The Impact of Minor Injury Cases at a Level I Trauma Center: A Retrospective Observational Study

Trauma is the leading cause of mortality and morbidity for individuals aged 1 through 44 years.^1,2 According to the World Health Organization, the first and second most common causes of death among persons aged 5 to 29 years worldwide are road traffic injuries and a fall from a height.^2,3 Major trauma and its sequelae have been described in abundance in published literature.^4-6 Institutions worldwide assess the burden of traumatic injury using the cause-specific mortality rate. The scope of the burden of trauma in a population also includes the larger number of patients with minor injuries who require either treatment in the ED or short-term hospitalization.

The injury pyramid, which was first described by Heinrich⁷ in 1936, is a graphical means of depicting major and minor injuries. The pyramid shown in Figure 1 illustrates the relationship between ED visits, hospitalizations, and mortality rate among patients with major and minor injuries, with ED visits (the largest number) at the base, hospitalizations (the second-largest number) in the middle, and mortality rate (the smallest number) at the apex. The pyramid was further adapted and validated by Wadman et al,⁸ who in 2003 proposed that data sources as of that time were inadequate to estimate the injury epidemics and their total effect on society. Their adaptation holds true to date. The size and shape of the injury pyramid can be used to inform both qualitative and quantitative analysis of the burden of traumatic injuries.

Some studies have quantified the burden of minor injuries. Worldwide, approximately 11% of DALYs are attributed to trauma.⁹ A 2017 report on the global burden of disease indicated that 181 177 500 minor injuries  resulted in 1 752 500 YLD worldwide.¹⁰ A 2012 study of epidemiologic data from the Netherlands indicated that unintentional injuries resulted in 67 547 years of life lost and 161 775 YLD respectively, amounting to 229 322 DALYs.¹¹ In terms of the total burden of injury, minor injuries accounted for 37.3% (85 504 DALYs; 5.2 per 1000), injuries requiring hospital admission accounted for 33.3% (76 271 DALYs; 4.7 per 1000), and fatalities accounted for 29.5% (67 547 DALYs; 4.1 per 1000). In that study, unintentional injuries at home, leisure activities, and road traffic injuries contributed the most to DALYs.

Several studies have been published on the burden of trauma on patients and the health care system, but few studies have been done on the burden of minor injuries in trauma care. Trauma registries often do not provide optimal information about patients who do not require hospital admission. It is essential for all trauma facilities worldwide to take note of the burden of minor injuries, which may at times overwhelm the functioning of even the best trauma facilities.

A retrospective observational study was conducted at a level I trauma center in a large urban area for 1 month (February 14, 2020 through March 14, 2020) to identify the patterns of minor injury for which ED care and/or short-term hospital admission were required. The study population included patients who required ED care for minor injuries. Data obtained included patient age and sex, time of presentation, anatomical region involved, and intervention performed.

Upon arrival, patients were triaged according to the seriousness of their injuries. Patients who require immediate priority are triaged “red”; patients who need urgent intervention are triaged “yellow”; and minor injuries are triaged “green.” A total of 3293 patients visited the authors’ trauma center during the study period, of whom 1255 were triaged as green, 1617 were triaged as yellow, and 421 were triaged as red. Three hundred seventy-three patients were admitted to the hospital. Of the 3293 total patients, 791 required ED intervention in the minor operation theater. No patient triaged as green required in-hospital admission or was transferred out for other trauma care. Of the patients who required ED intervention, 667 (84.32%) were male and 124 (15.68%) were female (Figure 2). Four hundred eighty-six patients (61.4%) were aged 21 to 40 years (Figure 3). Of the 791 patients who required ED intervention, 354 (44.75%) were treated during the day shift (8:00 AM–8:00 PM) and 437 (55.25%) were treated during the night shift (8:00 PM–8:00 AM). A total of 849 injuries were present in 791 patients. In decreasing order, the 3 most common modes of injury were road traffic injuries (68.4%), fall (15%), and interpersonal violence (13.8%), followed by self-inflicted (1.5%), being struck by a heavy falling object (0.88%), and animal-related (0.38%). Maxillofacial injuries were present in 26.15% of patients (n = 222), head and neck injuries in 25.8% (n = 219), lower extremity injuries in 24% (n = 204), upper extremity injuries in 21.9% (n = 186), and other injury in 2.1% (n = 18).

The JPNATC, All India Institute of Medical Sciences, is a high-input, level I trauma center that serves a large urban population. A 1-month retrospective study of injury demographics involving minor trauma was conducted to assess the burden of minor injury, the level of trauma care provided, and the efficacy of existing protocols. The results of this study validate the injury pyramid, in that only 11.32% of patients (373 of 3293) required hospital admission. In a study by Polinder et al,¹¹ 37.3% of patients sustained a minor injury, which is comparable to the findings of the current study, in which 38.1% of patients presented with minor trauma.

Few studies have investigated the burden of minor injuries on trauma centers. Rouhani et al¹² and Hyder et al¹³ studied injury demographics in Haiti and Pakistan, respectively. A comparison of their findings and those of the present study is shown in the Table. In the study by Rouhani et al,¹² 41.8% of patients required minor surgical procedures, and in Hyder et al,¹³ 44.5% of patients required minor surgical procedures. Both those studies were of 6 months’ duration. In comparison, in the current 1-month retrospective study, 29.5% of patients required minor surgical procedures. These procedures included dressing, wound lavage, suturing, interdental wiring, and foreign body removal, among others.

At the authors’ institution, patients assigned to the green triage category are evaluated by a trauma surgeon; if necessary, experts in other specialties are asked to consult as well. Analgesic and tetanus prophylaxis are administered. After a thorough examination, if it is determined that a wound requires intervention, the patient is sent to the minor operation theater, which is a room in the ED where simple wounds can be managed with adequate sterility, lighting, and analgesia. After the procedure, the patient is either discharged or kept under observation for 6 to 12 hours. Dedicated surgeons (ie, trained trauma surgery and plastic surgery residents working under the close supervision of experienced surgeons) are present around the clock for this purpose. Because of the scarcity of admitting beds and operating room slots in this high-volume center, most minor injuries are managed in the ED. Patients with complex wounds, such as those resulting from crush injuries, railway-associated injuries, or machine-related injuries, are treated in a red or yellow area.

In the current study, the male-to-female ratio of traumatic injury was 5.4:1. In low- and middle-income countries, adult males are often the primary wage earners and thus, they more frequently incur road traffic injuries, interpersonal violence injuries, and workplace injuries. The male-to-female ratio in the pediatric population was 1.5:1 in the present study. Children are more prone to sustain an injury while playing or as the result of a fall from a height. Most patients in the current study (61.4%) were aged 20 to 40 years. The current study validates the fact that younger individuals are most commonly involved in a traumatic injury and that road traffic injury (68.4%) is the most common cause for trauma.^2,14 In the current study, more patients needed wound care during the night shift than during the day shift. Whereas road traffic, workplace, and pediatric injuries were more common during the day shift, injuries from alcohol-related falls, interpersonal violence, and domestic violence were more common during the night shift. Maxillofacial injuries, head and neck injuries, and injuries to the upper and lower extremities were commonly managed with minor surgical procedures (Figures 4-6).

The diversity of traumatic injuries demands the collaboration of surgical specialists from a variety of fields. Most injuries can be managed by the trauma surgeons, plastic surgeons, and maxillofacial surgeons who work in the minor operation theater, but specific injury patterns require a specialist in pediatric surgery, ophthalmology, otorhinolaryngology, or gynecology, for example. Pediatric patients are often apprehensive and not cooperative for procedures performed under local anesthesia; thus, they are managed under sedation and/or anesthesia in major operating rooms.

This study has limitations. It is a retrospective observational study with only 1 month of clinical data. In addition, it is a single-center study.

Trauma center preparedness is reflected in the attention paid to the effective and efficient protocol-based treatment of patients with minor trauma. In a resource-constrained country, a level I trauma center is often overwhelmed by patients seeking consultations for minor injury. The major demand of a typical ED is to facilitate optimal care to all patients. It is important to recognize and address the burden of minor trauma on the patient population, hospital resources and staffing, the mental health of health care providers, and the national economy. Capacity building and registry is the need of hour.