# Presentation: 136113

## Carme Clavel -Arcas Alberto Concha-Eastman CDC- PAHOICE Injury Statistics Meeting Cuernavaca, Mexico June 1-2, 2005 

**Implementing a Hospital- based Injury Surveillance Systems in Nicaragua , **
**El Salvador and Colombia **

## Where we are working  

**CALI**

**Where we are working **** **

**Notes:**
1. Assisted in establishing a landmine/UXO injury surveillance system in Kosovo
August, 1999
2. “Rapid Response Landmine/UXO Injury Surveillance System “ 1999 
`Post-conflict settings
`Nicaragua ( CDC) Ethiopia ( WHO )
  Packaged” surveillance system, OGH Grant $60,000
3. Expand to include all injuries
4. Pilot test WHO- CDC “ Injury Surveillance Guidelines “ for less-resourced countries 
		Nicaragua 2000  
		Colombia 2001
		El Salvador 2001
5. Pilot test ICECI ( Cali, Colombia 2002 ) 
6. Regional Workshop , El Salvador, January 2003 
7. Evaluation Workshop, Cali, April 2005 

## Countries  

**Nicaragua ( 2000 )**
- 2 in the capital
- 3 departmental
**El Salvador** **( 2001)**
- 2 in the capital
- 6 departmental
**Colombia**, **Cali ( 2001)**** **
- 5 in Cali
- 1 Santander de Quilichao

**Notes:**
Nicaragua since 2001 with 2 hospitals now  5 hospitals since 2003.Two in Managua, the capital ( trauma and pediatric ) , Jinotepe, Leon, Jinotega
El Salvador : national reference for trauma and pediatric  
3 hospitals since 2002  ,since 2005 8 hospitals : San Salvador(2 ) , Chalatenango, San Miguel, Santa Ana, Zacatecoluca, Santa Teresa
Colombia since 2004 : 6 hospitals 
5 in Cali San Juan de Dios; Universitario del Valle;Mario Correa;  Siloe ; Fundacion Valle del Lili; 
1 in Santander de Quilichao 

## Evaluation of Hospital Injury Surveillance Systems 

**Evaluation of Hospital Injury Surveillance Systems **
**in Nicaragua, El Salvador and Colombia**

**International Workshop****  **
**Cali, Colombia 6- 8, 2005**

## Evaluation Methodology 

**Qualitative component**
- Hospital description
- Timeline
- Flowchart
- Simplicity, acceptability
- Goals, obstacles, needs
- Data: dissemination , use , timeliness

**Quantitative  component**
- Sensitivity
- Predictive Value
- Completeness
- Quality of data entry
- Costs

- Based on a standardized template

## Hospital description : Injury Surveillance System

**Hospital description : Injury Surveillance System**

**Data analysis  **

**Statistician & Epidemiologist **
**Data entry and quality control **

**Identification of injured person**** **

**Fill out Format**

**Dissemination of the results  **

**Intervention for Injury Prevention **

**Notes:**
Participatory Approach 
1. Promote a technical committee in every hospital 
2. Agreement to develop the forms to be complete in Emergency Rooms 
3. Sources of information and stakeholders
4. Selection local technical coordinator
5. Timelines
6. Training

----------------------------------
So how does an emergency room injury surveillance system work?

First, the patient arrives in the hospital emergency room. They may have first had an interaction with the police or social workers who directed them to the hospital. 

Once they arrive in the emergency room, the patient is identified as injured. They may have been injured in a road accident, through an act of violence, drowning, burns, self-inflicted wounds or a myriad of other violent or unintentional means. 

Once the doctors triage the injured patient, they will complete a standardized national injury form. In many cases, this form is included in hospital’s admissions form, for convenience. 

A statistician in each hospital will collect all the forms on a daily basis, and input data into a basic computer statistics program such as EpiInfo. The variables they will consider include age, sex, type of injury, cause of injury, and location of injury. They may also include what the patient was doing at the time of the injury. 

This data will all be collected and analyzed by the epidemiologist, who will then work with the hospital to provide it to the Ministry of Health in a timely manner. The analyzed data will also be sent back to the doctors who collected it originally, because it may be useful to them as they plan hospital priorities. The data may be published in a national bulletin or journal, and also shared at national and international conferences. 

The results of this data can then be used by public health officials and governments to make policies that can reduce injuries. For example, in El Salvador, once it was discovered that a large percentage of their motor-vehicle related injuries were occurring along the same stretch of road, they were able to put up barriers and reduce the number of injuries in that area. 

The injury surveillance system should continue to function autonomously, providing monthly data that can be used to uncover seasonal or larger annual trends. 

## Case Definition

**First visit **
**to the hospital **
**Emergency**
**Department for**
**any type of injury**

**Notes:**
Per ICD 10 Chapter Definition 
INCLUDES
Fatal and nonfatal, Intentional, Unintentional, Landmine, Work-Related
EXCLUDES
Pain without injury, Psychological injury, Food poisonings, Chronic illness

## Manual Data Collection

**	****Hospital Emergency Department Medical Record (Intake Form)**

**Notes:**
Now : the surveillance- form is the Emergency Record for all patients going into the ER, is not an extra paper. Except in one hospital in Cali 

## El Salvador format for the Injury Surveillance System in  ER

## Slide 10

## Slide 11

## Slide 12

## Results

**Nicaragua team**

**Policies working group**

**Group**

## Achievements 

- Injury data collection in ED is possible
- Health authorities are interested
- Extension of injury surveillance
- Creation of injury prevention programs
- Promote intersectorial injury mortality surveillance
- Data being used to make decisions

**Notes:**
Is possible with quality 
Health authorities are interested to expand and to create injury prevention programs like in El Salvador approved “ Injury Prevention Program “ inside the MOH in Nov 2004. MOH in Nicaragua wants to extend the system to all public hospitals 32

## Results - Components

**Qualitative**
- Staff rotation
- Training diverse
- Interruptions at the beginning
- Flowchart was considered simple
- “ *they don’t have enough time* “
- More action than information

**Quantitative**
** **
- 10- 35 % of ER visits are injuries
- 75- 95 % unintentional
- 23-4 %  intentional -violence
- 2-1 % self inflected
- 70 % young male
- Falls main mechanism

**Notes:**
Qualitative 
High levels of staff rotation in the hospitals
Training diverse between hospitals  
At the beginning of the process interruptions were key ( Salvador ) 
Flowchart was considered simple, but wasn’t  followed systematically 
Most important reasons for not accept the system is “ they don’t have enough time “
More action than information in some places
Quantitative component 
Falls is the most important mechanism follow up by blunt force, stab/cut and motor vehicle , men vehicle is the 3.
Less 5 years old more than 60 years old 

## Injury Pyramid Pediatric Hospital. San Salvador 2004

** ****34**
- Deaths

**	****2486**
-   Hospitalizations

**9495 **
-     Injury Emergency Visits

- Injuries in the community ?

**6 % of all deaths**** **

**33 % of all emergency **
**visits****  **

**17 % of all  hospitalizations**

- 1

- 73

- 279

**Ratio **

**Notes:**
All deaths : 561 
(6 % )
All  hospitalizations: 
14,247 (17.45 %) 
All emergency visits  
28,576 ( 33% )

## Colombia :  Percent of ER visits due to injury, Sensitivity, Predictive Value Positive

| Hospital | % injuries/
ER visits 
 | Sensitivity % | PVP % |
| --- | --- | --- | --- |
| HUV – L3 | 50 | 76 | 99 |
| FVL – L3 | 11 | 73 | 83 |
| HFPS – L2 | 21 | 60 | 95 |
| HMCR-L2 | 20 | 92 | 84 |
| HSJD- L2 | 23 | 69 | 86 |
| CSS – L1 | 14 | 64 | 90 |

**Notes:**
In the Universitary pediatric hospitals injuries represent the 50 % of visits 

## Data quality : Percent of Missing Data in two 

**General Hospitals . 2004 **

| Variable | El Salvador 
N = 4,890
 | Nicaragua 
N= 8, 120  |
| --- | --- | --- |
| Age | 1 | 0.1 |
| Sex | 0 | 0 |
| Place injury occurred  | 2 | 98  |
| Day event  | 27  | 99 |
| Intentionality | 0 | 0 |
| Activity | 0 | 0 |
| Mechanism | 0 | 0 |
| Alcohol Use  | 20 | 97 |
| Nature of Injury  | 0 | 0 |
| Disposition  | 9 | 0 |

**Notes:**
Hospital HEODRA

## Data quality : Percent of Missing Data in two 

**General Hospitals . 2004 **

| Variables : 
Specific Modules  | EL Salvador 
Cases  | %  Missing data  | Nicaragua
Cases  | % Missing data  |
| --- | --- | --- | --- | --- |
| Person injured or road user  | 574 | 4 | 
978 | 
0.1  |
| Relationship of perpetrator to victim  | 364 | 12 | 
702 | 
0.1  |
| Precipitating Factors  | 61 | 38 | 
141 | 
0 |

## Data Entry Quality : Pediatric Hospital El Salvador, 2004 

| Variable | % |
| --- | --- |
| Age | 100% |
| Sex | 100% |
| Address of event  | 94% |
| Day of event  | 100% |
| Intentionality  | 100% |
| Activity | 100% |
| Mechanism | 100% |
| Alcohol Use  | 94% |
| Nature of Injury  | 100% |
| Disposition  | 88% |
| SPECIFIC MODULES : |  |
| Person injured or road user   | 100% |
| Relationship of perpetrator to the victim   | 80% |
| Precipitating Factors  | 100% |

**Data Entry Quality : Pediatric Hospital El Salvador, 2004 **

## Dissemination data

**Nationally **
- National Electronic Bulletins ( Nicaragua )
- Hospital Electronic Bulletins ( El Salvador )
**Internationally **
-  Last two Injury World Conferences

**Notes:**
Nicaragua 
13 editorials related to injuries ( 2003- 2004 ) :burns, attempts of suicide, pesticides, VAW, youth violence, etc. 
El Salvador 
Bloom and Rosales
Other international conferences : Atlanta 
Vietnam 
El Salvador
Puerto Rico 

## Results- Interventions  

- Campaign against burns by “ pólvora “
- Bicyclist Injury Prevention Plan
- “ Life Campaign”
- Summer Prevention Plan
- Improvement of conditions at hospital level

**Notes:**
Campaign against burns by “ polvora “ gunpowder ( December 2003 ) 
Media campaign 2003, 2004 
Approved regulation from the Congress to control of gunpowder 2004 
Strength the capacity to attend burns in Bloom ( “Burning Unit “ 2004-2005 
Bicyclist Injury prevention Plan in Nueva Concepcion with intersectorial participation : MOH, Justice, Police, Transportation, Mayor Office, NGO, high school students, etc. 
Data from the System was used to describe and  monitor the problem
Proposals : road safety education , road safety park , promote use of helmet, regulation, etc
Improve the conditions at hospital level in San Juan de Dios in Cali, Colombia and in Bloom with the Burns Unit 

## Challenges ~ Recommendations 

- Strengthen quality of data
- Reduce minimum data set
- Improve the dissemination of data, especially through articles
- Increase injury research
- Identify best practices for injury prevention

**Notes:**
Strengthen the quality of data : In place “ adapted “ Manual of procedures 
Minimum data set : alcohol use, injury modules ( relationship , road user, precipitating factors ? ) 
Methodology must be flexible
Improved data dissemination : Increase the users of data 
Use of System to identify the research questions, Initiated Cost studies
Include the system inside the health public agenda ( Cali, Colombia ) 
Include the evaluation inside the interventions 
Best practices , for the priorities in every country road traffic, violence, suicide,...including the evaluation in the process 

## Next steps 

-  Develop a methodological plan for Injury Information System in the Americas ( PAHO ) :
- Hospital Based : CAREISS
- Mortality data ( Observatorios Municipales )
- Specific topics like Intimate Partner Violence/ Sexual Violence

## THANKS  to the technical teams and the hospital staff  in the three countries

**Carme Clavel-Arcas**
- e-mail: _[zgn4@cdc.gov](mailto:zgn4@cdc.gov)__ _
**Alberto Concha- Eastman**
- e-mail : _[conchaal@paho.org](mailto:conchaal@paho.org)__ _
- _[www.cdc.gov/ncipc](http://www.cdc.gov/ncipc)_
- _[www.paho.org](http://www.paho.org/)__ _