|Year : 2014 | Volume
| Issue : 2 | Page : 76-79
Quality assessment of trauma care in a teaching hospital in North Western Nigeria
Usman Adamu Gwaram, Abdurrahman Abba Sheshe, Kabir Musa Adamu, Mohammed Kabir Abubakar, Amina Ibrahim El-Yakub, Abdurrahman Alhaji Mamuda, Ismail Inuwa
Department of Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||6-Sep-2014|
Dr. Usman Adamu Gwaram
Department of Surgery, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Background: The quality of care assessment is important to improve performance. The aim of this study is to assess the quality of trauma care in Aminu Kano Teaching Hospital, through the mortality methodology and analyze the failures of care. Materials and Methods: All patients above 18 years that died from trauma from 1 st January 2012 to 31 st December 2012 in the accident and emergency unit of AKTH were studied. Bio-demographic data, cause of injury, mode of presentation, time interval between injury and death and probable causes of death were recorded. A panel of surgeons reviewed these and failures of care were analyzed and categorised. Results: Out of 63 mortalities in the unit, only 58 (92%) had complete data for inclusion in the study. Forty-seven (81%) were from road traffic accident, six (10%) were gunshot wounds, four (7%) were fall and one from assault. Their age ranged from 18 to 76 with a mean of 31.9 years. There were 49 males and 9 females. Thirty (52%) were head injured, three mortalities (5%) had extremity injury, one each had abdominal and spinal injuries while 23 (40%) were multiply injured. Forty-nine (85%) patients had clearly identified failures of care. Seventeen of the head injuries were awaiting transfer to Intensive Care Unit (ICU) before death and 13 had airway problems at presentation. Of the non-Central Nervous System mortalities, six were fluid resuscitation and haemorrhagic shock, two had missed injuries, eight were from sepsis two of which were poorly controlled diabetics and two patients died from tetanus. Conclusion: There is high rate of failures of care directly contributing to the trauma mortality, mostly in head injuries. We recommend increased capacity of the ICU and involvement of anaesthetist in major trauma resuscitation for airway management to reduce the mortalities.
Keywords: Management failures, quality assessment, trauma care
|How to cite this article:|
Gwaram UA, Sheshe AA, Adamu KM, Abubakar MK, El-Yakub AI, Mamuda AA, Inuwa I. Quality assessment of trauma care in a teaching hospital in North Western Nigeria. Niger J Basic Clin Sci 2014;11:76-9
|How to cite this URL:|
Gwaram UA, Sheshe AA, Adamu KM, Abubakar MK, El-Yakub AI, Mamuda AA, Inuwa I. Quality assessment of trauma care in a teaching hospital in North Western Nigeria. Niger J Basic Clin Sci [serial online] 2014 [cited 2020 Jan 17];11:76-9. Available from: http://www.njbcs.net/text.asp?2014/11/2/76/140333
| Introduction|| |
Injuries cost the global population some 300 million years of healthy life every year, causing 11% of disability adjusted life years (DALYs) worldwide. 
There is evidence that the surgical services received by patients are often suboptimal, with best treatments and strategies not always implemented,  failures to implement recommended care and common medical errors. 
Quality assessment is the evaluation of clinical performance and quality to improve care. It involves the analysis of performance measures: Input, process and outcome.  Input measures inventories of resources of the institution; process measures attempt to verify that the system is using its resources appropriately in response to demands, while outcome measures results of patient interaction with health care facility.
The three models, which have been used during the past 20 years for quality assessment of trauma care include the mortality and morbidity methodology to critically analyze failures of care, review of hospital charts by panel of experts, comparison of observed survival with probability of survival obtained from national registries and population-based epidemiological studies. 
The aim of this paper is to assess the quality of trauma care in Aminu Kano Teaching Hospital, Kano by the mortality methodology to critically analyse failures of care.
| Setting and Design|| |
Aminu Kano teaching hospital is a 600-bed teaching hospital in north-western Nigeria and together with National Orthopedic Hospital Dala are the two tertiary hospitals providing specialist trauma services in Kano state with a population of 9,383,682.  The hospital receives referrals from other hospitals in the state and other neighbouring states.
The trauma care is integrated into the overall surgical emergency services of the hospital in the accident and emergency (A and E) unit of the hospital. There are 22 beds, an adjoining theatre, full radiological services including computerised tomographic (CT) scan laboratory and blood transfusion services all accessible for 24 hours. There is a four-bed Intensive Care Unit (ICU) for all critical patients in the hospital including trauma patients; this is managed by anaesthesiologists in addition to their operating room responsibilities. No beds are specified for trauma victims in the accident and emergency or the surgical wards.
Injury management is by triage and initiation of resuscitation by casualty officers, which are essentially registrars on emergency rotation and informing the requisite surgical subspecialty unit to take over the management.
This is a 1-year retrospective analysis of all patients that died from trauma in the accident emergency from 1 st January 2012 31 st December 2012. All patients above the age of 18 years that died from trauma excluding burns were included. Demographic data was collected in addition the cause of injury, mode of presentation, time interval between injury and death and probable causes of death were recorded. A panel of surgeons: Including three general surgeons, three orthopaedic surgeons and a cardiothoracic surgeon reviewed the individual patient folders and failures of care were analyzed and categorised.
| Results|| |
A total of 728 patients were admitted for trauma in the accident and emergency during the period, 293 of which were treated in the A and E while 435 were transferred into the surgical wards. There were 81 mortalities from the A and E 18 of which were brought in dead. Out of the 63 mortalities, only 58 had complete data necessary for inclusion into the study. Road traffic accident (RTA) accounted for 47 (81%) mortalities, gunshot wounds (GSW) six patients, and four were from fall and one patient from assault. Their age ranged from 18 to 76 with a mean age of 31.9. There were 49 males and 9 females with a male:female ratio of 5.4:1. Fourteen patients presented by themselves with injury, 15 (25.9%) were referred from other hospitals in the state and 29 (50%) from other states (13 from Jigawa, eight from Katsina, five from Bauchi two from Kaduna and one from Gombe states). Thirty patients were head injured, three patients had extremity injury, one abdominal injury, one spinal cord injury and 23 (39.7%) were multiply injured [Table 1].
Forty-nine patients had clear failures of care from consensus of the reviewing panel of surgeons. Thirty were central nervous system (CNS) mortalities and 19 were non-CNS mortalities [Table 2].
Anaesthesiologist reviewed 17 of the CNS mortalities and waiting transfer to intensive care unit (ICU) before death and 13 had airway issues at presentation. Out of the non-CNS mortalities, seven were fluid resuscitation and haemorrhagic shock, three had missed injuries eight were from sepsis two of which were poorly controlled diabetics and one died from tetanus.
| Discussion|| |
This study addresses the type and nature of major patterns of death for trauma patients in a teaching hospital in northwestern Nigeria. Mortalities from referred head injury patients predominate, similar to the findings in the western world where traumatic brain injury is the most common cause of death following injury.  These patients died awaiting transfer to ICU for airway management and critical care and not requiring surgical intervention. Airway issues were found to be error pattern that result in mortality from Italy  and Utah  which were environments with poorly developed trauma systems. In our setting it is in addition related to the lack of anaesthesiologists in major trauma resuscitation, availability of space in the ICU and the cost with most patients being unable to pay readily resulting in serious management delays, which may have contributed to the mortalities in the patients. In addition, though there is a neurosurgeon, but is not dedicated solely to the care of trauma patients as is the practice in a trauma centres within a trauma system. 
Like other studies, the causes of death were clear delays in treatment and, missed injuries and mismanagement. ,,,,, All of the patients referred from other states were for neurosurgical care with head injury or with head injury as component of their multiple injuries. There was no pre-hospital care including poor transportation, trained personnel in trauma resuscitation and standard referral protocol, which may have contributed to death.
There are established standards of adequacy of hospital trauma care.  These include time errors; which assess pre-hospital time less than 30 minutes, admission to theatre time less than 2 hours in patients requiring laparotomy or thoracotomy, or less than 4 hours in patients requiring craniotomy, transfer to a higher hospital more than 6 hours after initial hospital arrival. Mismanagement is considered when the patient management was not according to Advanced Trauma Life Support (ATLS) guidelines, lack of airway control in patients with loss of consciousness, intravenous fluids in exsanguinating patients, bleeding control, immobilisation, pleural decompression when required, diagnostic peritoneal lavage (DPL), ultrasound scan or laparotomy in haemoperitoneum with unstable haemodynamics or conducting laparotomy in patients with retro-peritoneal haematoma from closed pelvic fracture without associated abdominal injury and lack of CT scan in Glasgow Coma Score less than 13 within 2 hours. When an injury as important as in patient's demise is missed because of misinterpretation or inadequate physical examination or diagnostic procedure is considered mismanagement.
These standards may not be applicable in our environment because it is not a trauma system without pre-hospital care and referral system. CT scan, though available is not readily affordable by most patients, at times waiting for days before funds are mobilised for the investigation. These, however, are patients without clinical indication for surgery. The management of these patients is along ATLS guidelines; however, there was no formal ATLS course for the personnel in the emergency. In the non-CNS mortalities, haemorrhagic shock and missed injuries would easily have been prevented by following the ATLS guidelines of resuscitation and management of injured patients, a training though widespread in other places is sadly, not available in this setting.
The young able-bodied men in the society who is lost to death will affect their families economically and socially constituted majority of the victims. Similar observation was made from other centres. ,
This study is likely to assist trauma reduction strategies by identifying areas to be targeted: In the short term, process of involvement of anaesthetists in major trauma resuscitation, increased space in the ICU and other measures to reduce delays and establish clear referral criteria and protocol. In the long term it require a change towards modern trauma management strategies; through commitment of infrastructure, personnel, protocols and training in trauma care as is obtained in a trauma system  with consideration of our social and economic limitation.
In conclusion, there is high rate of failures of care directly contributing to the trauma mortality from the study, mostly in referred patients with head injuries, other causes include missed injuries, volume resuscitation and sepsis from delayed presentation. We recommend increased capacity of the ICU and involvement of anaesthesiologist in major trauma resuscitation for airway management to reduce the mortalities in the patients with head injuries.
| References|| |
|1.||Murray CJ, Vost T, Lozaro R, Naghavi M, Flaxman AD, Michaud C, et al. Disability adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2000: A systematic analysis for the Global Burden of Disease study 2010. Lancet 2012; 380:2917-223. |
|2.||Institute of Medicine Committee on the Quality of Health Care in America. Crossing the quality chasm: A new Health system for the 21 st century. Washington: National academy press; 2001. |
|3.||Rhodes M, Sacco W, Smith S, Boorse D. Cost effectiveness of trauma quality assurance audit filters. J Trauma 1990;30:724-7. |
|4.||Gruen RL, Gabbe BJ, Stelfox HT, Cameron PA. Indicators of the quality of trauma care and the performance of trauma systems. Br J Surg 2012;99:97-104. |
|5.||Chiara O, Cimbanassi S, Pitidis A, Vesconi S. Preventable trauma deaths: From panel review to population based-studies. World J Emerg Surg 2006;1:12. |
|6.||Report of Nigeria's National population commission on the 2006 census. Population and development Review. March 1 2007. |
|7.||Finfer SR, Cohen J. Severe traumatic brain injury. Resuscitation 2001;48:77-90. |
|8.||Stocchetti N, Pagliarini G, Gennari M, Baldi G, Bandiiri E, Campari M, et al. Trauma care in Italy: Evidence of in hospital trauma deaths. J Trauma 1994;36:401-5. |
|9.||Sanddal TL, Esposito TJ, Whitney JR, Hartford D, Taillac PP, Mann NC, et al. Analysis of preventable trauma deaths and opportunities for trauma care improvement in Utah. J Trauma 2011;70:970-7. |
|10.||West JG, William MJ, Trunkey DD, Wolferth CC Jr. Trauma systems. Current status-future challenges. JAMA 1988;259:3597-360. |
|11.||Kim H, Jung KY, Kim SP, Kim SH, Noh H, Jang HY, et al. Changes in preventable death rates and traumatic care systems in Korea. J Korean Soc Emerg Med 2012;23:189-97. |
|12.||Esposito TJ, Sanddal ND, Hansen JD, Reynolds S. Analysis of preventable trauma deaths and inappropriate trauma care in a rural state. J Trauma 1995;39:955-62. |
|13.||Iau PT, Ong CL, Chan ST. Preventable trauma deaths in Singapore. Aust N Z J Surg 1998;68:820-5. |
|14.||Mandong BM, Madaki JK, Mohammed AZ, Kidmas AT, Echejoh GO. Epidemiology of accident deaths in Jos, Nigeria. Ann Afr Med 2006;59:149-52. |
|15.||Solagberu BA, Adekanye AO, Ofoegbu CP, Udoffa US, Abdur-Rahman LO, Taiwo JO. Epidemiology of trauma deaths. West Afr J Med 2003;22:177-81. |
[Table 1], [Table 2]