Introduction

Injuries are a serious cause of mortality and morbidity worldwide, with trauma being the
leading cause of death in the first four decades of life. In 2013, injuries accounted for 10% of
the global burden of disease with over 90% of injury-related deaths occurring in poor
resource setting countries. [1] As rates of injury in high-income countries decline, low
income countries are experiencing an increase, largely due to a rise in road traffic cases. [2]
In 2013, an estimated 973 million people sustained injuries and 4.8 million people died from
injuries globally. [1]

In 2015 as per World Health Organization report globally, 5.1 million people per year have
been reported to die due to injury, accounting for around 9.2% of global mortality [3]. The
magnitude and burden of injuries and violence are more devastating in developing
economies, with more than 57% of the injury burden concentrated in low and middle income
countries (LMICs) [3]. Among LMICs mortality due to road injuries has been projected to
rise by 60% from 2015 to 2030, falls by 43% and self-inflicted injuries by 23% [3]. Injuries
are the second most common cause of death after 5 years of age in India [4]. As per the
National Crime Records Bureau (NCRB) report, there was a 51.8% increase in unintentional
injury deaths and a 23% increase in suicidal deaths from year 2002 to 2013 [5]. Moreover
from an economic viewpoint, injuries are the leading cause of death in the economically
productive age group of 15–29 years [6].

Further, a large population of predominantly young people along with high vehicular density
makes the problem of road traffic crashes even more significant in an Indian context [7]. The
economic growth has also meant a rapidly increasing Frequency of vehicles sold every year
(around six million) and one of the highest reported mortality rates from road traffic injuries
in the world. [8] Traffic fatalities have increased by about 5 % per year from 1980 to 2000,
and since then have increased by about 8 % per year [9]. The burden of traumatic injuries in
India is certainly high, but remains ill-defined and poorly quantified.

Injuries account for nearly one-tenth of the total deaths in India and are the leading cause of
death among persons aged 15–29 years—the economically productive age group.[10-12]
Injuries rank among the leading causes of morbidity and mortality in the world with a steady
increase in developing countries like India. About 5.8 million people die each year as a result

1
of injuries. This accounts for 10 % of the world’s deaths, 32 % more than the Frequency of
fatalities that result from malaria, tuberculosis and HIV/AIDS combined [13]

According to the National Crime Records Bureau report in India, there was a 62.9% increase
in unintentional injury deaths and a 15.8% increase in suicidal deaths during the period 2004–
2014.[14] It is estimated that between 2004 and 2030, injury-related deaths will increase by
30%. Individuals with injuries continue to face significant risks of hospitalization and the
associated burden of high costs of financing care. A review of the evidence in LMICs shows
the devastating financial burden of injury care on households.[15] Estimating the cost and
economic burden of injuries was identified among five priority items to address the global
burden of unintentional injuries.[16]

In 2015 based on NCRB report [17] total 4, 13,457 accidental deaths reported in which
Maharashtra has reported highest Frequency (64566). Highest rate of accidental deaths was
reported from Chhattisgarh 19273 (75.1) in year 2015(per lakh population) which is very
high as per national accidental average death rate (32.8). In 2015 in India traffic accident
cases were 496762 out of which 177423 died. In Chhattisgarh total reported accidental cases
was 14977 out of which 4613 died. In India poisoning cases was reported to be 27657 out of
which 26173 died. In Chhattisgarh total poisoning cases were 2059 out of which 2059 died.

There are currently no comprehensive studies, to our knowledge, that document the burden of
road traffic injuries in India and Chhattisgarh. Systematic and scientific efforts in injury
prevention and control have gained little momentum, largely due to lack of data on the
epidemiology of injuries. Data on injuries is essential to prioritize evidence based safety
strategies and prevention efforts. Reliable estimates on injury burden and pattern will also aid
in organization and delivery of acute trauma care.

Thus, there is greater emphasis on the need to generate reliable and consistent information on
the pattern and distribution of injuries so as to design effective prevention strategies.
Consequently, injury surveillance systems are widely gaining ground as a tool for collecting
such systematic data on injuries. Although they are well-developed in high resource settings,
they are almost non-existent in resource poor Low and Middle income countries (LMICs).

This study describes the experience of setting up an Injury Surveillance System in a Tertiary
Level Hospital in India and the pattern of injuries encountered therein. It also aims at

2
exploring the feasibility of a Tertiary level hospital-based surveillance system in a resource
poor setting with high injury burden and also to understand its challenges and constraints.

3
 Research Question

What is the outcome of the patient reaching to Dr.BRAM hospital emergency department
(Casualty) due to accidental injuries; in terms of recovery, disability or death from March
2018 to February 2019 by systematic analysis of data?

4
 Aims &Objectives

1. To estimate the outcome of the patient reaching to Dr. BRAM hospital emergency
department (Casualty) due to accidental injuries; in terms of recovery, disability or
death from March 2018 to February 2019.
2. To know the associated Factors (patient related factors, vehicle related factors, event
related factors) related to patients morbidity/mortality.

5
 Review of Literature

Review of literature in categories’ as general and specific review of literature. General

literature talks about general description of injuries, whereas specific shows the focused
studies on injuries and other associated factors.

General review of literature

What is an injury?

The standard definition of an “injury” as used by WHO is: “Injuries are caused by acute
exposure to physical agents such as mechanical energy, heat, electricity, chemicals, and
ionizing radiation interacting with the body in amounts or at rates that exceed the threshold of
human tolerance. In some cases (for example, drowning and frostbite), injuries result from
the sudden lack of essential agents such as oxygen or heat”

An injury is the physical damage that results when a human body is suddenly or briefly
subjected to intolerable levels of energy. It can be a bodily lesion resulting from acute
exposure to energy in amounts that exceed the threshold of physiological tolerance, or it can
be an impairment of function resulting from a lack of one or more vital elements (i.e. air,
water, warmth), as in drowning, strangulation or freezing. The time between exposure to the
energy and the appearance of an injury is short.

The energy causing an injury may be:

• Mechanical (e.g. an impact with a moving or stationary object, such as a surface, knife or
vehicle)

• Radiant (e.g. a blinding light or a shock wave from an explosion)

• Thermal (e.g. air or water that is too hot or too cold)

• Electrical

• Chemical (e.g. a poison or an intoxicating or mind-altering substance such as alcohol or a

drug).

In other words, injuries are the acute, physical conditions listed in Chapter XIX (Injury,
poisoning, and certain other consequences of external causes) and Chapter XX (External

6
causes of morbidity and mortality) in the International Statistical Classification of Diseases
and Related Health Problems, Tenth revision (ICD-10) [18].

Whereas the above definition of an injury includes drowning (lack of oxygen), hypothermia
(lack of heat), strangulation (lack of oxygen), decompression sickness or “the bends” (excess
nitrogen compounds) and poisonings (by toxic substances), it does NOT include conditions
that result from continual stress, such as carpal tunnel syndrome, chronic back pain and
poisoning due to infections. Mental disorders and chronic disability, although these may be
eventual consequences of physical injury, are also excluded by the above definition.

The most common events causing injuries are: 1) interpersonal violence and sexual abuse; 2)
collective violence including wars, civil insurrections and riots; 3) traffic collisions and 4)
incidents at home, at work and while participating in sports and other recreational activities.

Types of injury

Injuries may be categorized in a Frequency of ways. However, for most analysis purposes
and for identifying intervention opportunities, it is especially useful to categorize injuries
according to whether or not they were deliberately inflicted and by whom. Commonly used
categories are:

• Unintentional (i.e. accidental);

Unintentional injuries account for about two thirds of all injury deaths in the India. Almost
half are attributable to motor vehicle-related incidents. In Table 1, the mechanism of injury is
matched with the place of injury occurrence. Shaded boxes indicate locations where the
injury occurs most often.

• Intentional (Violence related injuries):

- interpersonal (e.g. assault and homicide)

- Self-harm (e.g. abuse of drugs and alcohol, self-mutilation, suicide)
- legal intervention (e.g. action by police or other law enforcement personnel)
- war, civil insurrection and disturbances (e.g. demonstrations and riots);

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• Undetermined intent.

Intentional Injuries (Violence-Related Injuries)

The World Health Organization (WHO) defines violence as:

The intentional use of physical force or power, threatened or actual, against oneself,
another person, or against a group or community, that either results in or has a high likelihood
of resulting in injury, death, psychological harm, maldevelopment, or deprivation.[19]

The three categories differentiate among violence a person inflicts upon oneself (self-
directed); interpersonal violence inflicted by another individual or by a small group of
individuals; and violence inflicted by larger groups such as states, organized political groups,
militia groups, and terrorist organizations.

Each broad category is subdivided into specific types of violence. Self-directed violence
includes suicidal behavior and self-abuse. Interpersonal violence includes two subcategories:
violence between family members and intimate partners, and community violence between

8
individuals who are unrelated (usually in a place other than the home). Collective violence is
subdivided into social, political, and economic violence. The social violence category
includes, for example, crimes of hate committed by organized groups, terrorist acts, and mob
violence. Political violence includes war and related violent conflicts, state violence, and
similar acts carried out by large groups. Economic violence includes attacks by large groups
motivated by economic gain. Clearly, acts committed by large groups can have multiple
motives.

A violent act can also be classified by its nature. The four categories are physical violence,
sexual violence, psychological violence, and violence involving deprivation or neglect. These
four types of violent acts occur in each of the broad categories described above—except self-
directed violence. For example, violence against children can include physical, sexual and
psychological abuse, or neglect. In the World Report on Violence and Health, [19] violence is
divided into three categories according to the person who commits the violent act and into
four categories according to the nature of the violence. The horizontal array shows who is
affected, and the vertical array describes how they are affected (Table 2).

According to WHO, an estimated 1.6 million people worldwide died in 2000 as a result of
self-inflicted, interpersonal, or collective violence. Nearly half of these deaths were suicides;
one third were homicides; and one fifth were war related. International estimates on physical
and sexual assaults are lacking, as systems for reporting and compiling these data are absent
in many countries, or are still being developed. There are often cultural and social pressures
to keep violence behind closed doors or to accept it as a natural facet of human relations.

9
Even in areas where surveillance systems are in place, victims may be reluctant to report
violent experiences.[19]

Epidemiology of injuries

Epidemiology is a specialized field of medical research with its own vocabulary. Generally
speaking, however, the term refers to the study all the factors that interact with each other to
account for the presence or absence of disease or injury.2 In the epidemiology of injury, as in
the epidemiology of disease, these factors can be categorized as:

• The host (i.e. the person injured)

• The agent (i.e. the force or energy)

• The vector (i.e. the person or thing that applies the force, transfers the energy or prohibits
its transfer)

• The environment (i.e. the situation or conditions under which the injury happens).

Models to analyze the epidemiology of injuries

The four factors that are involved in injury, and the relationships between them, are
illustrated in the diagram below (see Figure 1). The example given is based on an incident in
which a man is injured when his motorcycle slides and crashes on a slippery roadway

10
Using a model of this type can help to identify all the factors involved in an injury. It also
helps people to think about where they might intervene to prevent such injuries from
happening in the future or to reduce the harm done when they do happen. For instance, in the
motorcycle collision model, there may be things about the rider, the motorcycle or the road
that contributed to the crash. Perhaps there are things about motorcycle riders, motorcycles
and/or road conditions that could be changed in order to prevent similar incidents in the
future. Possible interventions that might occur to anyone thinking about the four elements of
the motorcycle collision model are given in Table 3.

Factor Possible interventions

Host - Protect motorcycle riders with helmets and stress-resistant
clothing
- Provide better physical therapy to help people recover from
injuries more quickly and more fully
Agent - Lower speed limits to reduce the energy involved in collisions
Vector - Ban the production and importation of motorcycles that are
capable of speeds well in excess of maximum permissible
limits
- Improve the design or features of motorcycles so they are less
likely to slide out of control (e.g. require tyres with better
traction)
Environment - Reduce the smoothness or oiliness of road surfaces in order to
provide better traction Use road signs or speed bumps to slow
down vehicles on bends

Table 3: A motorcycle collision model: possible injury prevention strategies

Using the injury spectrum

The so-called “injury spectrum” is another useful device for analysing injuries. The injury
spectrum, which is illustrated in Figure 2, maps an injury over time, starting with the host’s
exposure to a hazard, followed by the event, through to the occurrence of the injury and
finally the possible resultant disability and/or death.

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Like the injury model described previously, the injury spectrum helps people to think about
what happened in a particular case and how interventions might have prevented the injury
from happening or reduced the damage done.

The Injury Pyramid

Mortality data are a powerful injury indicator, but deaths from injury comprise just a fraction
of the impact of injuries on a population. For each death from injury, many more result in
hospitalization, emergency department or general practitioner treatment, or treatment that
does not involve formal medical care.

According to WHO, in the world’s high-income countries, for every person killed by injury,
30 people are hospitalized, and 300 are treated in emergency rooms; even more are treated in
other health care facilities. This does not reflect the situation in developing countries, which
have fewer resources for prevention, treatment, and rehabilitation of injuries. In all countries,
people of low income are especially prone to injury and are less likely to survive or recover
from disability.[19]

The injury pyramid shown in Figure 3 helps illustrate this fact. The pyramid top is composed
of deaths, which are fewer in Frequency, but more visible. Following deaths are severe
injuries resulting in hospitalization and disability, usually classified by health sector, public
or private. The third category is less-severe injuries, requiring emergency treatment. Next are
injuries treated in basic health facilities. At the bottom of the pyramid are injuries which do
not receive attention in a health institution. Estimates of these injuries can only be obtained
through surveys or special research. For instance, a survey conducted in Nicaragua of 10,000
households showed that only 1 in 10 injured persons visited a local hospital for treatment.
[20]

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 Fatal
Injuries

Injuries resulting
in hospitalizations

Injuries resulting in visits

to emergency departments

Injuries resulting in visits to

primary care facilities

Injuries treated outside the health system, not

treated , or not reported

Figure 3-Injury Pyramid

Changes between 1990 and 2013—all injury

Between 1990 and 2013 injury DALY rates have declined by 30.9%, an annualized rate of
decline of 1.6%. Table 4 shows the global incidence and deaths by cause of injury. Injuries
accounted for 10.1% (UI 9.5 to 10.8) of the global burden of disease in 2013. YLLs were
responsible for 85.2% (UI 81.2 to 88.7) of injury DALYs. The proportion of DALYs due to
disability (YLD) is much higher for collective violence (69.1%; UI 54.3 to 81.8), falls
(46.4%; UI 38.3 to 54.1) and forces of nature (43.0%; UI 26.0 to 56.7). The main contributors
to injury DALYs are road injuries (29.3%; UI 26.4 to 32.2), self-harm (14.0%; UI 11.8 to
16.2), falls (12.0%; UI 9.8 to 14.1), drowning (8.7%; UI 6.3 to 11.2) and interpersonal
violence (8.4%; UI 6.5 to 10.4).

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 Table 4 : Global incidence and deaths by cause of injury with 95% UI, 2013
Incidence outpatient Incidence in-
injuries* patient injuries*
Cause of injury Rate per Deaths
Rate per
Millions Millions 10,0, (thousan Deat
10,0, 000
000 ds) h rate
Transport injuries 102 1176 12.3 142 1483 20.7
Road injuries 86 990 11 128 1396 20.7
Other transports injuries 17 186 1.3 15 87 1.2
Unintentional injuries (not
transport injuries) 758 8377 39.9 435 2007 28
Falls 134 1435 20.5 220 556 7.8
Drowning 0.9 10 0.8 9 368 5.1
Fire, heat and hot
substances 31 337 2.9 32 238 3.3
Poisonings 2.8 31 0.5 6 98 1.4
Exposure to mechanical
forces 383 4185 4.1 45 197 2.8
Adverse effects of
medical treatment 13 140 7.3 81 142 2
Animal contact 62 709 1.5 17 80 1.1
Foreign body 39 467 1 12 166 2.3
Other unintentional
injuries 94 1062 1.2 14 163 2.3
Intentional injury 30 336 3 34 1247 17.4
Self-harm 1.7 19 1.5 17 842 11.8
Interpersonal violence 28 317 1.5 17 405 5.7
War and disaster 26 383 1 17 50 0.7
Exposure to forces of
nature 5.4 76 0.3 4 19 0.3
Collective violence and
legal intervention 21 307 0.8 13 31 0.4
Total 916 8257 56.2 461 4787 66.9

*Inpatient injuries refer to injuries warranting hospital admission and outpatient injuries refer
to injuries warranting some other type of care. UI, uncertainty interval.

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 Specific Review of Literature

An analysis by Haagsma JA et al (2013) on the global burden of injury: incidence, mortality,

disability-adjusted life years and time trends from the Global Burden of Disease study 2013
shows that In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained
injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died
from injuries. Between 1990 and 2013 the global age-standardized injury DALY rate
decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22
cause-of-injury categories, including all the major injuries. Injuries continue to be an
important cause of morbidity and mortality in the developed and developing world. The
decline in rates for almost all injuries is so prominent that it warrants a general statement that
the world is becoming a safer place to live in. However, the patterns vary widely by cause,
age, sex, region and time and there are still large improvements that need to be made [21].

A study by R Dandona et al (2006) on Patterns of road traffic injuries in a vulnerable

population in Hyderabad, India revealed that Involvement in an RTC as a pedestrian or MTV
user was reported for 1513 (4.4%, 95% CI 4.2 to 4.6%) people in the last one year. In these
crashes, the person involved was an MTV user in 1264 (83.5%), aged 21–40 years in 973
(64.3%), and male in 1202 (79.4%). Six (0.4%) people died in RTCs and the cause was
collision with a vehicle/person in 1133 (75%) crashes. Among the 1306 people who were
injured and survived, 174 (13.3%) were treated as inpatients, 38 (2.9%) could not return fully
to routine daily activities, 630 (48.2%) took leave from their regular occupation, and 13 (1%)
lost their jobs following injury. Using a three month recall period, the annual incidence per
100 000 population of RTC as a pedestrian or MTV user was 2288 and of non‐fatal RTI was
1931, and that of fatal RTI using one year recall period was 17.3 in this population.These
findings on how RTI are caused, their type, and outcomes in pedestrians and MTV users can
assist in identifying interventions to improve road safety for this vulnerable population in
India, and can also be useful for monitoring the effectiveness of such interventions [22].

Another study by R Dandona et al (2008) on Incidence and Burden of Road Traffic Injuries
in Urban India found that The age-sex-adjusted annual incidence of non-fatal RTI requiring
recovery period of ≤7, >7-29 and ≥30 days was 13% (95% CI 12.6 to 13.4%), 5.8% (95% CI
5.5 to 6.0%) and 1.2% (95% CI 1.1 to 1.4%), respectively. The overall adjusted rate for non-
fatal RTI was 20.7 (95% CI 20.0 to 21.3%). The relative risk of RTI requiring recovery
period of >7 days was significantly higher in the third per capita monthly income quartile

15
(p<0.05). The incidence of non-fatal RTI was highest as a pedestrian, motorized two-wheeled
vehicle and cycle user, 6.4, 6.3 and 5.1/100 persons/year, respectively. Annual RTI mortality
and disability rates were 38.2 (95% CI 17.5 to 58.8) and 35.1 (95% CI 12.4 to 57.7) per
100,000 population [23].

An epidemiological study of road traffic accident cases admitted in a tertiary care

hospitalstudy by Pathak SM et al (2014)shows that Two-wheelers were the commonest
vehicle involved in vehicular accidents. Most accidents happened at a speed of 40–60 km/h
(37.9%). Most of the patients were aged between 20 and 30 years. Majority had a driving
experience of less than 5 years. Monsoons witnessed 46.7% cases. Most cases occurred
between 6 and 10 pm. Among severe injuries, the commonest was lower limb fractures
(19.8%) [24].

A study on Road use pattern and risk factors for non-fatal road traffic injuries among children
in urban India by R Dandona et al (2011) revealed that Boys (11.5) had a higher mean
Frequency of road trips per day than girls (9.6), and the latter were more likely to walk and
less likely to use a cycle (p < 0.001). With increasing household income quartile,the
proportion of trips using cycles or motorized two-wheeled vehicles increased while trips as
pedestrians decreased (p < 0.001). Based on the 3-month recall period, the age-sex-adjusted
annual rate of RTI requiring recovery period of >7 days was 5.8% (95% CI 4.9–6.6). Boys
and girls had similar RTI rates as pedestrians but boys had a three times higher rate as
cyclists. Considering the most recent RTI in the last 12 months, children of the highest
household income quartile were significantly less likely to sustain pedestrian RTI (0.26, 95%
CI 0.08–0.86). The odds of overall RTI were significantly higher for those who rode a cycle
(2.45, 95% CI 1.75–3.42) and who currently drove a motorized two-wheeled vehicle
(2.83,95% CI 1.60–5.00).These findings can assist in planning appropriate road safety
initiatives to reduce cycle and pedestrian RTI among children to reduce RTI burden in India
[25].

Another study by Rakhi Dandona et al (2008) on Underreporting of road traffic injuries to

the police: results from two data sources in urban India found that In the population-based
study, of those who had non-fatal RTI and sought out-patient or in-patient services, 2.3%
(95% 1.1% to 3.5%) and 17.2% (95% CI 3.5% to 30.9%) respectively, reported RTI to the
police. Of the non-fatal consecutive RTI cases who came to the emergency department,
24.6% (95% CI 21.3% to 27.8%) reported RTI to the police. In the population-based study,

16
77.8% (95% CI 65.1% to 90.5%) of the fatal RTI were reported to the police, and among
consecutive fatal RTI cases who came to the emergency department 98.1% (95% CI 95.5% to
100%) were reported to the police. Not necessary to report and hit-and-run case were cited as
the major reasons for not reporting RTI to the police [26].

A study by Ziyab Ah et al (2012) on Incidence and trend of road traffic injuries and related
deaths in Kuwait: 2000-2009 found that during this period 11,591 non-fatal RTIs and 3891
RTIs-related deaths occurred in Kuwait. Non-fatal severe RTIs accounted for 28.2% of the
total non-fatal RTIs. Of the 2945 RTI-related deaths that occurred from 2003 to 2009,
majority were amongst males (87.3%) and in the age range of 20-59 years (70.8%). The mean
(SD) annual mortality rates for the 10-year study period (2000-2009) were 14 (1) per 100,000
population and 36 (2) per 100,000 registered vehicles. From 2000 to 2009, population-based
and registered vehicle-based overall RTI-related crude mortality rates decreased by 20% and
29%, respectively. However, Poisson regression analyses showed that the overall slightly
decreasing trends were statistically non-significant both for population-based crude mortality
rate (trend coefficient=-0.016; p(trend)=0.587) and registered vehicle-based crude mortality
rate (trend coefficient=-0.024; p(trend)=0.192).[27]

Hyder AA et al (2006) estimated the burden of road traffic injuries among children and
adolescents in urban South Asia. They reported that the majority of injuries occurred in males
(67-80%) and the most frequent age group injured was between ages 0 and 9 representing
40% of cases. Children and adolescents represent an average of 22% of all those with RTI
whom seek care. Children and adolescents represented an average of 13% of all RTI deaths.
Regional RTI incidence rate was calculated at 880 per 100,000 urban persons aged 0-19.
Mortality due to RTI was at 17 deaths per 100,000 urban persons aged 0-19 in South Asia.
Burden of disease was calculated 16 HeaLYs per 1000 general population from road traffic
mortality alone. With disability data added, then 27.7 HeaLYs per 1000 general population
are lost from road traffic injuries in South Asia. The increasing burden of RTI in young
persons in South Asia is a call for considering appropriate research and effective
interventions. This relatively high loss of healthy life from RTI needs to be addressed by
public health systems in South Asia. [28]

A cross-sectional analysis of National Sample Survey 2014 study by JP Tripathy et al

(2014) on Cost of injury care in India found that The median expenditure per episode of
hospitalization due to any injury was US$156, and it was three times higher among the
richest quintile compared with the poorest quintile (p<0.001). There was a significantly

17
higher prevalence (p<0.001) of catastrophic expenditure among the poorest quintile (32%)
compared with the richest (21%). Mean private sector OOP hospitalization expenditure was
five times higher than in the public sector (p<0.001). Medicines accounted for 37% and 58%
of public sector hospitalization and outpatient care, respectively. Patients treated in a private
facility, hospitalized for over 7 days, in the poorest wealth quintiles and of general caste had
higher odds of incurring catastrophic expenditure.People who sustain an injury have a high
risk of catastrophic household expenditure, particularly for those in lowest income quartiles.
There is a clear need for publicly funded risk protection mechanisms targeting the poor.
Promotion of generic medicines and subsidization for the poorest wealth quintile may also
reduce OOP expenditure in public sector facilities [29].

A cohort study on Economic Burden of Hospitalization Due to Injuries in North India by

Prinja S et al (2016) revealed that Out of the total 227 patients, 60% (137/227) had sustained
road traffic injuries (RTI). The average OOP expenditure per hospitalization and up to 12
months post discharge was USD 388 (95% CI: 332–441) and USD 1046 (95% CI: 871–1221)
respectively. Mean OOP expenditure for RTI and non-RTI cases during hospitalization was
USD 400 (95% CI: 344–456) and USD 369 (95% CI: 313–425) respectively. The prevalence
of catastrophic expenditure was 30%, and was significantly higher among those belonging to
the lowest income quartile (OR-26.50, 95% CI: 6.70–105.07, p-value :< 0.01) and with an
inpatient stay greater than 7 days (OR-10.60, 95% CI: 4.21–26.64, p-value :< 0.01). High
OOP expenditure for treatment of injury puts a significant economic burden on families.
Measures aimed at increasing public health spending for prevention of injury and providing
financial risk protection are urgently required in India. [30]

A data analysis report of trauma center of Dr. RML Hospital, New Delhi (March 2016)
analyzed 162 case in reported from 1st march to 31st march 2016. 78% of injured cases were
male and 22% were females. Of them 92% were residing in urban areas. Out of 162 cases
(115) 74% had road traffic injury, (24)15% fall, (12) 8% assault, (5) 3% burns, (2) stab/cut.
Age wise classification for road traffic accidents shows that shows that 61/115 (53%) were in
age group of 20-35 years and of that 42 (61%) were use helmet. In Road traffic accident cases
69 (60%) were two wheeler rider. Out of 115 RTI cases 65 (57%) were died and 50 (43%)
recovered.

Data from Chhattisgarh Police website shows that in year 2018 instate total 13864 road
accidents took place in that 12715 people got injured and 4592 died. More than half of the
deaths were 18-35 years of age. People died were (27%) 1242 from urban area and (73%)

18
3350 were from rural area. In 2018 out of 4592 deaths in RTI accidents (47.8%) 2193 were
two wheeler users, 10% (461) were truck users, (9.5%) 435 were jeep/car/taxi users, (9.5%)
438 were pedestrians, (3%) 133 were bicycle users and (1.5%) 69 were auto users. Whereas
since, January –April 2019, 5081 accidents and 4922 injury cases reported. Half yearly road
traffic accidents report 2019 shows that 2775 people were died. Of that (32.6%) 876 were
two wheeler users, (21%) 652 were hit and run, (17.8%) 477 were truck users, (9.5%) 254
were car users, (8.7%) 234 were tractor users. [32]

Lakshmi PV et al (2016) did a pilot study of a hospital-based injury surveillance system in a

secondary level district hospital in India: lessons learnt and way ahead. A prospective study
was conducted during Jan-Dec 2012 at the emergency department of a District Hospital in
Fatehgarh Sahib in a North Indian state of Punjab. A total of 649 injuries were reported in
2012. The surveillance system used the existing resources at the hospital to collect data
without the need for additional manpower, equipments etc. About 78 % of injuries reported
were unintentional in nature. More than half (52.9 %) of the patients had injuries due to Road
Traffic Crashes. Head (29.7 %) was the most common site of injury. Incised injury (50.2 %)
was the most common type of injury and most of the injuries occurred while travelling
(61.8 %). [33]

Uthkarsh PS et al (2011) examined Profile of injury cases admitted to a tertiary level

hospital in South India. The objective of this study is to know the profile of the injury cases
admitted to M S Ramaiah hospital, Bangalore, India, using a cross-sectional study design for
six months, i.e. from Oct 2008 to April 2009. The mean age of the study population was 35.3
years (SD = 15.38), 69.1% were injured in road traffic accidents (RTA), 28.7% due to falls
and 2.2% due to burns. Nearly 14.4% were under the influence of alcohol. Nearly 73.6% of
RTA cases were two-wheeler users, 48.5% had not followed sign boards and 56.5% had not
obeyed the one-way rules, 63.5% of the two-wheeler users did not use helmets. Also, 38% of
two wheelers had two pillion riders, whereas 57% of four-wheeler users had not used a seat
belt. Among falls, 58% occurred at home, 49% occurred due to slippery surface. Road traffic
accidents were the most common cause for injuries, in which two wheelers were most
commonly involved. Strict enforcement of traffic rules and education on road safety are very
essential to prevent injuries.[34]

Suryanarayana SP et al (2010) did a Surveillance of injuries in a tertiary care hospital. A

total of 1055 cases of injures sought health care during the study period. The mean age of the

19
injured was 31.3 years (SD: 14.7 years). 745 (74%) of the injured subjects were between 15
and 44 years. 72.1% of injuries occurred within the Bangalore city. Road traffic injuries
continue to predominate the injury scene as 694 (65.8%) were injured on the road, 200(19%)
were injured at home, and 95 (9%) were injured at workplace. Poisoning was cause of injury
among 123(12.3%) followed by falls 68 (6.4%) and assault 62 (5.9%). 457 (65.8 %) of the
road traffic injuries occurred in city/ municipal roads, 105 (10%) occurred in the highway,
and around 54 (5.1%) occurred in rural roads. Among 694 road traffic accident patients, 304
(43.8%) were twowheeler riders, 87 (12.5%) two-wheeler pillion, 28(4.03%) three-wheeler
drivers, 43 (6.1%) car occupants, 19 (2.7%) car drivers, and 129 (18.5%) were pedestrians. It
was observed that nearly 55% of the road traffic injuries involved two wheelers among whom
only 198 (50%) used helmets. Thus any attempt to prevent and control RTI, this major risk
group has to be the target for focused intervention. Among the 62 car drivers/occupants
injured, only 12 (19.3%) had used seat belts. Among the injured, 702 (66.5%) were admitted
for medical/surgical care, 77 (7.3%) were treated in emergency room and referred to another
hospital, and 149 (14.1%) were treated in emergency room and sent home. At the end of
casualty management, 557 (52.8 %) improved, 44(4.2%) condition worsened, and 17 (1.6%)
died. [35]

A feasibility study on Bengaluru Injury/Road Traffic Injury Surveillance Programme by

NIMHANS in 2009 reported that 45% of all injuries were due to road traffic injuries, 10%
due to poisoning, 17% due to burns, and 7% due to falls. [36]

Singh A, et al. (2009)did Epidemiological Study of non-fatal road traffic accidents in

Rohilkhand Region. 195 cases agreed to participate in this study, thus giving a response rate
of 95%. Male outnumbered females and male/female ratio was approximately 2.5:1. The
maximum number of RTA were recorded in the age group of 25- 45 years accounting for
maximum 76(38.97%) of total RTA. Majority of victims were motorcyclist 66Majority of
victims were motorcyclist 66 (33.84%). [37]

Ganveer &Tiwari (2005) did a study to examine the Injury pattern among non-fatal road
traffic accident cases: a cross-sectional study in Central India. Out of total 423 subjects, 363
(85.8%) were male while only 60 (14.2%) were female subjects. Majority of the victims
(75%) were in the age group 18- 37 years. Sideways collision was the most common type of
accident seen in 269 (63.59%) cases. Two wheelers and LMV was the common vehicle being
involved in accidents (69.97%).[38]

20
Abhilash KP et al. (2016) reported profile of trauma patients in the emergency department of
a tertiary care hospital in South India. Most of the trauma incidents (65%) were the result of
an RTA. Two-wheeler accidents (46%) were the most common followed by pedestrian
injuries (7.8%), four-wheeler accidents (7.2%), auto rickshaw accidents (2.7%), and other
vehicular accidents (0.8%) which included trains, tractors, and large trucks.[39]

Lilhare S et al. (2017) did a study of injury characteristics in road traffic accidents by
different road user category. Findings of the study showed that motorcyclists were
predominantly affected (77.3%) in RTA. Males (80.67%) in the working age group 21-40
years (64.66%) were most commonly affected leading to huge economic losses to their
families [40]

Kumar SV et al (2010) did a study on poisoning cases in a tertiary care hospital reported that
out of 2,226 patients were admitted to the hospital with different poisonings; the overall case
fatality rate was 8.3% (n = 186). More detailed data from 2007 reveals that two-third of the
patients were 21–30 years old, 5.12% (n = 114) were male and 3.23% (n = 72) were female,
who had intentionally poisoned themselves.[41]

Ramesha KN et al. (2009) examined Pattern and outcome of acute poisoning cases in a
tertiary care hospital in Karnataka, India reported that incidence was more common among
males (75.4%) compared to females (24.3). Most cases of acute poisoning presented among
20- to 29-year age group (31.2%) followed by 12- to 19-year age group (30.2%). A majority
of poisoning cases (36.0%) were due to organophosphorus compound (OPC). Total mortality
was found to be 15.4%. [42]

B. Maharani and N. Vijayakumari (2013) analyzed profile of poisoning cases in a Tertiary

care Hospital, Tamil Nadu, India. Among 150 cases, 61.3% were Males and 38.7% were
females. Peak occurrence 31.335 was in the age group of 21-30 years. [43]

Patil A et al. (2014) examined the profile of Acute Poisoning Cases Treated in a Tertiary
Care Hospital: a Study in Navi Mumbai. A total of 74 cases of acute poisoning were studied,
of which 51.4% were men. Most of the patients aged 20 to 29 years (44.6%). Most of the
patients reside in urban areas (52.7%). All patients were treated successfully with no
mortality. [44]

21
 Materials & methods

Study Design-This is a prospective cross sectional observational study.

Study Setting-Emergency department of Dr. BRAM hospital, Raipur(C.G)

Study Duration- March 2018 to February 2019

Sample Size-All the emergency cases reaching emergency department of Dr. BRAM
hospital, Raipur during March 2018 to February 2019

Variables of the study-

 Patient name, age, sex

 Location and activity of patient at the time of injury; nature of collision; vehicle in
which patient was traveling; striking vehicle and type of road user
 Information on the presence of safety equipment like helmet and seatbelt
 Primary referral center and whether pre-hospital care was given or not
 Alcohol and substance abuse
 Duration from time of accident to arrival at emergency department
 Follow up of patient after treatment- complete recovery/disability/death.

Confounding variables

1. Co-existing medical illness which can lead to worsening of patient during hospital
stay
2. Wrong history by patient or attendant

Method of data collection

 A comprehensive injury proforma developed based on MOHFW.

 The questionnaire will have three major sections: patient demographics, details of the
injury and events after injury.
 The details of the injury, amongst others, included the intent, mechanism, nature and
site of injury, activity that the patient was involved in when the injury occurred, place
of injury and alcohol or substance use.

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  Post-graduate student in the hospital will be trained to collect information from the
patients who visited the emergency department with an injury on a structured
proforma
 Upon arrival of a patient in the emergency department, routine admission procedures
and management as per the treatment protocols will be followed. No changes will be
made to the usual care of the patient.
 The trained post graduate student, after stabilizing the patient will collect information
on socio-demographics and injury history from the attendant or the patient, if able,
after informed consent.
 Follow up of the patients will be taken till their stay in hospital in co-operation with
all the departments.

Study Outcomes
 Primary outcome
Functional outcome of patients after treatment-
1. Complete recovery(patient fully functional as before)
2. Disability
3. Death

 Secondary outcome- Associated Factors (patient related factors, vehicle related

factors, and event related factors.) related to patient’s morbidity/mortality.

Inclusion Criteria- All the patients brought to emergency department of Dr. B.R.A.M
Hospital, Raipur after road traffic accidents, homicidal or suicidal or fall from height history,
from the period of March 2018 to February 2019.
Exclusion Criteria
1. Patient coming to Emergency department with emergency conditions apart from
accidental condition.
2. Patients declared brought dead on arrival in emergency department.

Data entry and analysis-Data entry was done in Excel and analysis was done using
SPSS 20.0 software. Wherever, possible percentage, Chi-square test and Yates correction
were applied.

23
Limitations of Present study-Alcohol abuses, activity at the time of injury, disability
status of the study subjects not assessed due to:

1. As majority of cases referred from different health facilities

2. Due to non-cooperation of patient.
3. Recall bias

24
Figure.1. Month wise Frequency of cases reported at emergency department (N=10629)

Percentage
8.68 8.66
8.57
8.49
8.35 8.37
8.26 8.25
8.17 8.16
8.03 8.03

25