Trauma registry--needs and challenges in developing countries.

807 Injury is a leading cause of morbidity and mortality in both the developed and the developing world.1,2 In Pakistan, injuries are the second leading cause of disability, 11th leading cause of premature death, and the fifth leading cause of healthy years of life lost per 1000 people.3,4 Apart from motor vehicle injuries and homicides, reliable information on the event, type and nature of injuries and their outcomes is not available. Reasons for lack of information include absence of a comprehensive national trauma data base.2,5,6 Data for injuries in many countries including Pakistan are obtained from Police. These data underestimate injury burden and provide no information on the types of injury, short and long term outcomes and quality of trauma care.2,5,7, Surveys, another source of data while comprehensive in terms of injury burden estimates, are often costly and lack the "real-time" impact.2,6 Facility or ambulance based surveillance on the other hand lack the depth of information required to effect quality of care improvements.8 One of the methods used to collect information on the quality of trauma care is through the use of Trauma Registry (TR). 7,9-11 TRs are an integral part of trauma systems data collection and outcome assessment methodology in most developed trauma systems.12,13 Evidence supports an improved trauma care through the use of functionally active and well organized trauma registries.12-16 In simple terms, trauma registry is a system of data collection that serves as a source of information for the evaluation of trauma care for a specific set of injured patients meeting well defined inclusion criteria.9,11,12 Primarily it consists of hospital based trauma data, and often contains information obtained from the Emergency Medical Services (EMS) and rehabilitation. Besides demographic information, A TR typically collects information on the type, cause and severity of injury; details of the care provided at various levels of care system (EMS, Emergency Department, Operating Room, ICU, Ward, Rehabilitation Units etc); outcome in terms of death and disability.11,16 TR also estimate the probability of death of a given patient compared to a patients with similar severity of injuries in the larger database from multiple centers.17 This information gives institutions an estimate of their performance compared to peer institutions. Data thus obtained is used for accreditation, verification and designation of trauma centers as well as the credentialing of health care providers.11 There are many challenges in implementing TR in developing countries though there is an interest in many developing countries such as Uganda, Ethiopia, Egypt and Haiti.7,18 First, obtaining the registry software can be a daunting task. Developing one locally is possible though it can be time consuming and requires collaboration between health care professionals and software developers. Clarity is needed on the choice of essential variables, type of data repository capable of storage of large amount of information, coding system backup, and data processing and analysis tools. The success of the software also depends upon the operating system requirements, its functionality as standalone vs. web-based database, hardware requirement such as disk space, server and backup systems.11 Implementation is often a bigger challenge requiring planning, continuous commitment, training, monitoring and evaluation. Obtaining buy-in from all stakeholders is the first challenge in successful implementation. It requires high level of commitment to the quality for the institutions and individual providers to open themselves up to the possible undesirable quality indicators. Secondly, the training human resources in medical terminology, data extraction, ICD coding, injury severity scaling and survival probability is essential. The third challenge is designing a data collection strategy to access patients' confidential data while conforming to the institutional guidelines and policies. Fourthly, data validation for timeliness, completeness and accuracy is of paramount importance to ensure their utility in meaningful interventions. Cost which is often a source of concern for developing country institutions can be reduced by limiting collection of redundant information.9 In summary, TR could play a vital role in filling the gap of injury information for health related outcomes in Pakistan. It will also help enhance trauma care quality by identifying trauma system gaps and practice improvement opportunities. The data generated through the registry could also be used for public health surveillance, injury research, economic analysis, and public policy interventions. Buy-in from health care leadership, a cost-effective and practical Editorial