Our manuscript describes a comprehensive assessment of the baseline capture rate of WHO-defined injury variables in a Sub Saharan country. In this study, we found a substantial lack of documentation of trauma variables in both general trauma patients as well as a sub-group of patients with potentially severe or major injuries. There is paucity of studies in this field, but some available studies have demonstrated the usability of implemented TRs without evaluating the baseline capture rate of variables (20,21). The development of successful national TRs is dependent on availability of standard set of injury variables that are consistently collected from all trauma patients (21–23). In all facilities, we also found significant under-documentation of patients in the facility HMIS register that is used to submit the facility trauma data to the Ministry of Health.
Many attempts to develop TRs in sub Saharan Africa have largely been unsuccessful or unsustainable beyond the initial research phase for a number of reasons, including lack of uniform clinical documentation of injury variables (24–27). The HMIS register is currently the only tool that provides injury data to inform the Ministry of Health about the national burden of injury, and so the quality and consistency of the data gathered is of paramount importance (28). However, while we recorded a very low rate of variables documented in the facility HMIS register, we also note that even at full capture the variables will not serve the needs of a TR, given that it records less than one fifth of WHO DSI variables.
Despite an overall low capture rate of injury variables, we found a high rate of documentation for patients demographics, which is attributed to the fact that most of the patients have to be registered for billing purposes (29). The initial clinical presentation of the patient was not documented for over three quarter of variables needed to inform the TR. Conscious level is an important marker that informs both care pathways and clinical prognosis: despite this importance, GCS or AVPU was almost never recorded (30–32).
The documentation of pre hospital care and mechanism of injury variables can inform TRs and help to demonstrate the priority areas for strengthening care to optimize outcome (3). Care prior to EU, signs of life, and mechanism of injury were documented in less than half of patients, and in some data providers mixed the chief complaint and mechanisms of injuries, limiting potential usability of data gathered to inform on the status of recommended injury prevention interventions. Training of providers on importance of injury variables can improve understanding and improve documentation (33).
Lack of resources and increased patient workload are known to impact documentation of vital signs in different settings (34). Vital signs were documented in less than one fifth of patients, with saturation of oxygen being recorded in the lowest proportion of patients. Only two hospitals had either a cardiac monitor or a pulse oximeter, obviously contributing towards the low oxygen saturation capture rate. In the current reality of the emergency care system, it will be very difficult to document severity of injuries seen in Tanzania (35).
We observed that a substantial proportion of performed assessment and interventions were not documented in the clinical chart. Surgical interventions, for example chest tube placement, was documented more thoroughly, and we believe this is related to both billing and administrative needs of documentation of surgical procedures (28). In all EUs, most discharged patients do not receive any documentation; we observed most patients receiving verbal discharge with follow up dates. We believe this is related to the lack of standardised EU documentation, and lack of EU filing system for patients who are not admitted. In facilities with the filing system the patients are provided with a copy of the discharge instructions that are filed with the hospital registry.
We noted a substantial shortage of EU beds with an average of one bed for every 43 patients in all EUs, giving ratio of one bed to four trauma patients. Compounding the challenge of EU bed capacity is the shortage of ICU bed in all the regional hospitals; two regional hospitals had no ICU capacity at all. In all EUs we found a low staffing level, similar to that observed in previous studies of EU staffing in Tanzania (9). A combination of limited infrastructure, low staffing and shortage of supplies might further explain the observed low capture rate of injury variables.
Limitations
The study was conducted in five regional hospitals with variable resources, patient flow system and volume. This may not reflect the reality in the rest of the health facilities in Tanzania. Our utilization of trauma form with complete WHO data set to assess the capture rate of variables in all patients regardless of the severity of injury might have contributed to poor documentation of and a low capture rate given that providers might not document variables they feel irrelevant for minor trauma, however we noted the same poor documentation for a sub-group of trauma patients with likelihood of serious or major injuries (admitted, died in EU and referred), as well as for variables that are part of core WHO data set, meant to be documented for any patient.