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BACKGROUND: Child survival initiatives historically prioritized efforts to reduce child morbidity and mortality from infectious diseases and maternal conditions. Little attention has been devoted to paediatric injuries in resource-limited settings. This study aimed to evaluate the demographics and outcomes of paediatric injury in a sub-Saharan African country in an effort to improve prevention and treatment. METHODS: A prospective trauma registry was established at the two university teaching campuses of the University of Rwanda to record systematically patient demographics, prehospital care, initial physiology and patient outcomes from May 2011 to July 2015. Univariable analysis was performed for demographic characteristics, injury mechanisms, geographical location and outcomes. Multivariable analysis was performed for mortality estimates. RESULTS: Of 11 036 patients in the registry, 3010 (27·3 per cent) were under 18 years of age. Paediatric patients were predominantly boys (69·9 per cent) and the median age was 8 years. The mortality rate was 4·8 per cent. Falls were the most common injury (45·3 per cent), followed by road traffic accidents (30·9 per cent), burns (10·7 per cent) and blunt force/assault (7·5 per cent). Patients treated in the capital city, Kigali, had a higher incidence of head injury (7·6 per cent versus 2·0 per cent in a rural town, P < 0·001; odds ratio (OR) 4·08, 95 per cent c.i. 2·61 to 6·38) and a higher overall injury-related mortality rate (adjusted OR 3·00, 1·50 to 6·01; P = 0·019). Pedestrians had higher overall injury-related mortality compared with other road users (adjusted OR 3·26, 1·37 to 7·73; P = 0·007). CONCLUSION: Paediatric injury is a significant contributor to morbidity and mortality. Delineating trauma demographics is important when planning resource utilization and capacity-building efforts to address paediatric injury in low-resource settings and identify vulnerable populations.
Rwanda has a population of 12·2 million (4·9 million people under the age of 15 years)16. There are 42 district and four referral hospitals; the referral hospitals also serve as teaching hospitals17. Rwanda has one of the few publicly‐funded national ambulance services in sub‐Saharan Africa. Prehospital emergency medical services, known as the Service d'Aide Médicale Urgente (SAMU), were established by the Ministry of Health in 200718. As few emergency or surgical services are provided at district hospitals, injured patients are often sent to the referral hospitals for evaluation and definitive care. The university teaching hospital in Kigali (Centre Hospitalier Universitaire de Kigali (CHUK)) is a public 520‐bed hospital in the capital of Rwanda. The university teaching hospital in Butare (Centre Hospitalier Universitaire de Butare (CHUB)) is a public 500‐bed hospital located 133·6 km south in Butare, Huye District, a university town with a population of 89 600 people at the 2012 census19. Ethical approval for the study was obtained from the University of Virginia institutional review board for health sciences research (number 15075) and the ethics committee at CHUK (EC/CHUK/006/10). Development of the Rwanda Injury Registry has been described previously14, 15, 20. This is a prospective trauma registry that was established at the two campuses of CHUK and CHUB in Rwanda to record systematically patient demographics, prehospital care, initial physiology and patient outcomes. Data were collected on a 31‐item paper registry form that was adapted locally for the Rwandan setting from registries in other sub‐Saharan African countries21, 22. Local training was conducted over a 1‐month period, and the form was rolled out for data collection in March 2011. Arrival data were collected by trained nurses in the accident and emergency department (ED) within 24 h of admission. Over the period of data collection, 2‐week and 1‐month in‐hospital outcome data were abstracted from patient chart review, ward registries and operating room logs by trained medical students, the principal investigator or the nurse coordinator. Inclusion criteria included: any injured patient referred from a district hospital for injury evaluation, any injury‐related mortality in the emergency department or any inpatient hospitalization or emergency stay greater than 24 h. Patients who arrived at the first hospital of contact and were treated and sent home within 24 h were excluded. Data were entered into a searchable Microsoft Access® 2010 (Microsoft, Santa Rosa, California, USA) database by a trained data registrar. Deidentified data for patients aged less than 18 years were abstracted over a 4‐year period from May 2011 to July 2015. Data collected during the implementation and transition period in March and April 2011 were excluded. Descriptive analysis was performed using SAS® 9.4 (SAS Institute, Cary, North Carolina, USA). Primary outcomes assessed using univariable analysis included overall and injury‐related mortality. Outcomes were compared between hospitals and based on injury mechanism using χ2 and Fisher's exact tests for non‐parametric data. Multivariable logistic regression analysis was performed to control for age, sex and injury severity. Variables were selected a priori based on clinical relevance and available data in the registry. For example, anatomical injury severity scores were not calculated, and respiratory rate was available for only two‐thirds of the paediatric patients. Injury severity was therefore determined using the modified Kampala Trauma Score (mKTS)23.
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