Advertisement

Mortality from fall: A descriptive analysis of a multicenter Indian trauma registry

Open AccessPublished:September 29, 2022DOI:https://doi.org/10.1016/j.injury.2022.09.048

      Highlights

      • Fall is the second leading cause of unintentional injury mortalities worldwide.
      • Isolated TBI and TBI associated with other injuries are the major contributors of mortality in injuries associated with fall.
      • 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.

      Keywords

      Introduction

      Fall is defined as “an unexpected event in which the participant comes to rest on the ground, floor or lower level.” [
      • Guirguis-Blake J.M.
      • Michael Y.L.
      • Perdue L.A.
      • Coppola E.L.
      • Beil T.L.
      • Thompson J.H.
      Interventions to prevent fall in community-dwelling older adults: a systematic review for the U.S. preventive services task force.
      ]. 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) [

      Falls. World Health Organization. World Health Organization; 2021 [cited 2022Oct8]. Available from: https://www.who.int/news-room/fact-sheets/detail/falls.

      ,
      • James S.L.
      • Lucchesi L.R.
      • Bisignano C.
      • Castle C.D.
      • Dingels Z.V.
      • Fox J.T.
      • et al.
      The global burden of fall: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017.
      ]. Data on fall reported from high income countries (HIC) mostly include injuries in children and elderly fragility fractures [
      • Ha V.A.T.
      • Nguyen T.N.
      • Nguyen T.X.
      • Nguyen H.T.T.
      • Nguyen T.T.H.
      • Nguyen A.T.
      • et al.
      Prevalence and factors associated with fall among older outpatients.
      ,
      • Ahmed N.
      • Greenberg P.
      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.
      ,
      • DeGrauw X.
      • Annest J.L.
      • Stevens J.A.
      • Xu L.
      • Coronado V.
      Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older, United States, 2006-2011.
      ].
      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 [
      • Ha V.A.T.
      • Nguyen T.N.
      • Nguyen T.X.
      • Nguyen H.T.T.
      • Nguyen T.T.H.
      • Nguyen A.T.
      • et al.
      Prevalence and factors associated with fall among older outpatients.
      ,
      • Hollis S.
      • Lecky F.
      • Yates D.W.
      • Woodford M.
      The effect of pre-existing medical conditions and age on mortality after injury.
      ,
      • Jindal H.A.
      • Duggal M.
      • Jamir L.
      • Sharma D.
      • Kankaria A.
      • Rohilla L.
      • et al.
      Mental health and environmental factors associated with fall in the elderly in North India: a naturalistic community study.
      ,
      • Ayoung-Chee P.
      • McIntyre L.
      • Ebel B.E.
      • Mack C.D.
      • McCormick W.
      • Maier R.V.
      Long-term outcomes of ground-level fall in the elderly.
      ,
      • Mahalakshmy T.
      • Dongre A.R.
      • Kalaiselvan G.
      Epidemiology of childhood injuries in rural Puducherry, South India.
      ,
      • Niven D.J.
      • Kirkpatrick A.W.
      • Ball C.G.
      • Laupland K.B.
      Effect of comorbid illness on the long-term outcome of adults suffering major traumatic injury: a population-based cohort study.
      ]. Studies from south-east Asia however suggest that the adult population (15-49 years) is most susceptible to fall, with a 2:1 male predominance [
      • Shrestha R.
      • Shrestha S.K.
      • Kayastha S.R.
      • Parajuli N.
      • Dhoju D.
      • Shrestha D.
      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.
      ,
      • Joshi S.K.
      • Shrestha S.
      A study of injuries and violence related articles in Nepal.
      ,
      • Bhuvaneswari N.
      • Prasuna J.G.
      • Goel M.K.
      • Rasania SK.
      An epidemiological study on home injuries among children of 0-14 years in South Delhi.
      ,
      • Fayyaz J.
      • Wadhwaniya S.
      • Shahzad H.
      • Feroze A.
      • Zia N.
      • Mir M.
      • et al.
      Pattern of fall injuries in Pakistan: the Pakistan national emergency department surveillance (Pak-NEDS) study.
      ,
      • Jagnoor J.
      • Suraweera W.
      • Keay L.
      • Ivers R.Q.
      • Thakur J.S.
      • Gururaj G.
      • et al.
      Childhood and adult mortality from unintentional fall in India.
      ].
      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 [
      • Mahalakshmy T.
      • Dongre A.R.
      • Kalaiselvan G.
      Epidemiology of childhood injuries in rural Puducherry, South India.
      ,
      • Shrestha R.
      • Shrestha S.K.
      • Kayastha S.R.
      • Parajuli N.
      • Dhoju D.
      • Shrestha D.
      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.
      ,
      • Bachani A.M.
      • Ghaffar A.
      • Hyder A.A.
      Burden of fall injuries in Pakistan–analysis of the national injury survey of Pakistan.
      ,
      • Mehmood A.
      • Razzak J.A.
      Trauma registry–needs and challenges in developing countries.
      ]. There are very few studies from LMIC that describe fall and outcomes associated with polytrauma [
      • Fayyaz J.
      • Wadhwaniya S.
      • Shahzad H.
      • Feroze A.
      • Zia N.
      • Mir M.
      • et al.
      Pattern of fall injuries in Pakistan: the Pakistan national emergency department surveillance (Pak-NEDS) study.
      ,
      • Mehmood A.
      • Razzak J.A.
      Trauma registry–needs and challenges in developing countries.
      ,
      • Babu A.
      • Rattan A.
      • Ranjan P.
      • Singhal M.
      • Gupta A.
      • Kumar S.
      • et al.
      Are fall more common than road traffic accidents in pediatric trauma? Experience from a Level 1 trauma centre in New Delhi, India.
      ,
      • Peden M.
      • Oyegbite K.
      • Ozanne-Smith J.
      • Hyder A.A.
      • Branche C.
      • Rahman A.
      • Rivara F.
      • Bartolomeos K.
      World Report on Child Injury Prevention.
      ]. 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) [
      • Jagnoor J.
      • Keay L.
      • Ganguli A.
      • Dandona R.
      • Thakur J.S.
      • Boufous S.
      • Cumming R.
      • Ivers R.Q.
      Fall related injuries: a retrospective medical review study in North India.
      ]. A similar study on fall from Ethiopia reported higher extremity injuries than TBI [
      • Fikadu A.
      • Sultan M.
      • Michael M.
      • Workina A.
      Pattern and outcomes of fall injuries and associated factors in emergency department at Addis Ababa Burn.
      ]. A study from kenya reported a higher incidence of fall related injuries as compared to road traffic injuries [
      • Janeway H.
      • O'Reilly G.
      • Schmachtenberg F.
      • Kharva N.
      • Wachira B.
      Characterizing injury at a tertiary referral hospital in Kenya.
      ].
      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) [

      TITCO collaborators (2017). TITCO dataset version 1. Available from https://github.com/titco/titco-I.

      ]. 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.
      VariableCategories
      DemographyAge (0-14, 14-24, 24-44, 44-65, 65+.)

      Gender (Male & Female)
      VitalsSystolic blood pressure

      Heart rate

      Respiratory rate
      Injury patternIsolated TBI

      TBI with associated injury

      Polytrauma without TBI

      Isolated chest injury

      Isolated limb injury

      Isolated face injury

      Isolated abdomen injury
      Injury Severity Score (ISS)Mild (3–8)

      Moderate (9–15)

      Severe (16–25)

      Profound (> 25)
      Glasgow Coma Scale (GCS)Mild TBI (13–15)

      Moderate TBI (9–12)

      Severe TBI (3–8)
      OthersType of Injury (Blunt or Penetrating)

      Mode of transport

      Length of hospital stay
      TBI: Traumatic Brain Injury.

      Outcome

      The primary outcome was in-hospital mortality.

      Data source

      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 [
      World Health Organization
      ]. The ISS were classified as mild, moderate, severe, and profound [
      • Bolorunduro O.B.
      • Villegas C.
      • Oyetunji T.A.
      • Haut E.R.
      • Stevens K.A.
      • Chang D.C.
      • et al.
      Validating the Injury Severity Score (ISS) in different populations: ISS predicts mortality better among Hispanics and females.
      ]. The GCS was classified as mild, moderate and severe [
      • Jain S.
      • Iverson L.M.
      Glasgow coma scale. 2021 Jun 20.
      ] (Table 1).

      Statistical analysis

      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 [
      • Gerdin M.
      • Roy N.
      • Dharap S.
      • Kumar V.
      • Khajanchi M.
      • Tomson G.
      • et al.
      Early hospital mortality among adult trauma patients significantly declined between 1998-2011: three single-centre cohorts from Mumbai, India.
      ]. Data was analyzed using R version 4.0.2 statistical software [
      R Core Team
      R: a language and environment for statistical computing.
      ].

      Results

      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.
      levelOverall
      Total no. of patients3686
      Age (median [IQR])28.0[9.0, 47.0]
      Age Group [n(%)]0 to 141123 (30.4)
      14 to 24480 (13.0)
      24 to 44979 (26.6)
      44 to 65763 (20.7)
      65+341 (9.3)
      Sex [n(%)]Male2714 (73.6)
      Female972 (26.4)
      Transfer status [n(%)]Transferred2699 (73.2)
      Direct987 (26.8)
      Mechanism of transport [n(%)]Ambulance2434 (66.0)
      Taxi, motor rickshaw617 (16.7)
      Private car569 (15.4)
      Police54 (1.5)
      Carried by man6 (0.2)
      Other6 (0.2)
      Type of injury [n(%)]Blunt3649 (99.0)
      Penetrating37 (1.0)
      Glasgow coma scale [n(%)]Mild2350 (63.8)
      Moderate587 (15.9)
      Severe749 (20.3)
      Injury Severity Score [n(%)]Mild643 (17.4)
      Moderate2351 (63.8)
      Severe419 (11.4)
      Profound273 (7.4)
      Mortality [n(%)]Died664 (18)
      Survived3022 (82)
      Table 3Analysis of in-hospital mortality among patients admitted with history of Fall.
      CharacteristicsLevelNumber of patients - n(%)MortalityProportion of mortality
      Proportion of mortality: (Mortality/n)x 100.
      (%)
      Age [n(%)]
      0 to 141123 (30.4)797.0
      14 to 24480 (13.0)7515.6
      24 to 44979 (26.6)19019.4
      44 to 65763 (20.7)18724.5
      65+341 (9.3)13339.0
      Sex [n(%)]Female972 (26.4)12913.2
      Male2714 (73.6)53519.7
      ISS score [n(%)]Mild
      • James S.L.
      • Lucchesi L.R.
      • Bisignano C.
      • Castle C.D.
      • Dingels Z.V.
      • Fox J.T.
      • et al.
      The global burden of fall: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017.
      ,
      • Ha V.A.T.
      • Nguyen T.N.
      • Nguyen T.X.
      • Nguyen H.T.T.
      • Nguyen T.T.H.
      • Nguyen A.T.
      • et al.
      Prevalence and factors associated with fall among older outpatients.
      ,
      • Ahmed N.
      • Greenberg P.
      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.
      ,
      • DeGrauw X.
      • Annest J.L.
      • Stevens J.A.
      • Xu L.
      • Coronado V.
      Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older, United States, 2006-2011.
      ,
      • Hollis S.
      • Lecky F.
      • Yates D.W.
      • Woodford M.
      The effect of pre-existing medical conditions and age on mortality after injury.
      ,
      • Jindal H.A.
      • Duggal M.
      • Jamir L.
      • Sharma D.
      • Kankaria A.
      • Rohilla L.
      • et al.
      Mental health and environmental factors associated with fall in the elderly in North India: a naturalistic community study.
      643 (17.4)538.2
      Moderate
      • Ayoung-Chee P.
      • McIntyre L.
      • Ebel B.E.
      • Mack C.D.
      • McCormick W.
      • Maier R.V.
      Long-term outcomes of ground-level fall in the elderly.
      ,
      • Mahalakshmy T.
      • Dongre A.R.
      • Kalaiselvan G.
      Epidemiology of childhood injuries in rural Puducherry, South India.
      ,
      • Niven D.J.
      • Kirkpatrick A.W.
      • Ball C.G.
      • Laupland K.B.
      Effect of comorbid illness on the long-term outcome of adults suffering major traumatic injury: a population-based cohort study.
      ,
      • Shrestha R.
      • Shrestha S.K.
      • Kayastha S.R.
      • Parajuli N.
      • Dhoju D.
      • Shrestha D.
      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.
      ,
      • Joshi S.K.
      • Shrestha S.
      A study of injuries and violence related articles in Nepal.
      ,
      • Bhuvaneswari N.
      • Prasuna J.G.
      • Goel M.K.
      • Rasania SK.
      An epidemiological study on home injuries among children of 0-14 years in South Delhi.
      ,
      • Fayyaz J.
      • Wadhwaniya S.
      • Shahzad H.
      • Feroze A.
      • Zia N.
      • Mir M.
      • et al.
      Pattern of fall injuries in Pakistan: the Pakistan national emergency department surveillance (Pak-NEDS) study.
      2351 (63.8)40517.2
      Severe
      • Jagnoor J.
      • Suraweera W.
      • Keay L.
      • Ivers R.Q.
      • Thakur J.S.
      • Gururaj G.
      • et al.
      Childhood and adult mortality from unintentional fall in India.
      ,
      • Bachani A.M.
      • Ghaffar A.
      • Hyder A.A.
      Burden of fall injuries in Pakistan–analysis of the national injury survey of Pakistan.
      ,
      • Mehmood A.
      • Razzak J.A.
      Trauma registry–needs and challenges in developing countries.
      ,
      • Babu A.
      • Rattan A.
      • Ranjan P.
      • Singhal M.
      • Gupta A.
      • Kumar S.
      • et al.
      Are fall more common than road traffic accidents in pediatric trauma? Experience from a Level 1 trauma centre in New Delhi, India.
      ,
      • Peden M.
      • Oyegbite K.
      • Ozanne-Smith J.
      • Hyder A.A.
      • Branche C.
      • Rahman A.
      • Rivara F.
      • Bartolomeos K.
      World Report on Child Injury Prevention.
      ,
      • Jagnoor J.
      • Keay L.
      • Ganguli A.
      • Dandona R.
      • Thakur J.S.
      • Boufous S.
      • Cumming R.
      • Ivers R.Q.
      Fall related injuries: a retrospective medical review study in North India.
      ,
      • Fikadu A.
      • Sultan M.
      • Michael M.
      • Workina A.
      Pattern and outcomes of fall injuries and associated factors in emergency department at Addis Ababa Burn.
      ,
      • Janeway H.
      • O'Reilly G.
      • Schmachtenberg F.
      • Kharva N.
      • Wachira B.
      Characterizing injury at a tertiary referral hospital in Kenya.
      ,

      NHFD 2022 annual report . The National Hip Fracture Database. Royal College of Physicians; 2018 [cited 2022Oct8]. Available from: https://www.nhfd.co.uk/

      ,

      TITCO collaborators (2017). TITCO dataset version 1. Available from https://github.com/titco/titco-I.

      419 (11.4)10525.1
      Profound (>25)273 (7.4)10136.9
      Pattern of injury [n(%)]Isolated TBI2406 (65.2)46419.3
      TBI with associated injuries545 (14.7)13124.0
      Poly-trauma without TBI221 (5.9)2712.2
      Isolated Abdomen injury192 (5.2)147.3
      Isolated chest Injury153 (4.1)1610.5
      Isolated Limb injury111 (3.0)76.3
      Isolated face Injury58 (2)58.6
      1 Proportion of mortality: (Mortality/n)x 100.
      Fig 2
      Fig. 2Kaplan Meier curve showing probability of survival among patients of different age group.
      Table 4Cox hazard ratio at different age group among patients with history of Fall.
      Age GroupHazard Ratio95% Confidence Interval
      0-14
      0-14 - reference.
      --
      14-241.51.1–2.1
      24-442.01.5–2.6
      44-652.62.0–3.4
      65+4.83.6–6.3
      1 0-14 - reference.
      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.
      Isolated TBITBI with associated injuries
      n (%)

      2406 (65.2)
      Mortality (467)Proportion of mortality
      Proportion of mortality: (Mortality/n) x 100.
      (%)
      n (%)

      545(14.7)
      Mortality (131)Proportion of mortality
      Proportion of mortality: (Mortality/n) x 100.
      (%)
      ISS [n(%)]
      Mild276(11.5)3512.633(6.1)39.1
      Moderate1790(74.4)32418.1270(49.5)4516.7
      Severe181(7.5)4926.7157(28.8)4729.9
      Profound159(6.6)5937.185(15.6)3642.4
      GCS[n(%)]
      Mild1403(58.3)896.3289(53.0)237.9
      Moderate455(18.9)9019.796(17.6)1818.8
      Severe548(22.8)28852.4160(29.4)9056.3
      TBI: Traumatic Brain Injury; ISS: Injury Severity Score; GCS: Glasgow Coma Scale.
      1 Proportion of mortality: (Mortality/n) x 100.

      Discussion

      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 [
      • James S.L.
      • Castle C.D.
      • Dingels Z.V.
      • Fox J.T.
      • Hamilton E.B.
      • Liu Z.
      • et al.
      Global injury morbidity and mortality from 1990 to 2017: results from the global burden of disease study 2017.
      ,

      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 [
      • Fikadu A.
      • Sultan M.
      • Michael M.
      • Workina A.
      Pattern and outcomes of fall injuries and associated factors in emergency department at Addis Ababa Burn.
      ,
      • Janeway H.
      • O'Reilly G.
      • Schmachtenberg F.
      • Kharva N.
      • Wachira B.
      Characterizing injury at a tertiary referral hospital in Kenya.
      ,
      • Mekkodathil A.
      • El-Menyar A.
      • Kanbar A.
      • Hakim S.
      • Ahmed K.
      • Siddiqui T.
      • et al.
      Epidemiological and clinical characteristics of fall-related injuries: a retrospective study.
      ]. 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 [
      • Peden M.
      • Oyegbite K.
      • Ozanne-Smith J.
      • Hyder A.A.
      • Branche C.
      • Rahman A.
      • Rivara F.
      • Bartolomeos K.
      World Report on Child Injury Prevention.
      ].
      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) [
      • Mekkodathil A.
      • El-Menyar A.
      • Kanbar A.
      • Hakim S.
      • Ahmed K.
      • Siddiqui T.
      • et al.
      Epidemiological and clinical characteristics of fall-related injuries: a retrospective study.
      ]. 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%) [
      • Wadhwaniya S.
      • Alonge O.
      • Ul Baset M.
      • Chowdhury S.
      • Bhuiyan A.
      • Hyder A.
      Epidemiology of fall injury in rural Bangladesh.
      ]. According to a US based study, the number of admissions due to fall have dramatically increased by 94% from 2005 to 2014 [
      • Khorgami Z.
      • Fleischer W.J.
      • Yuen-Jing A.C.
      • Mushtaq N.
      • Charles M.S.
      • Howard C.A.
      Ten-year trends in traumatic injury mechanisms and outcomes: a trauma registry analysis.
      ]. 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 [
      • Mekkodathil A.
      • El-Menyar A.
      • Kanbar A.
      • Hakim S.
      • Ahmed K.
      • Siddiqui T.
      • et al.
      Epidemiological and clinical characteristics of fall-related injuries: a retrospective study.
      ,
      • Khorgami Z.
      • Fleischer W.J.
      • Yuen-Jing A.C.
      • Mushtaq N.
      • Charles M.S.
      • Howard C.A.
      Ten-year trends in traumatic injury mechanisms and outcomes: a trauma registry analysis.
      ], or in children at the other end of the spectrum [
      • Peeters W.
      • van den Brande R.
      • Polinder S.
      • Brazinova A.
      • Steyerberg E.W.
      • Lingsma H.F.
      • et al.
      Epidemiology of traumatic brain injury in Europe.
      ]. In a study from Japan it was seen that in elderly patients, TBI was more common in fall from height as compared to ground level falls [
      • Yokota M.
      • Fujita T.
      • Nakahara S.
      • Sakamoto T.
      Clarifying differences in injury patterns between ground-level falls and falls from heights among the elderly in Japan.
      ].
      The in-hospital mortality from fall injury was 18% in our study, which is more than four times higher compared to US data (4.2%) [
      • Khorgami Z.
      • Fleischer W.J.
      • Yuen-Jing A.C.
      • Mushtaq N.
      • Charles M.S.
      • Howard C.A.
      Ten-year trends in traumatic injury mechanisms and outcomes: a trauma registry analysis.
      ]. 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 [
      • Mekkodathil A.
      • El-Menyar A.
      • Kanbar A.
      • Hakim S.
      • Ahmed K.
      • Siddiqui T.
      • et al.
      Epidemiological and clinical characteristics of fall-related injuries: a retrospective study.
      ]. The crude mortality reported from fall was 9.55 per 100 000 population in China in the year 2016 [
      • Cheng P.
      • Wang L.
      • Ning P.
      • Yin P.
      • Schwebel D.C.
      • Liu J.
      • et al.
      Unintentional fall mortality in China, 2006-2016.
      ]. Analysis of the Qatar trauma registry data revealed in-hospital mortality to be around 3 percent [
      • Mekkodathil A.
      • El-Menyar A.
      • Kanbar A.
      • Hakim S.
      • Ahmed K.
      • Siddiqui T.
      • et al.
      Epidemiological and clinical characteristics of fall-related injuries: a retrospective study.
      ]. 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 [
      • Roy N.
      • Gerdin M.
      • Schneider E.
      • Veetil D.K.K.
      • Khajanchi M.
      • Kumar V.
      • et al.
      Validation of international trauma scoring systems in urban trauma centres in India.
      ]. 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 [
      • Akkoca M.
      • Tokgöz S.
      • Yılmaz K.B.
      • Güler S.
      • Akıncı M.
      • Balas Ş.
      Mortality determiners for fall from height cases.
      ].

      Limitations

      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 [

      TITCO collaborators (2017). TITCO dataset version 1. Available from https://github.com/titco/titco-I.

      ]. 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.

      Appendix. Supplementary materials

      References

        • Guirguis-Blake J.M.
        • Michael Y.L.
        • Perdue L.A.
        • Coppola E.L.
        • Beil T.L.
        • Thompson J.H.
        Interventions to prevent fall in community-dwelling older adults: a systematic review for the U.S. preventive services task force.
        Agency for Healthcare Research and Quality (US), RockvilleMD2018
      1. Falls. World Health Organization. World Health Organization; 2021 [cited 2022Oct8]. Available from: https://www.who.int/news-room/fact-sheets/detail/falls.

        • James S.L.
        • Lucchesi L.R.
        • Bisignano C.
        • Castle C.D.
        • Dingels Z.V.
        • Fox J.T.
        • et al.
        The global burden of fall: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017.
        Injury Prev. 2020; 26: i3-i11
        • Ha V.A.T.
        • Nguyen T.N.
        • Nguyen T.X.
        • Nguyen H.T.T.
        • Nguyen T.T.H.
        • Nguyen A.T.
        • et al.
        Prevalence and factors associated with fall among older outpatients.
        Int J Environ Res Public Health. 2021; 18: 4041
        • Ahmed N.
        • Greenberg P.
        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.
        J Trauma Acute Care Surg. 2019; 87: 672-677
        • DeGrauw X.
        • Annest J.L.
        • Stevens J.A.
        • Xu L.
        • Coronado V.
        Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older, United States, 2006-2011.
        J Saf Res. 2016; 56: 105-109
        • Hollis S.
        • Lecky F.
        • Yates D.W.
        • Woodford M.
        The effect of pre-existing medical conditions and age on mortality after injury.
        J Trauma. 2006; 61: 1255-1260
        • Jindal H.A.
        • Duggal M.
        • Jamir L.
        • Sharma D.
        • Kankaria A.
        • Rohilla L.
        • et al.
        Mental health and environmental factors associated with fall in the elderly in North India: a naturalistic community study.
        Asian J Psychiatry. 2019; 39: 17-21
        • Ayoung-Chee P.
        • McIntyre L.
        • Ebel B.E.
        • Mack C.D.
        • McCormick W.
        • Maier R.V.
        Long-term outcomes of ground-level fall in the elderly.
        J Trauma Acute Care Surg. 2014; 76: 498-503
        • Mahalakshmy T.
        • Dongre A.R.
        • Kalaiselvan G.
        Epidemiology of childhood injuries in rural Puducherry, South India.
        Indian J Pediatr. 2011; 78: 821-825
        • Niven D.J.
        • Kirkpatrick A.W.
        • Ball C.G.
        • Laupland K.B.
        Effect of comorbid illness on the long-term outcome of adults suffering major traumatic injury: a population-based cohort study.
        Am J Surg. 2012; 204: 151-156
        • Shrestha R.
        • Shrestha S.K.
        • Kayastha S.R.
        • Parajuli N.
        • Dhoju D.
        • Shrestha D.
        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.
        Kathmandu Univ Med J (KUMJ). 2013; 11: 241-246
        • Joshi S.K.
        • Shrestha S.
        A study of injuries and violence related articles in Nepal.
        JNMA J Nepal Med Assoc. 2009; 48: 209-216
        • Bhuvaneswari N.
        • Prasuna J.G.
        • Goel M.K.
        • Rasania SK.
        An epidemiological study on home injuries among children of 0-14 years in South Delhi.
        Indian J Public Health. 2018; 62: 4-9
        • Fayyaz J.
        • Wadhwaniya S.
        • Shahzad H.
        • Feroze A.
        • Zia N.
        • Mir M.
        • et al.
        Pattern of fall injuries in Pakistan: the Pakistan national emergency department surveillance (Pak-NEDS) study.
        BMC Emerg Med. 2015; 15: S3
        • Jagnoor J.
        • Suraweera W.
        • Keay L.
        • Ivers R.Q.
        • Thakur J.S.
        • Gururaj G.
        • et al.
        Childhood and adult mortality from unintentional fall in India.
        Bull World Health Organ. 2011; 89: 733-740
        • Bachani A.M.
        • Ghaffar A.
        • Hyder A.A.
        Burden of fall injuries in Pakistan–analysis of the national injury survey of Pakistan.
        East Mediterr Health J. 2011; 17: 375-381
        • Mehmood A.
        • Razzak J.A.
        Trauma registry–needs and challenges in developing countries.
        J Park Med Assoc. 2009; 59: 807-808
        • Babu A.
        • Rattan A.
        • Ranjan P.
        • Singhal M.
        • Gupta A.
        • Kumar S.
        • et al.
        Are fall more common than road traffic accidents in pediatric trauma? Experience from a Level 1 trauma centre in New Delhi, India.
        Chin J Traumatol. 2016; 19: 75-78
        • Peden M.
        • Oyegbite K.
        • Ozanne-Smith J.
        • Hyder A.A.
        • Branche C.
        • Rahman A.
        • Rivara F.
        • Bartolomeos K.
        World Report on Child Injury Prevention.
        World Health Organization, Geneva2008
        • Jagnoor J.
        • Keay L.
        • Ganguli A.
        • Dandona R.
        • Thakur J.S.
        • Boufous S.
        • Cumming R.
        • Ivers R.Q.
        Fall related injuries: a retrospective medical review study in North India.
        Injury. 2012; 43: 1996-2000
        • Fikadu A.
        • Sultan M.
        • Michael M.
        • Workina A.
        Pattern and outcomes of fall injuries and associated factors in emergency department at Addis Ababa Burn.
        Emergency Trauma Hosp. 2021; 13: 381-389
        • Janeway H.
        • O'Reilly G.
        • Schmachtenberg F.
        • Kharva N.
        • Wachira B.
        Characterizing injury at a tertiary referral hospital in Kenya.
        PLoS One. 2019; 14e0220179
      2. NHFD 2022 annual report . The National Hip Fracture Database. Royal College of Physicians; 2018 [cited 2022Oct8]. Available from: https://www.nhfd.co.uk/

      3. TITCO collaborators (2017). TITCO dataset version 1. Available from https://github.com/titco/titco-I.

        • World Health Organization
        ICD-10: international statistical classification of diseases and related health problems: Tenth revision. 2nd ed. World Health Organization, 2004
        • Bolorunduro O.B.
        • Villegas C.
        • Oyetunji T.A.
        • Haut E.R.
        • Stevens K.A.
        • Chang D.C.
        • et al.
        Validating the Injury Severity Score (ISS) in different populations: ISS predicts mortality better among Hispanics and females.
        J Surg Res. 2011; 166: 40-44
        • Jain S.
        • Iverson L.M.
        Glasgow coma scale. 2021 Jun 20.
        StatPearls. StatPearls Publishing, Treasure Island (FL)2022
        • Gerdin M.
        • Roy N.
        • Dharap S.
        • Kumar V.
        • Khajanchi M.
        • Tomson G.
        • et al.
        Early hospital mortality among adult trauma patients significantly declined between 1998-2011: three single-centre cohorts from Mumbai, India.
        PLoS One. 2014; 9: e90064
        • R Core Team
        R: a language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna, Austria2020 (Available from)
        • James S.L.
        • Castle C.D.
        • Dingels Z.V.
        • Fox J.T.
        • Hamilton E.B.
        • Liu Z.
        • et al.
        Global injury morbidity and mortality from 1990 to 2017: results from the global burden of disease study 2017.
        Inj Prev. 2020; 26: i96-i114
        • Mekkodathil A.
        • El-Menyar A.
        • Kanbar A.
        • Hakim S.
        • Ahmed K.
        • Siddiqui T.
        • et al.
        Epidemiological and clinical characteristics of fall-related injuries: a retrospective study.
        BMC Public Health. 2020; 20: 1186
        • Wadhwaniya S.
        • Alonge O.
        • Ul Baset M.
        • Chowdhury S.
        • Bhuiyan A.
        • Hyder A.
        Epidemiology of fall injury in rural Bangladesh.
        Int J Environ Res Public Health. 2017; 14: 900
        • Khorgami Z.
        • Fleischer W.J.
        • Yuen-Jing A.C.
        • Mushtaq N.
        • Charles M.S.
        • Howard C.A.
        Ten-year trends in traumatic injury mechanisms and outcomes: a trauma registry analysis.
        Am J Surg. 2018; 215: 727-734
        • Roy N.
        • Gerdin M.
        • Schneider E.
        • Veetil D.K.K.
        • Khajanchi M.
        • Kumar V.
        • et al.
        Validation of international trauma scoring systems in urban trauma centres in India.
        Injury. 2016; 47: 2459-2464
        • Akkoca M.
        • Tokgöz S.
        • Yılmaz K.B.
        • Güler S.
        • Akıncı M.
        • Balas Ş.
        Mortality determiners for fall from height cases.
        Ulus Travma Acil Cerrahi Derg. 2018; 24: 445-449
        • Cheng P.
        • Wang L.
        • Ning P.
        • Yin P.
        • Schwebel D.C.
        • Liu J.
        • et al.
        Unintentional fall mortality in China, 2006-2016.
        J Glob Health. 2019; 9010603
      4. International Osteoporosis Foundation: IOF. International Osteoporosis Foundation. INTERNATIONAL OSTEOPOROSIS FOUNDATION; 2022 [cited 2022Oct8]. Available from: https://www.osteoporosis.foundation/.

        • Yokota M.
        • Fujita T.
        • Nakahara S.
        • Sakamoto T.
        Clarifying differences in injury patterns between ground-level falls and falls from heights among the elderly in Japan.
        Public Health. 2020; 181: 114-118
        • Peeters W.
        • van den Brande R.
        • Polinder S.
        • Brazinova A.
        • Steyerberg E.W.
        • Lingsma H.F.
        • et al.
        Epidemiology of traumatic brain injury in Europe.
        Acta Neurochir (Wien). 2015; 157: 1683-1696