Training
Processes
Organization
Administration
Protocols

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 Patient load
Emergency Department footfall
60000 56987
62308 66654 66982
52992
59158
50000 55698 47138 47104
43230
49894
40000 38217

Red
30000
Yellow
Green
20000
15672

8729 9365 8780

10000 6200
5363
3103 3240 3116 4304 4206
2948

0
2011 2012 2013 2014 2015 2016

Multiple Casualty Incidents 15-20/yr

09-11-2017
 Patient load
Follow Up OPD
40000 37926
36383
35000
31216 30616
30000
26910 26096
25000

20000

15000

10000

5000

0
2011 2012 2013 2014 2015 2016

09-11-2017
 Patient load
Total Admissions
5500

5400
5408
5300 5373
5200 5254
5100
5192

5000

4900
4930
4800
4814
4700

4600

4500
2011 2012 2013 2014 2015 2016

09-11-2017
 Patient load
Major Surgeries Performed Annually
7000

6000 5773 5656

5383 5437
5000 4805
4541

4000

3000

2000

1000

0
2011 2012 2013 2014 2015 2016

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 TRAUMA CENTRE
TRAUMA
INFRASTRUCTURE
DEDICATED
Resuscitation
TRAUMA
Unit
CRITICAL CARE
Trauma ED
IN HOSPITAL IN HOSPITAL
ACUTE CARE DEFINITIVE TRAUMA NEURO
Radiology Blood CARE
Bedside X- CRITICAL CRITICAL
Ray, USG
Bank +
and CT Em. Lab. CARE CARE
Acute
Rehab.
Radiology Blood
Interventional (Physical Laboratory
Including
Radiology +/- and Neuro) Bank Medicine
Intervention

Immediate or IN PATIENT
Emergent PHYSIOTHERAPY
WARDS
Operating UNIT
NS, TS and
Room Physical, Chest and
Ortho
Neuro Rehab.
Forensic
Till patient in
Forensic
Services Trauma Center Services

09-11-2017
 Trauma Emergency Department
PATIENT FLOW

4
Red Area Yellow Area Green Area
Compromised Stable ABCD Minor Injuries
ABCD with Major Injury Major Injury with stable ABCD
Architectural Triage

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 ED Equipment
RED AREA YELLOW AREA GREEN AREA

Resuscitation Monitoring and Treatment of cuts

Monitoring and Stabilization of bruises and Minor
Emergent Surgical Injuries Injuries
Procedures

Resuscitation Carts Resuscitation Carts Suturing/ Dressing

Adult / Pediatric Adult / Pediatric Basic Monitoring
Multi-parameter Monitors Multi-parameter Monitors Splints
Defibrillators Surgical Trays Plaster room
Transport Ventilators ICD/ Suturing/ SPC etc. X-Ray room
Surgical Trays IV Fluids Disposables and
ICD/ Suturing/ SPC etc. Warmers Consumables
IV Fluids X-Ray room
Warmers Splints
Portable USG for FAST Plaster room
Portable X-Rays (CXR+Pelvis) Disposables and
Disposables and Consumables
Consumables

09-11-2017
 ED Manpower
RED AREA YELLOW AREA GREEN AREA

Resuscitation Monitoring and Treatment of cuts

Monitoring and Stabilization of bruises and Minor
Emergent Surgical Injuries Injuries
Procedures

Senior Resident Doctors Senior/ Junior Resident Suturing/ Dressing

General Surgery
Emergency Physicians
Orthopedics frequent
rounds
Neurosurgery frequent
rounds
Red Area Nurses
Em./ OT Technicians
Hospital Attendants
Sanitary Attendants
Doctors Basic Monitoring
General Surgery Splints
Emergency Physicians Plaster room
Orthopedics X-Ray room
Neurosurgery frequent Disposables and
rounds Consumables
Yellow Area Nurses
Em./ OT Technicians
Hospital Attendants
Sanitary Attendants

24X7 FACULTY COVER (TS, ED, ORTH,NS,ANAEST, CRIT CARE)

09-11-2017
 Trauma ED Protocols
TRIAGE Protocols

RED AREA YELLOW AREA GREEN AREA

Resuscitation Protocols
According to Adv. Trauma Life Support or any other Intl. Protocols
Admission Protocols
No confusion Continuity of Care is maintained
Radiology Protocols
Right studies for the right patient
Interventional Radiology if required
Medico-legal and Transfer Protocols
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 Trauma Definitive Care

O
T

DISCHARGE

I
C
U
DEATH
TRAUMA ED

W
a
r
d

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 Trauma Definitive Care

Admitting departments Support Departments

Trauma Surgery Emergency Medicine
Neurosurgery Anesthesiology
Orthopedic Surgery Trauma Critical Care
Plastic and Reconst. Sx Neuro Critical Care

Other 24x7 Support Services

Radio-diagnosis with Interventional Radiology
Blood Bank
Lab Services & Infection Control
Forensics & Care of the deceased
 Trauma Operating Rooms
EMERGENT NON-EMERGENT
SURGERIES SURGERIES
ORTHOPEDICS NEUROSURGERY TRAUMA SURGERY PLAST/ RECON Sx

Anesthesiology and Pain Clinic Backup

09-11-2017
 Trauma Operating Room Protocols
EMERGENT NON-EMERGENT
SURGERIES SURGERIES

Damage Control Surgery Protocols

Massive Blood Transfusion Protocols
Anesthesiology Protocols
Damage Control Resuscitation
Protocols for regional Anesthesia
Any other definitive Surgical Protocols of Individual specialties

09-11-2017
 Trauma Critical Care Units
Trauma Surgery & Neuro-trauma
Critical Care ICU ICU

Sufficient Critical Care Manpower 24x7

ICU Protocols

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 Other Critical Support Departments
Basic Lab
Radiodiagnosis Blood Bank
Medicine

Trauma Blood Protocols

Emergent
Urgent
Massive Transfusion Protocols

09-11-2017
 Nursing Empowerment &
New Nursing Paradigms
Trauma Nurse Coordinators
Coordination amongst various services
Quality Control
Injury Surveillance & Registry Data
Teaching & Training
Wound Care Nursing
Dedicated wound surveillance
Wound care (Out/ In patient services)
Teaching & Training
Hospital Infection Control
Infection Surveillance and Control
Teaching and Training
Nursing Informatics
Centre-wide Computerization
New IT Solutions
IT Teaching and Training
Transplant Coordinators

09-11-2017
 Teaching and Training Facilities

Advanced Trauma Skills

and Simulation Facility
(ATSSF)

Cadaveric Training and

Research Facility (CTRF)

Seminar Room
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 Teaching and Training
Short Term Courses
International Courses
ATLS (Advanced Trauma Life Support course)
ATCN (Advanced Trauma Care for Nurses)
AUTLS / Em-SONO (AIIMS Ultrasound Trauma Life Support)
PHTLS (Pre-Hospital Trauma Life Support)
RTTDC (Rural Trauma Team Development)
AO Spine and Pelvis Trauma Courses
Indigenous Courses
Cadaveric Courses in N Sx/ Ortho/ Trauma Sx/ Plastic Sx
Basic and Advanced Pelvic Trauma Course
AIIMS BECC
AIIMS Trauma Assessment & Management Course (ATAM)
AIIMS Trauma First Responder Course (AIIMS TFR)
Management of Acute Wounds in Emergencies (MAWE)
Personality Development and Communication Skills
09-11-2017
 Teaching and Training contd..

Long Term Courses

M.Ch. In Trauma Surgery & Critical Care (3 Yr)
In-service Training of Doctors and Nurses from
Armed forces and States (6Wks- 2 years)
Training of Paramilitary Doctors/ Nurses/
Paramedics (2 6 weeks)
In Pipeline
Fellowship in Pelvis & Acetabular Trauma
Fellowship in Spinal Trauma
09-11-2017
 Trauma Quality
and
Performance
Teaching Improvement Trauma Registry
and Depersonalized
Training Outcome based

Community TRAUMA
Outreach CENTER Research
Primary Prevention
Organ Donation

09-11-2017
DEVELOPMENT OF A HOSPITAL BASED
INJURY SURVEILLANCE
&
TRAUMA REGISTRY
AT
JPN APEX TRAUMA CENTER, AIIMS
 WHERE IS THE DATA COMING FROM

MORTALITY DATA

NATIONAL CRIME RECORDS BUREAU

PROJECTIONS

09-11-2017
 HOSPITAL BASED DATA
NOT ONGOING
NO PROSPECTIVE OR PERMANENT DATABASE
MOST EFFORTS ADHOC PROJECTS
INJURY SURVEILLANCE

NO OUTCOME BASED DATABASE

NO INJURY SEVERITY

09-11-2017
 CONTRIBUTIONS TO EMERGENCY
MEDICINE RESEARCH

Trauma registries are valuable sources of

information that could potentially be used in
quality of care improvement, policy
development , injury prevention and clinical
and epidemiologic research for a variety of
specialities including emergency medicine.

09-11-2017
 BARRIERS TO EFFICIENT TRAUMA
REGISTRY
Little or no pre-hospital care
Non-availability of evacuation and
transportation system
Limited inter-hospital communication in case
of transfers.
Lack of standardized and uniform hospital
data formats
Limited availability of electronic data storage
and retrieval facilities
09-11-2017
 BARRIERS TO EFFICIENT TRAUMA
REGISTRY
Inadequate funding

Unfavourable government health policies

Inadequate census and population data

Lack of awareness in the communities.

09-11-2017
 BASIC ELEMENTS OF TRAUMA
REGISTRY
A trauma registry uses both computer software packages and
hardware for the collection, verification, storing and analysis
of data.
Defining a Trauma Patient
Inclusion/ Exclusion Criteria
Defining the Dataset
Extensive vs Minimal
Type of Data Collected
Confidentiality of Registry data
Data Validation and Quality
Report writing
09-11-2017
 APEX TRUAMA CENTER
WHO (Injury prevention group)
Multi-centric feasibility study on Injury Surveillance
To study the feasibility of injury surveillance and to identify
a model for sustained data collection, analysis and
reporting.
Retrospective Data Collection
On a data collection format finalized by the AIIMS team in
line with the prescribed WHO Injury Surveillance performa
Retrospective Data collected from Medico-legal Registers,
and Autopsy registers
Data collected from
1st Jan 2005- 30th June 2006

09-11-2017
 LESSONS FROM PILOT STUDY
Hospital Injury surveillance is feasible and can
give a variety of information regarding injury
patterns in hospital patients
The retrospective study has guided us
Incorporation of more variables in the MLRs
Formulations of in-hospital injury surveillance and
registry format was developed
Point of data entry into such a performa was defined
Electronic data storage and data archiving platform
was developed
Difficulties

09-11-2017
 DEVELOPMENT OF A HOSPITAL BASED
TRAUMA REGISTRY AT JPN APEX TRAUMA
CENTER
The JPNATC Trauma registry started its preliminary
data collection from April 2009

Initially the Inclusion criteria had been kept as all

those patients who were admitted to the Apex
Trauma Center

From March 2010 the Inclusion criteria also has

added all yellow tagged (triaged) patients in the ED
09-11-2017
 CURRENT REGISTRY INCLUDES
Basic Identification data
Unique Hospital number
Demographic profile
MLC/ Non-MLC
Detailed Event description (not coded by ICD 10 at present)
Description of brought by personnel and vehicle (eg. Trained v/s Untrained;
Ambulance v/s Non-Ambulance)
Direct attendance or Referred case
Condition at time of arrival (including physiological parameters)
ED Interventions performed
Detailed Diagnosis (coded as per AIS 2005 Update 2008) (Coding as per
ICD10 not yet started)
Definitive Surgeries/ Procedures
Disposition/ Outcome (Discharge/Death/ LAMA/ Abscond etc.)

09-11-2017
 WHO COLLECTS THE DATA??
Trauma Nurse
Coordinators
ED Data

In hospital course

Disposition

09-11-2017
 HOW IS IT STORED??
Hard Copy
TRAUMA REGISTRY FORMS

Development of Software to enter data into

an electronic format
Separate Server for Registry (confidentiality
issues)
5 Thin clients (entry points)

09-11-2017
 Trauma Form

09-11-2017
09-11-2017
 TITCO
Towards improved trauma care outcomes in
India
Karolinska Instituet, Sweden
Tata Institute of Social Sciences
JPNATC, Delhi
LTMMC, Mumbai
Chennai
Kolkata
Srinagar

09-11-2017
 Reducing the burden of injury in India and Australia through development
and piloting of improved systems of care

TRAUMA REGISTRY WITH NATIONAL MINIMAL

DATASET IS ONE OF THE GOALS OF THE PROJECT

Research Project will run for the next four years

Try to find the best ways of delivering needed care to injured people
09-11-2017
 Early streamlining existing trauma registries
within India
Shared Indian Trauma Registry

Benefits
More efficient data
collection
Improved data quality
Better data utility
More secure data
 Registry Development
Pre-pilot: >130 variables

Post-pilot: 81variables

Consistent with WHO MDS

Provides information for AITSC interventions

Good data quality

 AITSC Trauma Registry
Inclusion Criteria
Minimum data set Patients presenting with injury (including
81 data items (core and intervention) near-drowning) as the primary diagnosis
Extracted from records, some observed and with at least one of the following
data items criteria:
a.Admission to hospital
Screening Criteria b.Death after triage but before
Patients presenting a potentially life- admission
threatening or limb-threatening injury
Specifically patients triaged as Red or
Exclusion Criteria
Yellow according to AITSC Trauma
Triage Protocol a.Death at scene
b.Alive at triage but not admitted to
hospital
c.Isolated poisoning
d.Isolated burns
e.Single digit finger or toe amputations
09-11-2017
 The dataset

Element number Element name

1 AITSC ID
2 Hospital ID
3 Data Collector
4 Observed
 Dataset
PRE-HOSPITAL DATA
5 Notification-date
6 Notification-time
7 Notifier
8 Blood Pressure
9 Pulse
10 Respiratory Rate
11 AVPU
12 Estimated arrival-date
13 Estimate arrival-time
14 Communicated to
15 Date trauma callout
16 Time trauma call out

17 Leader present on arrival

18 Trauma Bay ready
19 Documentation

09-11-2017
 Dataset
INJURY EVENT DATA
20 Injury Date
21 Injury Time
22 Injury Place
23 Injury Mechanism
24 Injury - Dominant type
25 Intent
26 Primary Vehicle
27 Patient role
28 Activity
29 Referring hospital
30 Mode of arrival

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 Dataset

DEMOGRAPHIC DATA
31 Age
32 Gender
33 Place of residence

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 Dataset HOSPITAL DATA
HOSPITAL DATA
34 Arrival date 48 VS1 - GCE-E
35 Arrival time 49 VS1 - GCS-V
36 Admission date 50 VS1 - GCS-M
37 Admission time 51 VS1 - GCS-Qualifier
38 Health record ID 52 ED Disposition
39 Ward(s) 53 ED Disposition-Date
40 Vital signs 1 - date
54 ED Disposition-Time
41 VS1 - time Type of Operating
42 VS1 - SBP 55 procedure

43 VS1 - HR 56 OP - Date

44 VS1 - RR 57 OP - Time commenced

45 VS1 - RR-Qualifier 58 Time of Chest X-ray

46 VS1 - SpO2 59 Time of CT
47 VS1 - O2 60 Type of CT
 Dataset
FOLLOW UP DATA
61 Incidents
62 Ventilation days
63 ICU stay - days
64 Hospital Disposition
65 Hospital Disposition-Date
66 Hospital Disposition-Time
67 Region of body
68 Free text
69 Sourced from
70 Severity
71 AIS-Code
72 ICD-10

09-11-2017
 Trauma registry form

09-11-2017
 Registry software
The JPNATC/AIIMS team has developed a web-based software platform, which is in now
ready to use in ED set up for registry data collection

09-11-2017
 Results
Registry has collected data from over 7000 patients at
the 4 sites
Some challenges include limitations to direct
observation data collection (especially during peak
hospital times), and low (but improving) rates of pre-
hospital and patient arrival data items.
High data completeness at 99.8 %
Intriguing data collected relating specifically to the
locale. Including prehospital care, injury mechanism,
admission demographics and hospital systems
Report of first year will be available by the end of 2017

09-11-2017
 Data Completeness
0.2 % Null values
4.4 % Not Recorded or inadequately
described

95.4 % Full data completion

Percentage of data completeness for data items 1 to 81,

comprising of full mean completeness, not recorded or
inadequately described and null values

09-11-2017
 Registry Results

Figure 1: All Trauma admissions by Age Group stratified by gender (n=5301).

09-11-2017
 Registry Results Mechanism of
Injury

Figure 2: Pie chart of common injury

mechanisms by independent sites.
Excluding null or unknown data. Sites
are anonymous and in no specific
order. n=5282

09-11-2017
 4.5 Admissions and deaths in Road transport accidents

Fig: Percentage admissions in

RTI admissions Fig: Percentage Deaths in RTI
admissions

73

09-11-2017
 5.1 Body Regions Injured for all sites
Head n=6772 36%

Face n=2476 13%

Neck n=119 1%

Thorax n=1633 9%
Spine n= 821 4%
Abdomen n=1085 6%

Upper n=2269 12%

Extremities
Lower n=3609 19%
Extremities
External n=14 0.1%

Notes Body region data were derived from the first number in AIS codes

Exceptions N= 18798 74

09-11-2017
 Steps in Reaching the Quality Goal
GOAL

Quality
Trauma
Care
External
Benchmarking
/Accreditation
Monitor &
Analyze
Monitor & Outcomes
Analyze
Processes

Amit Gupta, JPNATC, AIIMS

Monitor &
Analyze
Efficient Trauma
Trauma Structure
Care
Optimal
Trauma
Care
Basic
Trauma
Care Across the System (Pre-Hosp In-Hosp. Post-Acute Care)
09-11-2017
 Quality Trauma Care
The way forward

Trauma
GOAL
Registries
Existing Hosp. Data
Quality
Trauma
Care
External
Govt. Benchmarking
Process Policy makers /Accreditation
Stakeholders Monitor &
Incorporation Analyze
Structure of Protocols Monitor & Outcomes
and Processes Analyze
Manpower Monitor & Processes
Training Analyze
Specialist Trauma
Provision of Cadre Efficient
Trauma Structure
Infrastructure
Care
at all levels Optimal
Trauma
Care
Basic
Trauma
Care
Across the System (Pre-Hosp In-Hosp. Post-Acute Care)
09-11-2017
09-11-2017