This section presents trends observed and analysis for 49,241 trauma cases collected between September 2018 and March 2020 across 10 health facilities in Malawi.
Demographic information
Figure 2 shows the demographic correlates of trauma cases in the sample. Injuries are most common for younger adults (median age of 30; IQR 22, 40). Two-thirds of trauma patients are male, with greater gender differences at younger ages. Overall, 33% of all trauma cases were females and 66% males. For serious injuries (i.e., AVPU < 4, GCS < 8, patients whose self-reported pain level was severe or extreme, or hospitalizations), 30% were females, and 60% were males (p-value < 0.001). Among hospitalized patients, 27% were females, and 73% were males (p-value < 0.001).
Injury details
We examine mechanism of injury, type of injury, disposition, injury severity, and timeliness of care for non-hospitalized and hospitalized trauma cases, using hospital admission as a proxy for severity.
Mechanism, diagnosis, and location of injury
The most common mechanisms of injury are falls (45.8%), followed by RTCs (19.5%), blunt trauma (15.5%), stabs and cuts (10.7%), and bites (5.8%) (Fig. 3). The most common diagnosis across all trauma cases is soft tissue injuries and contusions (46%), followed by fractures (27%), lacerations (12%), bites (5%), penetrating wounds (2%), burns (1%), and dislocations (2%) (Fig. 4). For hospitalized trauma cases, the most common mechanism of injury was RTCs (48%), falls (22%), blunt trauma (12%), and penetrating wounds (11%). The most common type of injuries for hospitalized patients was fracture (35%), followed by soft tissue injuries and contusions (23%), and lacerations (12%). For all trauma cases, 71% of injuries were to the extremities, while 7% were to head and neck, and 8% to the face, 3% to the thorax, and 2% to the abdomen.
Injury severity
Injury severity (proxied by hospital admission) varied by injury cause. Hospital admissions include all cases where a patient was admitted to a ward, intensive care unit (ICU), operating theatre, or if the patient died in the casualty department. While falls were the most common mechanism of injury, only 4% resulted in admission. By contrast 18% of RTCs resulted in admission. Overall, 7% of trauma patients were hospitalized (admitted overnight). 21% (768) of hospitalized cases had injuries in the head and neck region. In addition to hospital admission, other measures of injury severity recorded in the trauma registry are Glasgow Coma Scores (GCS) and AVPU score, as well as the patients’ subjective pain rating. Out of all hospital admissions with injuries in the head and neck region (768), 11% had severe injuries (GCS ≤ 8), 11% had moderate injuries (GCS between 9 and 11). Overall across all trauma cases, 40% of patients reported none or mild pain, 53% reported moderate pain, and 6% either severe or extreme pain. 4% of patients had a Kampala Trauma Score lower than 14, denoting moderate to severe injury.
Variation across health facilities
A unique feature of this registry is the broad coverage of multiple levels of health facilities: referral hospitals (2) and district (7) and community hospitals (1). We analyze the distribution of trauma across these categories of hospitals. Facilities varied significantly in the number of trauma cases seen, percentage of patients hospitalized, the percentage of patients who present with serious trauma, and the percentage of trauma caused by RTCs (Fig. 5). RTC cases as percent of the total trauma caseload varies within a narrow range (16–28%) with the exception of Dedza District Hospital; this hospital is 1.5 h from Kamuzu Central Hospital and other facilities in Malawi’s capital, Lilongwe, so RTCs nearer to Lilongwe than Dedza may divert to these facilities. Hospitals vary widely in the percentage of cases admitted (from 3 to 16%) and in the percentage of patients presenting with serious trauma, as defined in the previous section (from 5 to 28%), with referral hospitals seeing approximately two times as much serious trauma, as a percentage of total caseloads, as district hospitals (21% to 11%).
Patterns of RTCs
Since RTCs represent almost half of all trauma cases requiring hospital admission, we examine them in more detail here. We report information on road users, vehicles involved, and crash details. 1.3% (133/9,595) of RTC patients were dead on arrival at the facility and 18% required admission to hospital. Soft tissue injuries and contusions are observed in 56% of RTC patients, followed by fractures (20%), and lacerations (11%). RTCs make up 21% of all trauma cases in central hospitals, compared to 19% for district hospitals. Additional file 1: Table S1 shows the detailed breakdown of the number of trauma cases, RTCs, and admission by hospital.
Non-motorized road users (pedestrians, cyclists, cart users) make up approximately half of all RTC trauma patients (49%) (Fig. 6). Among hospitalized road traffic crash patients, passengers of car/bus/trucks make up a third (32%) of the road users in RTC cases, followed by pedestrians (20%) and cyclists (16%). Overall, 50% of hospitalized pedestrians were struck by private vehicles or trucks, 23% by public transit vehicles, 17% by motorcycles, and 4% by bicycles. We present geographic variation in pedestrian crashes in the regions surrounding the facilities by looking at the percent of RTCs involving pedestrians out of the total RTC recorded in each facility from the 10 hospitals. Queen Elizabeth Central Hospital (45%), Dedza District Hospital (20%), Balaka District Hospital (18%), Ntcheu District Hospital (17%), Mzuzu Central Hospital (17%), and Kasungu District Hospital (16%) each have more than 15% of the RTC caseload involving pedestrians (see Additional file 1: Table S1 for total number of RTC for each hospital). Figure 7 shows the peak hours of road traffic crashes as recorded in the trauma registry. There are two peaks of RTCs consistent across all the road users coinciding with morning and evening rush hours, one between 4:00 and 8:00 h, and a second peak between 16:00 and 20:00 h. Non-motorized users (pedestrians and cyclists) have a higher percentage of RTCs happen during those peaks and almost none in the night hours. By contrast cars, trucks, and buses have a higher percentage of crashes between 23:00 and 4:00 h, likely due to lower visibility, fatigue, or speeding, and the reduced presence of pedestrians on roads. Presence of alcohol was noted, based on self-report, in 6.7% (45/678) of all drivers of cars, trucks, buses and suspected for 2% (15/678).
Hospital care and trauma outcome
Median time elapsed between occurrence of trauma and patient arrival at hospital is 8 h 59 min (IQR 1 h 50 min, 23 h 50 min). However, this aggregate figure includes minor cases for which rapid treatment is not needed. We separately examine timeliness of treatment for the subset of severe trauma cases that represent urgent need for care based on four characteristics: patients who were admitted to hospital, or with AVPU < 4, or with GCS < 8, or patients whose self-reported pain level was severe or extreme. Finally, long recorded delays can also reflect patients’ decisions not to seek care immediately, and therefore may not reflect gaps in emergency transport. Therefore, we also examine time elapsed for the subset of patients who seek care on the same day (within 24 h of the trauma).
Figure 8 shows the arrival times and time to receive care post-arrival across all trauma, RTCs, and severe trauma. Severely injured patients arrive after a median time of 5 h 20 min (IQR 1 h 20 min, 24 h), and RTC patients arrive after a median time of 1 h 50 min (IQR 57 min, 8 h 40 min). For seriously injured patients who seek care on the same day as their trauma, median time elapsed between occurrence of trauma and patient arrival at hospital is 2 h (IQR 1, 10 h). However there is notable variation across hospitals (Additional file 1: Fig. S1), and for non-RTC serious trauma, the median time increases to 4 h. For RTCs, patients are seen by a clinician within a median 35 min after arrival. For minor trauma, patients are seen approximately an hour after their arrival. Severely injured patients are seen within 10 min of their arrival (Fig. 9).
For hospitalized trauma cases, the most common modes of transport to hospitals are private (29%) and commercial vehicles such as taxis (21%), public modes such as minibuses (16%), and ambulances (6%).
Disposition
The trauma registry also records the final outcome of the trauma case in the casualty department on the day they visit the hospital. 92% (45,374) of all trauma cases were treated and sent home the same day, 6.5% (3,232) of cases were admitted to another ward, 0.1% (74) were taken to the operating theatre, 0.04% (19) were taken to the ICU, 0.1% (49) of patients died in the casualty department, 0.5% (242) were referred to another facility, and 0.4% (177) were dead on arrival. Of all patients admitted in the ward, intensive care unit, or operating theatre, 1,636 (49%) patients remained in the hospital 24 h later. Information about the treatment provided was collected for patients who stayed in the facility overnight. For 88% of the cases that stayed overnight, a form of pain relief (diclofenac, Panado, paracetamol) was given, 32% of the cases were given antibiotics, 24% of cases received a plaster of Paris cast/backslab, and 21% of cases received blood, intravenous fluids, or oxygen. (If multiple treatments were given to a patient, all the treatments were recorded in the trauma registry.)