Road traffic crashes (RTCs) lead to 1.3 million deaths and 50 million injuries worldwide each year (World Health Organization (WHO), 2009). More than 90% of road traffic injuries (RTIs) occur in low and middle income countries (LMICs), costing them 1–2% of their gross national product (GNP) (Peden et al, 2004). Moreover, it has previously been predicted that traffic fatalities will increase by 65% in LMICs over the next two decades, requiring immediate prevention effort (Koptis and Cropper, 2005). Lack of reliable RTI data in LMICs remains a major obstacle in allocating appropriate resources for injury prevention and control (WHO, 2009).
Road traffic injuries (RTI) data quality in developing countries
Accurate and reliable data plays an important role in assessing RTI prevention and control by providing burden estimates, building political will, and facilitating decisions for implementing specific interventions (WHO, 2010). At minimum, road crash data should:
Few developing countries have road safety specific crash surveillance data fulfilling all these conditions (Peden et al, 2004; WHO, 2009).
The quality of actual data collection in LMICs depends primarily on who reports the data and what is the main purpose of their use (Wotton and Jacobs, 1996). For instance, the focus of police reporting, the most involved agency in RTI data collection in LMICs, is to assess responsibility of drivers (Wotton and Jacobs, 1996; Peden et al, 2004).
Health services use RTI data to assess healthcare use and the outcome of their care (Mehmood and Razzak, 2008). Linking police and health data as shown in some LMICs has provided overall burden estimates, but as yet has not fulfilled the promise of reliable information for prevention purposes (Razzak and Luby, 1998; Razzak and Laflamme, 2005). Prehospital care data may offer several advantages as health professionals reach crash locations, but the quality of data for such purposes has so far been understudied in LMICs (Hijar et al, 2000; Razzak and Laflamme, 2005; Sasser et al 2005; WHO, 2010).
RTI burden and data problems in Pakistan
Pakistan, similar to other LMICs, faces a huge burden of RTIs in terms of RTC deaths and rates (Hyder et al, 2000). A WHO report indicated an approximate RTI fatality rate of 25.3/100 000 inhabitants (WHO, 2009). Two independent surveys showed a RTI rate of 15–17/1000 person years, indicating that over two million RTI occur each year in Pakistan (Ghaffar et al, 2004; Fatmi et al, 2007). This leads to an extensive burden on health facilities and in particular, those with low socioeconomic status (Raja et al, 2001; Shamim et al, 2011). However, effective prevention and control of RTIs is hampered by unreliable data collection in Pakistan (Razzak and Laflamme, 2005). For example, RTI data collection in Pakistan mostly relies on police data which highly underreports RTIs, as shown in previous studies (Razzak and Luby, 1998; Nishtar et al, 2004; Bhatti et al, 2011).
Recent developments in establishing prehospital care in Pakistan
Prehospital trauma care has been long neglected in Pakistan (Razzak et al, 2001; Nishtar et al, 2004). A previous study showed that there were no public spending on prehospital care in the fiscal year of 1998 (Bishai et al, 2003). The private philanthropic organizations such as Edhi ambulance services have been mostly involved in providing prehospital care free of charge to RTI patients (Razzak and Luby, 1998; Razzak et al, 2001). In the absence of paramedic training specific to prehospital care settings, ambulances supplies are limited and only bandaging and oxygen are provided to injured patients (Nishtar, 2004; Razzak, 2001).
A government funded prehospital care system has been established since 2004 in the province of Punjab, called Rescue 1122 (Waseem et al, 2010). This initiative provides specific training to ambulance drivers and paramedics. The service provides prehospital care free to all RTC patients in the urban areas of Punjab province, while maintaining an average response time of 7 minutes. In a six-year period, out of a total 633 121 calls, 40% have been related to RTCs (Waseem et al, 2010). This model has been adapted in two other provinces of Pakistan (Khyber Pukhtunkhwa and Sindh). A private organization (Aman foundation) in Karachi, Sindh, offers a prehospital care service with trained doctors.
Previous studies on the potential of prehospital care data use in Pakistan
Previous research on the use of prehospital care data for injury surveillance, in particular RTIs, showed that this data reports a higher number of RTIs than police and can be comparable to hospital data (Bhatti et al, 2011; Razzak and Laflamme, 2005). These studies were mostly based on the registers used by a philanthropic transport service in Karachi, the largest city of Pakistan (Razzak et al, 2001; Razzak et al, 2004; Razzak and Laflamme, 2005).
The studies showed that in absence of adequate centralized trauma registries or databanks, prehospital care data might be useful in studying demographic trends and road user categories. However, the information vital for implementing measures, such as injury event circumstances and mechanisms, was inadequately reported in those registers (Razzak et al, 2004; Sasser et al, 2005).
Process of RTI data reporting in Rescue 1122
For any call made to the toll free number of Rescue 1122, an ambulance with a driver and two paramedics (emergency medical technicians) are dispatched to the scene (Waseem et al, 2010). At the crash scene, the priority is to transfer the patient safely to the nearest government hospital in the shortest possible time.
An encounter paper sheet is filled by the paramedics accounting for the date and time of dispatch; arrival at the crash location; arrival at the hospital; age; sex; road user category; external cause of injury, and vital signs of the patients.
At the same time, data regarding the call, response time, and reason of call are recorded at the dispatch centre. A global positioning system tracking device is installed in each ambulance to independently record response times. The dispatch centre data is electronically recorded, whereas encounter sheet data is not yet recorded electronically.
Qualitative analyses of Rescue 1122 prehospital care data
To assess the quality of data reported in encounter sheets, we undertook a retrospective review. Approximately 1890 RTC related calls were responded to in May 2009. We randomly selected 300 encounter sheets. The data entry was carried out on Microsoft Excel and then analyzed for basic demography. We observed that approximately 364 RTI patients were recorded in 300 encounter sheets. Most patients were males (87%); 40% were aged 21–30 years, and 21% were 11–20 years. The injury mechanisms were: motorcycle with vehicle (38%), pedestrians (29%), motorcycle with other motorcycle (10%), and motorcycle with another structure (8%).
One of eight patients (12%) were discharged from the scene. The most common intervention in the field was taking vital signs and dressing wounds (98%). Simple analgesia—an intramuscular (IM) injection of Diclofenac®—was administered in 76% cases. Ninety percent of hospital transferred patients were reported alive and stable at the time of transferring. Missing data on vital signs in the encounter sheets did not permit us to compute revised trauma score (RTS). The word ‘stable’ was used most often to comment on patients' status.
No fatalities were reported in these encounter sheets, neither on the scene nor during transfer, although 10% of the patients were found to be unstable. No follow-ups were carried out on any patient. The response time of the service was below 7 minutes in 70% of the cases which is consistent with previous findings (Waseem et al, 2010). All the patients were transferred to the nearest health facility, except for patients with head injury. These patients were always triaged to the only neurosurgical facility in the city that is Lahore General Hospital which has a 24-hour CT facility and on-site neurosurgical cover. At the moment, there is no data linkage between the collected prehospital data and the hospital records.
Observed gaps and recommendations for data improvements
Several discrepancies in encounter sheet data were observed. For example, one encounter sheet was used per RTC. Therefore, in the case of multiple patients, data were found to be missing. In addition, the outcome was often subjective as it was mostly quoted ‘stable’ or ‘okay’ and standardized scores such as RTS intended for evaluation could not be calculated because of the missing data. Nonetheless, it was clear that in the absence of trauma registries, encounter sheets might be useful for collecting RTC data.
Based on our findings, the following recommendations could improve prehospital care data as well its utility:
Conclusion
Availability of prehospital care services in a developing country such as Pakistan could play an important role in filling RTI related information gaps (Waseem et al, 2011). Paramedics could be easily trained to document mechanisms of RTIs, involved factors, and crash circumstances; and the guidelines for which might be adapted from elsewhere (National Highway Traffic Safety Administraion (HTSA), 2003). As yet, the potential for a prehospital service has not been explored in Pakistan, and devoting appropriate structural and human resources could be the key for future RTI advocacy and decision-making (WHO, 2004; Sasser et al, 2005).
This review sheds light on studies assessing the quality of prehospital care data for road traffic injury (RTI) prevention purposes in Pakistan. The current data is limited to burden assessment and would require additional training and resources to fully utilize this data source for prevention purposes. Nonetheless, results do suggest the potential of prehospital care data in addressing knowledge gaps for RTI prevention in Pakistan.