|Year : 2022 | Volume
| Issue : 4 | Page : 199-204
Epidemiology and clinical features of injuries at the shahid beheshti hospital, Kashan, Iran: A report from the national trauma registry of Iran
Hamid Reza Jahantigh1, Payman Salamati2, Mohammadreza Zafarghandi2, Vafa Rahimi-Movaghar2, Esmaeil Fakharian1, Mohammad-Sajjad Lotfi1, Seyed Mohammad Piri2, Moein Khormali2, Khatereh Naghdi2, Somayeh Bahrami2, Vali Baigi2
1 Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
2 Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
|Date of Submission||09-Apr-2022|
|Date of Decision||25-Dec-2022|
|Date of Acceptance||28-Dec-2022|
|Date of Web Publication||28-Feb-2023|
Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Background and Objectives: Trauma is a prominent reason for morbidity and death in Iran. The objective of this study was to provide epidemiological and clinical features of the injured patients admitted to one of the collaborating centers of the national trauma registry of Iran (NTRI). Materials and Methods: The study was carried out at the one NTRI center from March 25, 2017, to November 20, 2020. Patients who had the NTRI criteria were included in the study. Data comprised demographics, injury information, prehospital and in-hospital information, procedures, International Classification of Diseases 10 codes, diagnoses, injury severity, and outcomes. Results: Overall, 4043 trauma patients were included in the trauma. Of whom, 3036 (75.0%) were men. There was a statistically significant association between the cause of trauma and the severity of the injury. The post hoc test results demonstrated that the percentage of the injury severity score (ISS) ≥9 in patients with falls was higher than in patients with road traffic injuries (RTI) (26.9% vs. 16.8%, P = 0.01). The univariable and multiple logistic regression analyses showed statistically significant associations between age ≥65, cause of trauma, years of school, and ISS ≥9 with intensive care units (ICU) admission. After adjusting for age and cause of trauma, the odds of ICU admission in patients with ISS ≥9 were 6.23 times more than in patients with ISS <9 (odds ratio = 6.23, 95% confidence interval [4.92–7.88]). Conclusion: The odds of ICU admission were higher in older patients (age ≥65), lower educated patients, patients with falling, and severe injuries.
Keywords: Fall, injuries, injury severity score, road traffic injuries, trauma registry
|How to cite this article:|
Jahantigh HR, Salamati P, Zafarghandi M, Rahimi-Movaghar V, Fakharian E, Lotfi MS, Piri SM, Khormali M, Naghdi K, Bahrami S, Baigi V. Epidemiology and clinical features of injuries at the shahid beheshti hospital, Kashan, Iran: A report from the national trauma registry of Iran. Arch Trauma Res 2022;11:199-204
|How to cite this URL:|
Jahantigh HR, Salamati P, Zafarghandi M, Rahimi-Movaghar V, Fakharian E, Lotfi MS, Piri SM, Khormali M, Naghdi K, Bahrami S, Baigi V. Epidemiology and clinical features of injuries at the shahid beheshti hospital, Kashan, Iran: A report from the national trauma registry of Iran. Arch Trauma Res [serial online] 2022 [cited 2023 Mar 27];11:199-204. Available from: https://www.archtrauma.com/text.asp?2022/11/4/199/370795
| Introduction|| |
Trauma is a prominent reason for morbidity and death in Iran.,,, Furthermore, traumas represent the cause of 10% of fatalities globally, and specifically, more than 90% of the global injury problem occurs in low- and middle-income countries.,, The trauma registry is one of the best tools for evaluating injuries in any community. This approach can be traced back to the ancient Egyptians., However, the modern era of trauma registries appeared in the United States of America in 1970, and its first purpose was to highlight the epidemiological factor of trauma., In addition, since one of the main objectives of trauma registries is to improve the care of injured patients, they provide information for medical scientists who cannot be addressed with management information systems. It has been shown that trauma systems enhance surviving levels of multi-traumatized patients and trauma registries represent an indispensable and essential part of these systems.
Until now, most hospitals in Iran have consistently documented utilizing the health information system (HIS). Still, there are significant discrepancies in the material and sources of registries. Although hospital administrative and medical records allow access to restricted data on injury patients, they often need more extensive information and necessary elements to educate continuously and potentially straight treatment and drive high-quality improvement. Concerning these conditions and regarding the trauma registry's advantages, the Ministry of Health and Medical Education of Iran supported enhancing the establishment of the national trauma registry of Iran (NTRI) in different centers. Trauma registries typically include information on individual demographics, the conditions of injury, prehospital care and transportation, and in-hospital treatments. This system can assess and create high-quality care, medical standards, and injury prevention plans. Developing local trauma platforms in the United States,, the UK, and Norway have enhanced severe trauma monitoring in these nations.
In Iran, NTRI was developed in 2016 at the Sina Trauma and Surgery research center (STSRC), Tehran, Iran. Since then, fourteen trauma centers in various states have signed up with the NTRI project, and a couple of qualitative and measurable studies have been accomplished to examine multiple facets of the project, for example, its minimal dataset and its inclusion criteria, and to illustrate the outcomes based upon information accumulated for NTRI throughout the pilot stage at STSRC.,
The objective of this study was to evaluate prehospital and hospital data from Shahid Beheshti Hospital in Kashan, Iran, as one of the NTRI collaborating centers.
| Methods|| |
The NTRI is a hospital-based multicenter registry across the country. Shahid Beheshti Hospital, located in Kashan, Iran, is an NTRI collaborating center that admits injured patients. It is a government-funded teaching hospital and the biggest referral hospital in Kashan city. Kashan is a city stationed in the center part of the Islamic Republic of Iran, with inhabitants of around 500 000. The data were collected prospectively from March 25, 2017, to November 20, 2020.
Patients with one or more traumatic injuries and one of the following inclusion criteria were included in the NTRI: (1) Hospital length of stay (HLOS) 24 h or more and (2) Patients with HLOS of <24 h that deceased after being admitted to the hospital or were transferred from intensive care units (ICU) of other hospitals to the NTRI collaborating centers.
The data were gathered via a face-to-face interview with patients or guardians and by reviewing their medical records. It included the demographics information, different cause of trauma (road traffic injury, falling, blunt force, stab/cut), prehospital status, patients' outcomes (length of the hospital stay, ICU days, ventilator days, discharge status, any fatality after hospital arrival), and damage severity information. Two dedicated and trained nurses collected and entered data directly into the NTRI web-based portal described elsewhere. Besides, one trained supervisor (a physician) checked the entered data for completeness, accuracy, and consistency. Furthermore, the supervisor assessed the accuracy of injury severity information, including the abbreviated injury scale (AIS), AIS predot code, and injury severity score (ISS).
This study has been ethically approved by the Ethics Committee of Tehran University of Medical Sciences with code number 95-02-38-259. Verbal informed consent was obtained from all patients or their legal guardians.
Frequencies and percentages were used to describe nominal and categorical variables. The association between the cause of injury and the ISS was assessed using the Chi-square test. Post hoc analyses were conducted using Bonferroni's test. Finally, the association between variables and ICU admission was investigated using univariable and multiple logistic regression models. P < 0.05 were considered statistically significant. The Stata software version 14.0 (Stata Corp, College Station, TX, USA) was used for the data analysis.
| Results|| |
Overall, 4032 trauma patients were included in the trauma registry. Of these, 3036 (75.0%) were men and 996 (25.0%) were women. In general, 3488 (86.5%) of the patients had a history of trauma hospitalization. The mean age of the patients was 39.5 years (standard deviation = 22.5, range 1–98).
Most patients had primary school education levels (26.5%) [Table 1]. Use of alcohol, drugs, and sedative drugs before the injury event was reported in 13 (0.2%), 19 (0.5%), and 87 patients (2.2%), respectively [Table 1]. Most patients were transferred to the health-care facility by ambulances (64.9%), and most injuries occurred during the week (73.9%) [Table 1].
[Table 2] shows the cause of trauma by the severity of injuries. There was a statistically significant association between the cause of injury and the severity of the injury (P < 0.001). The pairwise comparison results showed that the percentage of fall injuries with ISS ≥9 was higher than that of road traffic injuries (RTI) injuries with ISS ≥9 (26.9% vs. 16.8%, P = 0.01).
[Table 3] shows the percentage of ICU admission, ventilation, and death by cause of trauma. Among the cause of trauma, the highest proportion of ICU referrals was related to falls. Besides, falling caused the highest death [Table 3].
|Table 3: Intensive care units admission, ventilation, and death by cause of trauma (n=4034)|
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The univariable logistic regression models showed a statistically significant association between age ≥65, cause of trauma (blunt force, fall, stab/cut), years of school, and ISS ≥9 with ICU admission [Table 4]. According to the results, the odds of ICU admission in patients with ISS ≥9 were 6.28 times that in patients with ISS <9.
|Table 4: Univariable logistic regression models of intensive care units admission, odds ratio (95% confidence interval for odds ratio) (n=3982)|
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Besides, as reported in [Table 5], the multiple logistic regression model showed almost the same results and a statistically significant association between age ≥65, cause of trauma, years of school, and ISS ≥9 with ICU admission [Table 5]. For example, adjusted for ISS and cause of trauma, the odds of ICU admission in patients with age ≥65 were 2.11 times that in patients with age ≤15 (odds ratio = 2.11, 95% confidence interval = [1.38–3.22]).
|Table 5: Multiple logistic regression model of intensive care unit admission, odds ratio (95% confidence interval for odds ratio) (n=3982)|
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| Discussion|| |
This study assessed the information related to the patients with traumatic injuries admitted at the trauma center. General data showed that most of the patients were male. Besides, RTI was the leading cause of trauma, followed by falls. However, falls were more related to high injury severity, ICU admission, and death. Furthermore, previous studies in different cities in the center and northeast Iran showed that RTI and falls were the leading cause of trauma in admitted patients to trauma centers.,,,,
As the previous report showed similar outcomes relating to the cause of trauma, falls stood for a significant percentage of the injuries with ISS ≥9, while RTI was the leading cause of trauma in patients with ISS <9. Based on the evidence, Iran has high fatalities of RTI annually., The age-standardized fatality rate of RTI in Iran was reported as more than twice the global standard. In addition, virtually 1.1% of Iranians seek hospital care for RTI injuries annually. On the other hand, falls were more related to more severe injuries due to a higher probability of head injury. In our study, patients with falls and RTI had a higher chance of ICU admission and death. Furthermore, this study is in line with the findings of Sharif-Alhoseini et al. Their study showed that RTI has a significant portion of severity score and death. In addition, another study in Shiraz, Iran, revealed that RTI was the leading cause of trauma in patients admitted to trauma centers. Besides, Rasouli et al. reported that RTI was the most common cause of injury-related deaths in Iran. Nonetheless, in elderly patients, RTI and falls were reported as the most typical deadly injury mechanisms. Besides, the study by Yadollahi et al. in 2019 showed that RTI is the major cause of trauma and death among patients admitted to the trauma center in Shiraz, Iran.
Previous literature showed a statistically significant association between ICU admission and the cause of injuries. For instance, the study by Sharif-Alhoseini et al. and Naghavi et al. showed that fall injuries were the major cause of ICU admission. Furthermore, in our research, both univariable and multiple logistic regression models for ICU admission data showed the same results. Findings suggested that ISS ≥9, age ≥65, and blunt trauma were statistically significant factors for ICU admission.
Of the 4043 patients, 3036 were male (75.0%), and the average age of patients was 39.5 years, with the age range between 1 and 98 years. Our report had the same results as other research studies. Forouzanfar et al. reported that injuries were the leading cause of death among 15–49 years of age in Iran (23.6%) in 2010. Furthermore, different investigations showed that most admitted patients in trauma centers were men and young people.,,, Moreover, the literature indicated that the distinction in the prevalence of male patients could be attributed to male domination of unsafe lines of work and social activities., For this reason, avoidance programs for men in the age mentioned above group, as the most at-risk people, should be highlighted.
Throughout the study, 64.9% of trauma patients were transferred by emergency medical services (EMS) ambulances which suggested the availability and coverage of EMS to some extent. In some countries like Switzerland, prehospital transports are managed mainly by physician-staffed teams. It was reported that physician-staffed teams reduce the mortality rate in pediatric and traumatic brain injuries and could relate to a better percentage of transportation to trauma centers with faster time for arrival., However, in many countries, ambulances are used only for transport and not as a curative vehicle,, so it is crucial to consider this data to improve the EMS system and reduce mortality.
Furthermore, the outcomes of the study revealed that the major of the admitted patent were without formal education or had primary school education. Furthermore, the previous study in the northeast of Iran and Kashan showed the same result. It indicated that mass media should act better to introduce and educate people about traffic law and safety roles for increased knowledge of people to have safer driving and work.,
A trauma registry's quality is generally challenging to measure on an unbiased scale. Black. have recently dealt with the quality of multicenter scientific data sources. The authors specified five parameters as data quality components: completeness, recruitment, freedom of observation of primary results, use of specific definitions of variables, and extent of results validation. We considered the significant elements to ensure the data were drawn perfectly out of HIS. Meanwhile, our quality control physicians reviewed the patients' files and their severity and International Classification of Diseases codes, resulting in a better approach to enhancing data quality.
This study had some limitations. We collected the data based on a minimum dataset checklist. In addition, our patients needed to be followed up after discharge. Given extended dataset checklists in long-interval prospective projects may increase our knowledge in future studies.
| Conclusion|| |
This research provided an analysis of a trauma registry applied in one NTRI and showed that RTI and falls were the leading causes of trauma, with higher incidents in men. Age ≥65 and ISS ≥9 had statistically significant associations with ICU admission. More in-depth research studies can be conducted to understand different aspects of trauma burden and patient quality improvement.
The authors would like to thank the staff of the Shahid Beheshti Hospital, Kashan, Iran, for their great help and the national trauma center of Iran for their funding.
Financial support and sponsorship
This project was financially supported by the Sina Trauma and Surgery Research Center.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khaji A, Ghodsi SM, Eftekhar B, Karbakhsh M. Trauma research in Iran: A report of the Sina trauma data bank. Arch Iran Med 2010;13:17-20.
Forouzanfar MH, Sepanlou SG, Shahraz S, Dicker D, Naghavi P, Pourmalek F, et al.
Evaluating causes of death and morbidity in Iran, global burden of diseases, injuries, and risk factors study 2010. Arch Iran Med 2014;17:304-20.
Badirzadeh A, Naderimagham S, Asadgol Z, Mokhayeri Y, Khosravi A, Tohidnejad E, et al.
Burden of malaria in Iran, 1990-2010: Findings from the global burden of disease study 2010. Arch Iran Med 2016;19:241-7.
Khosravi A, Taylor R, Naghavi M, Lopez AD. Mortality in the Islamic republic of Iran, 1964-2004. Bull World Health Organ 2007;85:607-14.
Violence WHODO, Prevention I, Violence WHO, Prevention I, Organization WH. Global Status Report on Road Safety: Time for Action. World Health Organization; 2009.
Nantulya VM, Reich MR. The neglected epidemic: Road traffic injuries in developing countries. BMJ 2002;324:1139-41.
Hamadani F, Razek T, Massinga E, Gupta S, Muataco M, Muripiha P, et al.
Trauma surveillance and registry development in mozambique: Results of a 1-year study and the first phase of national implementation. World J Surg 2019;43:1628-35.
Boyd DR, Rappaport DM, Marbarger JP, Baker RJ, Nyhus LM. Computerized trauma registry: A new method for categorizing physical injuries. Aerosp Med 1971;42:607-15.
Rutledge R. The goals, development, and use of trauma registries and trauma data sources in decision making in injury. Surg Clin North Am 1995;75:305-26.
Trauma NRCCO, Shock NRCCO National Research Council, Accidental Death, and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences; 1966.
Kozieradzka-Ogunmakin I. Patterns and management of fractures of long bones: A study of the ancient population of Saqqara, Egypt. Bull John Rylands Libr (Anc Med Heal Syst Their Leg West Med) 2013;89:133-56.
Corfield AR, MacKay DF, Pell JP. Association between trauma and socioeconomic deprivation: A registry-based, Scotland-wide retrospective cohort study of 9,238 patients. Scand J Trauma Resusc Emerg Med 2016;24:90.
Black D, Morris JN, Smith C, Townsend P. Inequalities in Health: Report of a Research Working Group. London, England: Department of Health and Social Security; 1980.
Sharif-Alhoseini M, Zafarghandi M, Rahimi-Movaghar V, Heidari Z, Naghdi K, Bahrami S, et al.
National trauma registry of Iran: A pilot phase at a major trauma center in Tehran. Arch Iran Med 2019;22:286-92.
MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al.
A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366-78.
Eastman AB, Mackenzie EJ, Nathens AB. Sustaining a coordinated, regional approach to trauma and emergency care is critical to patient health care needs. Health Aff (Millwood) 2013;32:2091-8.
Cole E, Lecky F, West A, Smith N, Brohi K, Davenport R, et al.
The impact of a pan-regional inclusive trauma system on quality of care. Ann Surg 2016;264:188-94.
Dehli T, Gaarder T, Christensen BJ, Vinjevoll OP, Wisborg T. Implementation of a trauma system in Norway: A national survey. Acta Anaesthesiol Scand 2015;59:384-91.
Gauss T, Balandraud P, Frandon J, Abba J, Ageron FX, Albaladejo P, et al.
Strategic proposal for a national trauma system in France. Anaesth Crit Care Pain Med 2019;38:121-30.
Davoodabadi A, Sharifi H, Erfan N, Dianati M, Abdol Rahim KE. An epidemiologic and clinical survey on gastric cancer patients refered to Shahid Beheshti Hospital of Kashan (1994-2001). Razi J Med Sci 2003;10:211-20.
Masoudi Alavi N, Safa A, Abedzadeh-Kalahroudi M. Dependency in activities of daily living following limb trauma in elderly referred to Shahid Beheshti Hospital, Kashan-Iran in 2013. Arch Trauma Res 2014;3:e20608.
Abbasi HR, Mousavi SM, Taheri Akerdi A, Niakan MH, Bolandparvaz S, Paydar S. Pattern of traumatic injuries and injury severity score in a major trauma center in Shiraz, Southern Iran. Bull Emerg Trauma 2013;1:81-5.
Modaghegh MH, Saremi E, Mohamadian M, Jafarzadeh R. Characteristics of trauma in North East Iran and the prevention strategies. Arch Iran Med 2013;16:576-9.
Adib-Hajbaghery M, Maghaminejad F. Epidemiology of patients with multiple trauma and the quality of their prehospital respiration management in Kashan, Iran: Six months assessment. Arch Trauma Res 2014;3:e17150.
Saeednejad M, Zafarghandi M, Khalili N, Baigi V, Khormali M, Ghodsi Z, et al.
Evaluating mechanism and severity of injuries among trauma patients admitted to Sina hospital, the national trauma registry of Iran. Chin J Traumatol 2021;24:153-8.
Bhalla K, Sharaz S, Abraham J, Bartels D, Yeh P-H. Road injuries in 18 countries: Methods, data sources and estimates of the national incidence of road injuries. Boston, MA: Harvard University; 2011.
Sadeghi-Bazargani H, Samadirad B, Shahedifar N, Golestani M. Epidemiology of road traffic injury fatalities among car users; a study based on forensic medicine data in East Azerbaijan of Iran. Bull Emerg Trauma 2018;6:146-54.
Bhalla K, Naghavi M, Shahraz S, Bartels D, Murray CJ. Building national estimates of the burden of road traffic injuries in developing countries from all available data sources: Iran. Inj Prev 2009;15:150-6.
Reihani H, Pirazghandi H, Bolvardi E, Ebrahimi M, Pishbin E, Ahmadi K, et al.
Assessment of mechanism, type and severity of injury in multiple trauma patients: A cross sectional study of a trauma center in Iran. Chin J Traumatol 2017;20:75-80.
Rasouli MR, Saadat S, Haddadi M, Gooya MM, Afsari M, Rahimi-Movaghar V. Epidemiology of injuries and poisonings in emergency departments in Iran. Public Health 2011;125:727-33.
Yadollahi M. A study of mortality risk factors among trauma referrals to trauma center, Shiraz, Iran, 2017. Chin J Traumatol 2019;22:212-8.
Naghavi M, Abolhassani F, Pourmalek F, Lakeh M, Jafari N, Vaseghi S, et al.
The burden of disease and injury in Iran 2003. Popul Health Metr 2009;7:9.
Padavic I, Reskin BF. Women and Men at Work. Thousand Oaks, CA: Pine Forge Press; 2002.
Bolandparvaz S, Yadollahi M, Abbasi HR, Anvar M. Injury patterns among various age and gender groups of trauma patients in southern Iran: A cross-sectional study. Medicine (Baltimore) 2017;96:e7812.
Krieger N. A glossary for social epidemiology. J Epidemiol Community Health 2001;55:693-700.
Heim C, Bosisio F, Roth A, Bloch J, Borens O, Daniel RT, et al.
Is trauma in Switzerland any different? Epidemiology and patterns of injury in major trauma – A 5-year review from a Swiss trauma Centre. Swiss Med Wkly 2014;144:w13958.
Popal Z, Bossers SM, Terra M, Schober P, de Leeuw MA, Bloemers FW, et al.
Effect of physician-staffed emergency medical services (P-EMS) on the outcome of patients with severe traumatic brain injury: A review of the literature. Prehosp Emerg Care 2019;23:730-9.
Knapp J, Häske D, Böttiger BW, Limacher A, Stalder O, Schmid A, et al.
Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis. J Trauma Acute Care Surg 2019;87:978-89.
Plummer V, Boyle M. EMS systems in lower-middle income countries: A literature review. Prehosp Disaster Med 2017;32:64-70.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]