About TITCO - India

'Towards Improved Trauma Care Outcomes(TITCO)


Why Trauma care in India

 

Trauma-care systems in India are at a nascent stage of development. Industrialized cities, rural towns, and villages coexist with a variety of health care facilities and an almost complete lack of organized trauma care. There is gross disparity between trauma services available in various parts of the country. Rural India has inefficient services for trauma care, due to the varied topography, financial constraints, and lack of appropriate health infrastructure. There is no national lead agency to coordinate various components of a trauma system. There exists no mechanism for accreditation of trauma centers and professionals. Education in trauma life-support skills has only recently become available. A nationwide survey encompassing various facilities has documented significant deficiencies in current trauma systems.

We know that our country is a developing country where the country can be categorized in pockets as developing, developed and underdeveloped regions because of its vast size and socio-cultural peculiarities. Industrialized cities, rural towns, and villages coexist, with an almost complete lack of organized trauma care.

In India, trauma systems and trauma care services have largely been the responsibility of state and territory governments. Pre-hospital services include a range of public and private road ambulances, taxi, private cars and scooters. Professional ambulance paramedics provide all pre-hospital care in some states or territories, whereas in others doctors are involved in the pre-hospital care of severely injured people.

Trauma, Acute and Intensive care refers to all aspects of Trauma Care including primary through definitive and intensive care thereby making membership available to General Surgeons, Orthopedic Surgeons, Neurosurgeons, Plastic Surgeons, Anesthesiologists, Emergency Physicians and Intensivists, and other sub-specialties of General Surgery who meet the same criteria as General Surgeons.

Most severely injured people are cared at designated trauma centres in private and government hospitals. These hospitals provide a full range of specialised medical, nursing and allied health services, ranging from emergency department reception, through inpatient diagnostics, surgery and critical care and discharge planning. Patient discharged from hospital goes to home and comes for follow up as informed by the doctor.

 


 

Figure 1 - TRAUMA CARE CONTEXT IN INDIA

 

Cities

Land Area(km2)

Population

Number of designated MTCs(wha is MTCs)

Delhi

1,484

1,82,48,290

1

Kolkatta

185

44,86,679

1

Chennai

1,189

48,28,853

1

Mumbai

603.4

1,27,72,094

4

 

Source for no. of designated trauma centre is through google

 

Definition of major trauma designated centre - Trauma centers are designated by the American College of Surgeons (ACS) into one of 4 levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated(1).

 

They are ranked by the American College of Surgeons (ACS), from Level I (comprehensive service) to Level III (limited-care). The different levels refer to the types of resources available in a trauma center and the number of patients admitted yearly. These are categories that define national standards for trauma care in hospitals. Level I and Level II designations are also given adult and or pediatric designations.3 These levels may range from Level I to Level IV. Some hospitals are less-formally designated Level V.

A Level I trauma center is required to have a certain number of the following people on duty 24 hours(4) a day at the hospital:

Additionally, a Level I center has a program of research, is a leader in trauma education and injury prevention, and is a referral resource for communities in nearby regions.5

 

 Level II

A Level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. Minimum volume requirements may depend on local conditions. These institutions are not required to have an ongoing program of research or a surgical residency program.

 

Need for Trauma registry

A trauma registry is a timely, accurate, and comprehensive data source which allows for continuous monitoring of the process of injury care. It is subjected to continuous data validation to reliably inform performance improvement, education, and research activities.  (7)



METHODS OF DATA COLLECTION, ANALYSIS AND REPORTING

 

Data sources

 

The TITCO Trauma Registry (TTR) collects information on seriously injured patients admitted to designated trauma centres in India. This work is a part of the research consortium - Towards improving trauma care outcomes (TITCO), that aims to contribute through research to improving hospital-based trauma care in India. It includes four major trauma centres that are part of the university teaching hospitals: the Apex Trauma Centre of the All-India Institute of Medical Sciences (AIIMS), New Delhi; Lokmanya Tilak Municipal General Hospital (LTMGH), Mumbai; King Edward Memorial Hospital, Mumbai; and Institute of Post-Graduate Medical Education and Research and the Seth Sukhlal Karnani Memorial Hospital (IPGMER & SSKM), Kolkata, with research support from Karolinska Institutet, Stockholm, Sweden and the Tata Institute of Social Sciences, Mumbai.

 

The trauma centres included were referral centres for trauma care, situated in large cities (populations of more than 10 million your data above shows 4.4 million odd patients in Chennai and Calcutta) that were geographically representative of urban India, namely Kolkata, Mumbai (2-centres), and Delhi. They also represent the of the world’s low- and middle-income cities, with a huge burden of injury and trauma patients. Except for the Apex trauma centre, which is a standalone trauma centre, the others were trauma units providing trauma care as a part of a general hospital. The user fees were nominal and classified as free-to-public. The hospitals mainly serve the lower socioeconomic strata of the population in the catchment area.
It started in Aug 2013 till Sep 2015 at different sites in India. The duration of the project varies across different hospitals.

In Aug 2013, trauma data was submitted to TTR electronically by each participating trauma centre. This data was a subset of data which participating trauma centres routinely collect.


Data Elements

Study Intake form is enclosed.

Data Quality

Data submitted to the TTR undergoes various quality control and validity checks  such as date and time formats and International  Classification of Diseases and Related Health Problems, Tenth Revision and Abbreviated Injury Scale 2005 (Updated 2008)(AIS) codes prior to data processing. If data did not pass these validations, an error file was generated and a notification sent to sites submitting the data to address and correct the error, if possible.

For this report:

  • All information provided by the sites is in accordance with ICH GCP guidelines and with TITCO inclusion and exclusion criteria for major trauma and definitions.
  • While the data has gone through validation checks, there may still be issues with data validity for certain data elements. Where identified, these cases have been omitted.
  • Wherever appropriate and relevant, data quality notes or exceptions are detailed throughout the report.

Patients included in the registry

All patients presenting to the casualty department with a history of injury (road traffic, railway, fall, assault or burns) and were admitted to the hospital for treatment, were included, hereafter called the ‘injured patient’. Patients who died just after arrival (but before admission) were also included.


Patients excluded from the registry

Patients who were dead on arrival were not included. Patients who died between arrival and admission are included.

  


Anonymity and protection from identification

The privacy of patients will be secured by removing any patient identifiers before uploading the data. Only patient study IDs will be retained. The confidentiality of data

will be secured by storing digital data on a secure server. Confidentiality of subjects and data is maintained as per the GCP guidelines and Declaration of Helsinki. The PI at each site will keep the paper forms in a locked room or locker, for as long as local legislation requires.

Several measures were taken in this report to preserve anonymity and minimise the chance of identification of centres:

  • Trauma centres are indicated by letter labels, but no absolute numbers are given, only percentages, such that the volumes of cases cannot be used for the purpose of comparison between states and territories.
  • Alphabetical labels used to represent states and territories have been randomly allocated and are different for each data item, therefore, while within any data item the figure and the table can be correlated, data cannot be compared between specific data items.
  • Graphs by centre are ordered from lowest to highest on the data item in question, and the order of centres in one graph bears no relation to the order of centres in other graphs.
  • Sample sizes or cells with counts of five or less are aggregated to the next level or suppressed.

WHO WAS INJURED AND HOW THEY WERE INJURED

Major trauma patients and mortality( Table will changed as per our new dataset of 16048 patients)

In total there were 11670 major trauma patients reported at Indian designated trauma centres during the period under review and 2448 (21%) died. Table 1 shows the percentage mortality among major trauma admissions to designated trauma centres in each state/territory.

Table 1 – Major Trauma Patients and mortality at designated trauma centres nationally and per state/territory.

Hospitals

2013

2014

2015

Patients

(No.)

Deaths

(No.)

Deaths

(%)

Patients

(No.)

Deaths

(No.)

Deaths

(%)

Patients

(No.)

Deaths

(No.)

Deaths

(%)

National

2903

731

25.18

8125

1481

18.22

575

175

30.30

0

620

97

15.64

2273

292

12.84

272

24

8.82

1

-

-

-

1467

270

18.40

119

17

14.28

2

586

159

27.13

1202

178

14.80

-

-

-

3

-

-

-

277

254

91.69

184

134

72.82

5

1697

475

27.99

2906

487

16.75

-

-

-


THE INJURIES THAT WERE SUSTAINED

Injury Severity Score (ISS)

(n = 4453)

Injury severity score (ISS) is an internationally-standardised approach to describing the overall severity of injury for each patient. It combines the severity of the three most significantly injured body parts. It enables comparison between populations of injured patients, and provides a standard inclusion criterion for trauma registries. The larger the number, the more severe the injury, up to a maximum of 75.


OUTCOMES OF THE INJURIES AND TRAUMA CENTRE CARE





QUALITY OF THE DATA


Table 18 – Completeness of data items by data source


Data Source

Mortality %

Age %

Gender %

Injury Type %

Injury Cause %

ISS %

Arrival Systolic %

Arrival Total GCS %

Transport Mode %

Referred Type %

Injury Time %

Arrival Date and Time %

Arrival Intubated %

ICU LOS %

0

96.18

100

100

99.93

99.7

97.5

99.68

99.9

99.69

100

99.1

99.96

24.87

98.5

1

94.7

100

100

99.49

99.6

89.6

38.46

42.55

98.67

98.54

96

97.98

1.57

99.9

2

72.3

99.9

99.94

99.94

98.2

96.3

96.98

96.03

99.83

99.83

99.2

99.83

23.45

72.3

3

14.71

99.6

100

99.78

99.6

98.7

45.02

5.62

99.78

100

94.6

72.51

29.22

85.5

5

72.6

100

99.95

100

100

90.3

72.58

82.22

96.78

99.89

99.4

99.04

0.15

72.2

TTR

70.10

99.9

99.98

99.83

99.4

94.5

70.54

65.26

98.95

99.652

97.7

93.86

15.85

85.7


 

Key


100%

90-99%

50-89%

1-49%

0%


 


 






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