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Journal of Current Surgery

Original Article

Volume 1, Number 1, December 2011, pages 19-24

Analysis of Hospital Mortality and Epidemiology in Trauma Patients: A Multi-Center Study

Many trauma patients are admitted through emergency departments every day. Trauma remains the most frequent cause of mortality in young people (aged 1 - 44 years) worldwide [1]. Because 81.8% of the population of Turkey is young, it is important to know how to manage trauma patients in this country [2]. Patients older than 60 who have suffered trauma in motor vehicle accidents and those with craniocerebral, thoracic, or abdominal injuries are at higher risk of in-hospital mortality [3]. Appropriate interventions and rapid transportation of the patients from the site of trauma can prevent mortality and morbidity [4, 5]. This study examined the clinical characteristics and factors influencing mortality in trauma patients in the southeastern coastal region of Turkey.

This retrospective observational registry study used trauma registry data from the emergency departments (EDs) of Harran and Gaziantep Medical Schools and from the emergency services of hospitals in Sanliurfa collected between June 2008 and December 2008. These four centers provide 24-hour trauma services and receive both direct admissions and transfers from affiliated district hospitals. The registry included all trauma patients sustaining potentially severe injuries during the 6 months under study who warranted an initial evaluation or resuscitation in a trauma resuscitation room, including patients with unstable vital signs or suspected severe injuries. The clinical management of these patients followed a multidisciplinary approach and Advanced Trauma Life Support (ATLS) principles. The age, sex, mechanism of trauma, time of trauma, type of trauma, mode of transportation, time to hospital admission, procedures or interventions, Glasgow Coma Scale (GCS) scores, Revised Trauma Scores (RTS), length of hospital stay, and mortality rates were analyzed in terms of patient outcomes.

The statistical analyses were performed using SPSS v15.0 (SPSS, Chicago, IL, USA). Intragroup comparisons (survivors vs. non-survivors) were performed using the Mann–Whitney U-test and χ² test. Data are presented as the means ± SEs (standard errors of the mean), with significance set at P < 0.05.

Approximately 140,000 patients were admitted to the ED during the 6-month study period. Of these, we evaluated 15,120 (10.8%) who had experienced trauma. The majority (67.9%) of patients were male, and the median patient age was 36.8 ± 0.7 (range: 4 - 84) years. Adults and children constituted 73.7% and 26.3% of the patients, respectively. Those 30 - 44 years of age accounted for a plurality (37.4%) of all trauma cases. The median time to arrival was 45 minutes. Motor vehicle accidents (MVAs) were the most common cause of admission to the ED and accounted for 38.7% of all trauma admissions; falls were the second most common cause of admission, accounting for 36.8% of the cases. Other causes of trauma-related admissions to the ED were knife wounds and gun shots (8.1%), burns (7.8%), homicides (6.5%), and workplace-related accidents (2.1%). The mean GCS and RTS scores were 13 ± 0.6 and 9 ± 0.4, respectively.

Craniocerebral injuries (49%, n = 7405) were the most common injury, followed by extremity (35.8%, n = 5413), thoracic (29.7%, n = 4491), abdominal (17.6%, n = 2661), pelvic (10.8%, n = 1633), and spinal cord (10.2%, n = 1542) injuries. Although 79.9% of the cases (n = 12,081) were discharged after treatment in the ED, 16.3% (n = 2,464) were referred to various departments for hospitalization, and 3.8% (n = 575) were admitted to the intensive care unit (ICU). The most common departments for admission were neurosurgery and orthopedics. The mean lengths of stay in the ICU and clinics were 14.7 ± 0.6 and 9.4 ± 0.8 days, respectively.

Motor vehicle accidents were the most common cause of admission to the ICU and accounted for 47% of trauma-related admissions to the ICU; falls were the second most common cause, accounting for 29% of such admissions. Additional causes of trauma-related admission to the ICU were homicides, knife wounds, gun shots, burns, and other types of injuries. The demographic characteristics of patients and the types of trauma are summarized in Table 1.

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Table 1. Demographic Characteristics and Types of Injury Among 15,120 Trauma Patients

The overall mortality rate was 3.8% (n = 575); the mortality rate was 4.7% (n = 487) in males and 1.8% (n = 88) in females (P = 0.005). The median age of those who died was 47.8 ± 0.9 and that of those who survived was 29.7 ± 0.4 years (P = 0.008). The mortality rate increased with age and was 25.6%, 27.9%, 31.4%, 44.8%, 60.2%, and 71.3% for those 0 - 15, 16 - 29, 30 - 44, 45 - 59, 60 - 74, and ≥75 years of age, respectively.

The median time to hospital arrival was 130 minutes among those who did and 42 minutes among those who survived (P = 0.003); the mean GCS score was 7.5 ± 0.3 among those who died and 12.8 ± 0.6 among those who survived (P = 0.026); and the mean RTS score was 8.7 ± 0.5 among those who died and 11.5 ± 0.7 among those survived (P = 0.038). Mortality occurred most frequently in the ICU (60.7%, n = 349), whereas the mortality rate was 7.5% (n = 184) at various departments. A small proportion of patients (0.34%, n = 42) died in the ED (P = 0.007). Of those who died, 84% had cranial injuries (P = 0.003) and 43.5% had thoracic injuries (P = 0.006). Hospital procedures or interventions (e.g., intubation or cardiopulmonary resuscitation) were performed on 88% of those who died and on 43.5% of the survivors (P = 0.029). Survival and mortality according to sex and hospital admission were presented in Table 2. Predictors of trauma-related death were summarized in Table 3.

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Table 2. Surviving and Non-Surviving Patients According to Sex and Route of Admission to Hospital

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Table 3. Predictors of Trauma-Related Death in Patients

Injuries are a major and preventable public health problem in terms of morbidity, premature mortality, or disability. About 5.8 million people worldwide die annually from injuries, and the projections for 2020 show that 8.4 million deaths are expected annually [6, 7]. The ED plays a vital role in managing injuries. Trauma requires an immediate and precise diagnosis [8] and is a significant problem in southeastern Turkey. According to our data, 10.8% of the 140,000 patients admitted to the ED during the 6-month study period had suffered trauma. Most injuries were suffered by those 16 - 44 years of age (57.6%), especially those 30 - 44 years of age (37.46%). By contrast, patients > 75 years of age accounted for only 0.65% of all admissions. Similar findings have been reported by other studies [9-11]. It is also clear that the involvement of those 16 - 44 years of age, the most productive group in society, in trauma-related injuries constitutes a huge economic loss to the country.

The preponderance of males among those injured is consistent with data from the World Health Organization (WHO) and the studies conducted by Ghaffar et al. [12], Mock et al. [13], and Moshiro et al. [14]. Similar to other findings, more males than females suffered from all types of injuries; our study identified 10,262 (67.9%) injured males and 4851 (32.1%) injured females.

Motor vehicle accidents are among the 10 leading causes of death and disability worldwide and have emerged as a serious public health concern [15]. According to a literature review, falls from heights were the most common cause of admission to the ED and the fourth leading cause of trauma-related death [16]. Additionally, falls from heights are a preventable health problem among adults [17]. In our study, MVAs were the most common cause of admission to the ED, and falls were the second most common cause. To ensure a safe environment, continuing health education programs focused on injury and prevention should be directed at parents and children, and legal measures to prevent injuries should be enacted.

The first 60 minutes after trauma is called the “golden hour” [18]. In our study, the median time to hospital arrival was 45 minutes: 130 minutes among those who died and 42 minutes among the survivors. We suggest that the hospital mortality rate for trauma-related patients has dropped because of the early administration of appropriate treatment. According to the WHO data for 2000, an estimated 5.2 million injury-related deaths occurred worldwide, comprising almost 9% of all deaths [19].

Most studies in which data have been analyzed according to sex have shown that both fatal and nonfatal injuries occurred more frequently among males than females [20, 21]. The overall mortality rate in our study was 3.8%, similar to that reported by Murray et al. [22] and close to the 4% reported by Bulut et al. [16] and the 2% reported by Meller and Shermeta [23]. According to our data, the ratio of the mortality among males to that among females was 2:7.

Tan et al. [24] demonstrated that increasing age was a risk factor for mortality after trauma. We also found that the mortality rate increased with age and identified the highest mortality rate (71.3%) among those 75 years and older and the lowest mortality rate (25.6%) among those 0 - 15 years of age. In our study, the mean age of those who died was 47.8 ± 0.9 years, and the mean age of those who survived was 29.7 ± 0.4.

Several studies have reported that the head region was the most commonly injured in the body [16, 25]. Bulut et al. [16] reported that injuries to the extremities were the second most common injury and that pelvic and vertebral injuries were seen less frequently. In our study, craniocerebral injuries were the most common type of injury, comprising 49% of injuries. Injuries to the extremities were the second most common injury, comprising 35.8% of injuries. Pelvic and spinal cord injuries were rather rare (10.8% and 10.2%, respectively). Head and thoracic injuries were related to significant rates of mortality (84%) in our study, and most of these involved severe craniocerebral injuries. The incidence of thoracic injuries was 43.5% among those who died and 21% among those who survived. Agalar et al. [26] found significant relationships between mortality and the Injury Severity Score (ISS), age, and RTS. In our study, the mean RTS and GCS score were significantly lower in non-survivors (both comparisons, P < 0.05) than survivors.

Hospital emergency-department-based injury registries are very useful in epidemiological studies of injuries. Frequent causes of trauma in our region are traffic accidents and falls from heights. Type of trauma, mechanisms of trauma, rapid arrival at the hospital, hospital procedures or interventions, age, and trauma scores can be used to predict mortality in trauma patients. The majority of trauma patients who present to the ED are treated at this location. Thus, observations in the ED may reveal details of injuries and demographic characteristics and can contribute to the prevention of mortality-related trauma and the development of more organized systems of trauma care.

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Journal of Current Surgery is published by Elmer Press Inc.