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Global Programs Emergency and Trauma Centre The Alfred, Melbourne, AustraliaEpidemiology and Biostatistics National Trauma Research Institute (NTRI) The Alfred, Melbourne,AustraliaSchool of Public Health and Preventive Medicine Alfred Campus, Monash University, Melbourne, Australia
Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, SwedenDepartment of Global Public Health, Karolinska Institutet, Stockholm, Sweden
WHO Collaborating Centre for Research in Surgical Care Delivery in LMIC, Mumbai, IndiaDepartment of Global Public Health, Karolinska Institutet, Stockholm, SwedenInjury Division, The George Institute, New Delhi, India
Fall is the second leading cause of unintentional injury mortalities worldwide.
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Isolated TBI and TBI associated with other injuries are the major contributors of mortality in injuries associated with fall.
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Mortality is directly proportional to age and ISS in patients with history of fall.
Abstract
Introduction
Fall is the second most common mechanism of trauma worldwide after road traffic injuries. Data on fall predominantly comes from the high-income countries (HICs) and mostly includes injuries in children and elderly. There are very few studies from low- and middle-income countries(LMICs) that describe fall related injuries other than fragility fractures in elderly. This study describes the profile of poly-trauma patients admitted with a history of ‘fall’ and assesses the variables associated with mortality.
Method
We analyzed data from the ‘Towards Improved Trauma Care Outcome’ (TITCO) database which prospectively collected data of poly-trauma patients admitted to four major tertiary care hospitals of India between 2013 to 2015. Patients across all age groups admitted to hospital with the history of ‘fall’; were included in our study. Single bone fractures were excluded. The Kaplan Meier survival analysis was used to estimate the survival probability in different age groups.
Results
A total of 3686 patients were included in our study. The median age of the patients was 28 years (IQR: 9, 47) with the majority being males (73.6%). Almost one-third of the patients were within the age group of 0-14 (30.4%). Most of the patients (79.9%) had a diagnosis of traumatic brain injury (TBI). The overall in-hospital mortality was 18% (664), but higher at 39.0% among patients over 65 years of age. Probability of survival decreased with increase of age.
Conclusion
Falling from height is a common injury mechanism in India, occurring more in young males and usually associated with TBI. Isolated TBI and TBI associated with other injuries are the main contributors of mortality in fall injuries. Mortality from these injuries increased with age and ISS.
]. Fall is the second leading cause of unintentional injury mortalities worldwide, with an estimated 684,000 annual deaths, 80% of these in low- and middle-income countries (LMIC) [
Examining outcomes in cases of elderly patients who fell from ground level at home with normal vital signs at the scene: an analysis of the National Trauma Data Bank.
Current published literature on unintentional injury from HIC identify several risk factors associated with fall; mainly frailty and comorbidities in older people; alcohol in younger individuals, unsafe environments, and behavioral problems in children [
A comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of Dhulikhel Hospital, Kathmandu university hospital and its outreach centers in rural area.
The mechanism of injury in the fall category contains many different types of events, including fall from height, fall from the same level such as slipping, tripping, collision or being pushed by another person. Fall from height is a high energy injury compared to ground level fall which is a low energy injury. The former is more common in LMIC and the latter, also known fragility fracture, is the common variety in HIC [
A comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of Dhulikhel Hospital, Kathmandu university hospital and its outreach centers in rural area.
]. Data from a single government hospital in India showed that 20% of emergency visits were due to fall and a third of these had polytrauma and two-third (66%) were diagnosed with traumatic brain injury (TBI) [
The factors that influence mortality and morbidity in fall injuries in elderly and fragility fractures are age, comorbidities, availability of ortho-geriatric co-management and early surgery. Fragility fracture audits like the United Kingdom hip fracture database (NHFD) report over 8% 30-day mortality and 25–30% one -year mortality [
NHFD 2022 annual report . The National Hip Fracture Database. Royal College of Physicians; 2018 [cited 2022Oct8]. Available from: https://www.nhfd.co.uk/
]. Similar information and burden from high energy fall are lacking, and therefore need to be studied as most of these are preventable. The aim of this study is to describe the profile of the Polytrauma patient admitted with a history of fall to four major tertiary care hospitals of India and to assess the variables associated with mortality.
Methods
Study design
We analysed the Towards Improved Trauma Care Outcomes (TITCO) in India cohort (www.titco.org) [
]. This cohort includes 16000 trauma patients who presented alive and were admitted to four urban tertiary care hospitals in India between 2013 and 2015. The cohort excluded patients with isolated limb injuries and single bone fractures.
Setting
Data was collected from four urban tertiary care centers spread across India. They include, Lokmanya Tilak Municipal Medical College and General Hospital, and King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, AIIMS Jai Prakash Narayan Apex Trauma Center, Delhi, and Institute of Postgraduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital (SSKMH), Kolkata. All hospitals except for SSKMH, had dedicated trauma care facilities at the time of the study.
Inclusion criteria
All patients with the history of fall admitted to the participating hospital were included in this study.
Exclusion criteria
Patients with the history of other mechanisms of injury or with incomplete records were excluded from the analysis.
Variables
On arrival at the hospital, vital signs such as heart rate (HR), systolic blood pressure (SBP), respiratory rate (RR), and GCS were measured and recorded. Demographic variables recorded included age, sex, mode of transport to the hospital, if the patient was transferred from other hospital, (henceforth known as transfer status) and type of injury (Table 1). International Classification of Diseases version 10 (ICD-10) was used to code injuries. Injury severity score (ISS) was used to assess the severity of injury in patients with multiple injuries (Table 1).
Table 1Variables used for analysis of patients admitted with history of Fall.
Variable
Categories
Demography
Age (0-14, 14-24, 24-44, 44-65, 65+.) Gender (Male & Female)
Designated project officers collected data on demographics, vital signs, pattern of injury and outcome by direct observation or from the patients' records, and by asking patients or their relatives.
Quantitative variables
Age was categorized as 0-14, 14-24, 24-44, 44-65, 65+ years. Date and time of admission and discharge/death recorded from patients’ hospital records were used to calculate length of stay (LOS). ICD 10 codes (S02.0, S02.1, S02.3, S02.7- 02.9, S06.0- S06.9, S07.0- S07.9, S09.7- S09.9) were used to determine the pattern of injuries [
The results are presented as numbers and percentages for qualitative variables while median and interquartile range (IQR) was used to describe quantitative variables. The Kaplan Meier survival analysis was used to estimate the survival probability in different age groups. Cox-Hazard ratio was used to calculate the effect size of the model. Log rank Test was used to calculate the p-value in the survival analysis. A p-value of <0.05 was considered statistically significant. A Complete case analysis was conducted to exclude patients with one or more missing values [
In this study, 5206 polytrauma patients with fall injuries were admitted to tertiary care centers. A total of 1520 patients were excluded from the analysis due to some missing data. The most common missing variables were GCS (9.1%), ISS (7.2%) and time to injury (5.3%). A total of 3686 patients were included in our study (Fig. 1).
In view of the large number of patients who were excluded due to missing data, we compared the complete and incomplete data and found no difference in demographic patterns or mortality. (Supplementary Digital Content).
The median age of the patients was 28 years (IQR: 9, 47) and the majority were males (73.6%). The incidence was high among children under the age of 15 years (30.4%) followed by the 24 to 44 year age group (Table 2). The overall mortality was 18% (664). The proportion of mortality was higher in elderly patients 65+ years of age (39.0%) (Table 3). This was reflected in the Kaplan Meier survival curve where age groups 65+ years were seen to have lower survival probability in comparison to other age groups (Fig. 2). The difference in survival between the age groups was found to be statistically significant (p < 0.001) (Table 4). Majority of the patients had a moderate ISS score (63.8%) and the proportion of mortality was higher among patients with a profound ISS score (36.9%) (Table 3).
Table 2Demography of patients admitted with history of Fall.
Examining outcomes in cases of elderly patients who fell from ground level at home with normal vital signs at the scene: an analysis of the National Trauma Data Bank.
A comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of Dhulikhel Hospital, Kathmandu university hospital and its outreach centers in rural area.
NHFD 2022 annual report . The National Hip Fracture Database. Royal College of Physicians; 2018 [cited 2022Oct8]. Available from: https://www.nhfd.co.uk/
A large majority of patients (79.9%) with a history of fall had a TBI. In the TBI cohort, 2406 (81.5%) suffered an isolated TBI and 545 (18.5%) had associated injuries. Proportion of mortality was highest among patients of TBI with associated injuries (24.0%) followed by isolated TBI patients (19.3%) (Table 3). There was a significant increase in proportion of mortality with increasing ISS and decreasing GCS in both isolated TBI and TBI with associated injuries (Table 5).
Table 5Correlation of in-hospital mortality with ISS and GCS in TBI patients admitted with history of Fall.
Our study identified that about a third of polytrauma patients admitted to four urban tertiary care tertiary care centers in India suffered a fall. Mortality was found to increase with increase of Age and ISS. More than two third of the patients of this study cohort was admitted with TBI and proportion of mortality was highest among patients having associated injuries with TBI. According to the Global Burden of Disease 2017 data, falls are the second most common mechanism of injury after transport injuries in terms of prevalence and Disability Adjusted Life Years (DALY)s. The data in the GBD report however is not explicit on the cause or height of falling and the pattern of injuries. The above report mentions negligible variation between the fall related age adjusted DALY rates across the world, apart from Australia, Central Europe, and Eastern Europe where fragility fractures from fall is a major contributor to injury burden in these countries. Fall from a standing height or ground level leading to fragility hip, vertebral or wrist fracture is common in the HIC geriatric population and higher in women [
International Osteoporosis Foundation: IOF. International Osteoporosis Foundation. INTERNATIONAL OSTEOPOROSIS FOUNDATION; 2022 [cited 2022Oct8]. Available from: https://www.osteoporosis.foundation/.
]. In contrast, the median age group of a fall injury was 28 years in our study with a preponderance of males. This is similar to reports from other LMICs where a Mean age of 41 years in Ethiopia, 42 years in Kenya and 33 years in Qatar were reported [
]. Children under the age of 15 years suffered 30.4% of the falls captured in the TITCO dataset and mortality were 7%. This is similar to mortality of 10% from fall injuries in children globally [
Retrospective data from a trauma registry in Qatar suggests that fall related admission constituted 32% of all trauma admissions at an urban Level I trauma center. More than 50% of such injuries happened at workplaces, with 72% of the victims being laborers. Fall at ground level accounted for 23% of these cases, while 48% were due to fall from height (>=3 m) [
]. A population-based survey from rural Bangladesh reported that around 70% of all fall occur because of slipping/tripping or stumbling and most of these ground level falls occurred on a sidewalk or street (62%), followed by fall in the home environment (18%). Falling from height was either due to falling from a tree (27%), stairs (25%), or furniture (18%) [
]. Unfortunately, our dataset did not capture the details of the energy level of the fall or the height from which the fall occurred.
A significant finding of our study is that approx. 80% of the patients admitted with history of fall had TBI. Considering that the median age of the study population was 28 years, we can extrapolate that these TBIs were due to falling from a significant height i.e., a high energy fall. Even in the elderly population of our study, TBIs was found to be more common. The pattern of fall related injury in HICs are different, it happens mostly due to ground level falls or less than 1 m height falls. These usually occur in elderly patients with multiple co morbidities and they present with fragility fractures [
]. This may be due to the nature of the fall i.e., high energy injury and difference in level of trauma care. Mortality was higher in our study among TBI patients and highest among TBI patients with other associated injuries. (Table 5) This is similar to findings from the US, where most of the patients who died from a fall had intracranial bleeding [
]. We feel that prevention of fall from heights, improved protection at work and improved trauma response are some of the factors that can reduce mortality rates following fall in LMIC.
The proportion of mortality was highest at 39% in the elderly age group while that in children was 7% (Table 3). As pointed out in the study by Roy et al., ISS is an imperfect scoring system to assess injuries in LMICs due to lack of extensive imaging in all trauma patients [
]. But in our study, mortality correlated well with ISS i.e., mortality increased with increase in ISS (Table 3). This is similar to the findings from studies, where proportion mortality increased with increase in ISS [
Mechanism of injury in the TITCO dataset was not classified according to ICD 10 codes. So, we do not have data on the cause or height of the fall injuries to group them into high or low energy injuries. The registry included patients admitted to urban tertiary care centers and therefore has selection bias. The in-hospital mortality may not represent the incidence of death due to falling from a height as only a few reach tertiary care hospital facilities in urban.
The TITCO registry set out to compile data on polytrauma patients admitted to tertiary care centers in India [
]. Single bone fractures were excluded to filter out single limb or isolated injuries. The dataset by default excluded fragility hip and wrist fractures, the common fall injuries in HIC. Therefore, the prevalence and mortality of fall captured in the TITCO dataset may not be comparable to fall data from HIC.
Conclusion
Falling from height is a common injury mechanism in India, occurring more in young males and usually associated with TBI. Isolated TBI and TBI associated with other injuries are the main contributors of mortality in fall injuries. Age and ISS are directly proportional to mortality when falling from a height.
Recommendations
Future Trauma registries should capture the height and cause of fall in their datasets to differentiate low and high energy falls, to enable global comparisons of outcomes of low and high energy falls, and inform prevention strategies.
Funding
The TITCO dataset by the research consortium of Indian Universities was funded by grants from the Swedish National Board of Health and Welfare and the Laerdal Foundation for Acute Care Medicine, Norway. The funding agencies had no influence on the conduct of the study, the contents of the manuscript, or the decision to send the manuscript for publication.
Ethical clearance
Ethics approval for data collection was obtained from all four centers from All India Institute of Medical Sciences (EC/NP-279/2013 RP-Ol/2013), Institutional Ethics Committee (IEC(I)/OUT/222/14), Ethics Committee of the Staff and Research Society (IEC/11/13), and IPGME&R Research Oversight Committee (IEC/279) for JPNATC, KEM, LTMGH, and SSKM, respectively. Informed consent was waived as the data collection did not alter the care provided to the patients in any way.
Declaration of Competing Interest
None.
Acknowledgments
We would like to thank Towards Improved Trauma Care Outcomes (TITCO), India, team for their support in our research work.
Examining outcomes in cases of elderly patients who fell from ground level at home with normal vital signs at the scene: an analysis of the National Trauma Data Bank.
A comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of Dhulikhel Hospital, Kathmandu university hospital and its outreach centers in rural area.
NHFD 2022 annual report . The National Hip Fracture Database. Royal College of Physicians; 2018 [cited 2022Oct8]. Available from: https://www.nhfd.co.uk/
International Osteoporosis Foundation: IOF. International Osteoporosis Foundation. INTERNATIONAL OSTEOPOROSIS FOUNDATION; 2022 [cited 2022Oct8]. Available from: https://www.osteoporosis.foundation/.
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