Background Having served more than 4000 personnel including the peacekeeping troops, UN police and civilian staff, the Chinese Peacekeeping Level 2 Military Hospital has accumulated 1235 inpatient medical records in 4 years. Assessment of the records stored in the CHN L2 identified that the data collected by different teams were incoherent and highlighted the need for implementation of a hospital-based combat injury registry and the establishment of a combat injury surveillance system.
Methods A one-page, 21-item registry form was designed to collect general information about the injuries, including such data as demographics, injury event, severity, diagnosis and treatment, and outcome. All relevant personnel was required to undergo a 2-day training in order to master the use of the registry form. The new registry form was used to collect the data on all of the cases recorded in the CHN L2 between 26 April 2014 and 31 March 2017.
Results Analysis of the collected data identified improvised explosive device as the most common (44.95%) mechanism of combat injury in Sector East of MINUSMA. Anefis, the centre of the UN logistic transit, was identified as the location where most of the combat injuries (42.20%) occurred. Based on these results, certain suggestions that addressed this threat were given to the Operation department in Sector East of MINUSMA.
Conclusion A hospital-based combat injury registry was successfully developed and implemented in the Chinese Peacekeeping Level 2 Hospital. It can provide data to support the policy changes to minimise the impact of combat injuries on peacekeeping troops. The designed registry form provides more accurate estimates of the magnitude of the morbidity due to different causes in the battlefield and lays a foundation for an injury surveillance system.
- combat injury registry
- chinese level 2 hospital
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A hospital-based combat injury registry was successfully developed and implemented in the Chinese Peacekeeping Level 2 Hospital.
The combat injury registry provides data to support the necessary policy changes to minimize the impact of combat injuries on the health of peacekeeping troops.
The designed registry form provides more accurate estimates of the magnitude of the morbidity due to different causes in the battlefield.
Since 26 April 2014, China has deployed four medical teams for the peacekeeping mission to GAO, Mali. The Chinese Peacekeeping Level 2 Hospital (CHN L2) is the only second-level medical care facility in Sector East of the United Nations Multidimensional Integrated Stabilisation Mission in Mali (MINUSMA). Level 2 is the first level where basic surgical expertise is available, and life support services and hospital and ancillary services are provided within the mission area. The capabilities of the CHN L2 include emergency surgery, damage control surgery, postoperative services and high-dependency care, intensive care resuscitation and inpatient services; it can also provide basic imaging services, laboratory, pharmaceutical, preventive medicine and dental services. As a level 2 facility, CHN L2 also has capabilities to maintain patient records and track the evacuated patients. Having served more than 4000 personnel including the peacekeeping troops, UN police and civilian staff, the CHN L2 has accumulated 1235 inpatient medical records in 4 years. Medical records give a valuable insight regarding the causes, severity, morbidity, mortality and outcomes of the combat injuries. Their analysis provides the evidence for improvements in casualty care and outcomes, helps to enhance use of the resources and plays a key role in injury prevention. An effective injury surveillance system underlain by a uniform data collection, accurate analysis and successful dissemination of data can immensely facilitate prevention of injuries. The lack of a uniform data collection method hinders understanding of the problems and the risk factors related to various combat injuries, thus making development and implementation of the appropriate strategies to prevent and treat them difficult. Assessment of the records stored in the CHN L2 identified that the data collected by different teams were incoherent and highlighted the need for implementation of a hospital-based combat injury registry and the establishment of a combat injury surveillance system. It was determined that the registry should aim to obtain such key information as the mechanism of the combat injury, most frequent geographic injury location and the severity of the injury to facilitate identification of the injury patterns and development of countermeasures strategies for the peacekeeping personnel in the mission area.
Design of the registry form
A one-page, 21-item registry form was designed to collect general information about injuries, including such data as demographics, injury event, severity, diagnosis and treatment, and outcome (online supplementary file 1). Demographic data section includes the same items as the ‘patient ’s information’ section in the UN form and provides personal information about the patient. Injury event data section includes such items as the geographical location where the injury occurred, mechanism of the injury, items that provide information on the pre-hospital stage of rescue and the mode of transportation. The severity data section includes vital signs readings on arrival at the hospital, Injury Severity Scores (ISSs) and anatomical location of the injury. The diagnosis and treatment data section includes information about the clinical examinations, procedures performed at the hospital and the code of the injury according to International Classification of Diseases coding system. The outcome information includes the discharge status and functional score.
Staff training and implementation
Nurses and doctors involved in the collection of the registry data and a special medical information recorder were required to undergo a 2-day training. During the training, the participants learnt about the purpose of the proposed combat injury registry and were given instructions on its use. Each item of the form was thoroughly explained and discussed and practical exercises, followed by the immediate feedback from the instructors, were conducted in order to reassure that each participant fully understood and mastered the use of the registry form. The new registry form was used to collect the data on all of the cases recorded in the CHN L2 between 26 April 2014 and 31 March 2017.
Between 26 April 2014 and 31 March 2017, 1235 cases in total were recorded in the CHN L2. Data on 871 cases data were retrospectively collected from the medical documents stored in the hospital, and data on 364 cases were prospectively collected during the time of our mission that took place from 19 May 2016 to 31 March 2017. The rate of completeness of both data groups was 51.09% and 98.63%, respectively. One hundred nine cases out of the 804 cases with the complete data were combat injury cases. Figures 1–3 show a breakdown of the mechanisms, geographical locations where injuries occurred and the anatomical sites of injuries. It can be inferred that improvised explosive device (IED) was the most common (44.95%) mechanism of combat injury in Sector East of MINUSMA. It usually causes mild or moderate damage (ISS>16 30.67%; ISS≤16 960.33%) to the in-vehicle occupants, especially to the lower extremities (32.11%). Some cases (17.43%) combined mild brain injury or head lacerated wound due to the occupants taking off their helmets during the vehicle locomotion at the time of IED detonation. Most of the combat injuries (42.20%) occurred in Anefis, the centre of the UN logistic transit. Air evacuation by helicopter (66.06%) was the main mode of transportation.
Suggestion output from the data analysis
According to the results of the analysis of the data obtained with the help of the new registry form, IED was the predominant threat to the peacekeeping troops in Sector East of MINUSMA. This conclusion is in line with the findings reported in the literature on Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in Afghanistan carried out by the US, UK and French armies.1–4 Based on this conclusion our team gave the following suggestions to the Operation department in Sector East of MINUSMA:
During transit between GAO and Anefis, more attention should be paid to IED attacks. An armoured vehicle should always be in front of the convoy and all other vehicles need to follow its route to avoid triggering the IED.
Safety belt should be fastened and helmet should not be taken off even inside the armoured personnel carrier because the displacement of the vehicle in IED explosion will most likely cause a head injury.
V-shaped hull is effective in protecting the in-vehicle personnel from injuries by IED attacks and should be used whenever possible.
Counter-IED training and awareness are of crucial importance to each member of the service. The drivers and guards, in particular, should take more time to learn the skills of IED detection, and for the personnel who is not proficient enough in English language, the relevant lessons should be prepared in their native language.
Significance of the combat injury record registry
In modern times, the primary purpose of the overseas operations of the Chinese People’s Liberation Army has been participation in the global peacekeeping. Medical teams have been deployed to different mission areas for more than 10 years. Numerous combat injury records have been accumulated but their inconsistency and the lack of standardisation made it hard to use these records for performance improvement and casualty safety, not to mention improvement of outcomes. It has been shown by several studies that mortality among injury victims can be reduced by implementation of a trauma system. A trauma system is a preplanned, organised and coordinated injury-control effort in a defined geographic area. The importance of trauma systems to improving its soldiers’ chances of surviving combat-related injuries was recognised by the US military forces, and in 2004 they developed and implemented the Joint Theatre Trauma System and its mainstay, the Joint Trauma Registry (JTTR).5 JTTR captured mechanism, acute physiology, diagnostic, therapeutic and outcome data on 23 250 injured patients admitted to deployed US military treatment facilities. This registry facilitated recognition of the trauma system issues leading to improvements in its performance and overall advancements in trauma care, which contributed to improved survival after battlefield injury.6 The successful experience of JTTR implementation inspired our efforts to develop and implement a trauma registry in our hospital.
Structure of the registry form
The 21-item registry form was especially designed for the peacekeeping mission. As it was shown in the study by O’Reilly et al on trauma registries in developing countries, most registries collect data on five main variable groups such as demographics, injury event, process of care, injury severity and outcome7; therefore, it was decided that these five variable groups should be included in our registry. The items that were chosen to be included or excluded in each group with a brief explanation, if needed, are given below:
Demographics: age, gender and occupation were included; education level, socioeconomic status and ethnicity were excluded. Due to the fact that treatment of combat injuries is free, some factors such as socioeconomic status have few effects on medical procedures.
Injury event: location, mechanism, pre-hospital rescue and transport method were included. Location subgroup includes common geographical locations where attacks take place in Sector East, such as Super Camp, Elevage Camp, GAO city, Anefis, Menaka and so on. In the mechanism subgroup, IED was put as the first item because as it has been shown by numerous studies, it is the most frequently encountered weapon in the currently active battlefields.8 9 For the aim of a more in-depth research, we decided to include subitems ‘dismount’ and ‘mount’. Pre-hospital mode of transportation was also included in this group.
Injury severity: vital signs on arrival at the hospital and ISS were included. ISS was chosen on grounds of it being the most commonly used scoring system in trauma registries. Anatomical site of injury was also included in this group.
Process of care: data on diagnostic tools and treatment can provide the information on use of medical resources, thus these items were included in the registry. ICD-10 codes were used in our registry form to provide data on diagnosis.
Outcome: discharge status and functional score were included. Functional score can be used for comparison with other similar cases or for investigation purposes in the future.
Limitations and future focus
The main limitation of this study was the lack of data from other Chinese Level 2 peacekeeping hospitals for comparison. However, we intend to conduct an investigation in other mission areas where Chinese military medical teams act as the leader of a UN peacekeeping Level 2 hospital. Although our hospital-based combat injury registry may have helped to guide prevention efforts, at the moment our ability to detect issues in the process of medical care using the registry is limited partially due to lack of data on injuries of the same type; however, as more data are accumulated, we will be able to overcome this limitation. In the modern military conflicts, evacuation by helicopter has been the primary mode of casualty transportation.10 The air rescue network in China is not developed, hence including more items that could provide data about air evacuation could potentially provide evidence for improvements for the Chinese military and also for the civilian trauma care system in China. Some registries include items providing data on the length of intensive care unit stay. These items are not included in our registry, nevertheless this information can be found in the medical records stored at the hospital; therefore, despite capturing general information about the injury, certain details can only be obtained if the registry is used in conjunction with other existing data sources. Our registry does not include items that could provide data on alcohol or drug intoxication at the time of injury. These items, although usually included in the civilian trauma registries, were not included due to their prohibition in the battlefield and the resulting inability to perform relevant tests in our laboratory. Although the registry does not include findings of laboratory and imaging examinations, in the future we would like to add such items as X-ray findings of pneumothorax and haemothorax, and findings of Focused Assessment with Sonography in Trauma (positive or negative). As for laboratory examination findings, we would like to include such items as haemoglobin level, base deficit and lactate level. We believe that adding these items can significantly improve the completeness of the data collected with the help of the registry and will broaden the application of the registry in research.
Hospital-based combat injury registries in Chinese Peacekeeping Level 2 Hospital provide data to support the necessary policy changes to minimise the impact of combat injuries on the health of peacekeeping troops. The designed registry form provides more accurate estimates of the magnitude of the morbidity due to different causes in the battlefield. Over time, methodical analysis of the registries will identify the trends in each type of injury by locations and causes, while identifying risk factors associated with these combat injuries and highlighting areas for further research. All of this will help to build a solid foundation for developing a strong injury surveillance system that requires minimal resources for maintenance and provides data to guide the development of combat injury control and treatment strategy.
Contributors JT was responsible for the overall design, supervision and execution of the project, and quality control. ZJ and NZ were responsible for designing the registry form and entering the statistical data. SZ was responsible for statistical analysis of the data collected with the use of the registries and input of the data. RS was responsible for structuring the content and writing of the manuscript.
Funding This study was funded by project of Medical Science and Technology Research of People’s Liberation Army (grant no. CSY15J001).
Competing interests None declared.
Patient consent Not required.
Ethics approval Ethics Committee of General Hospital of Shenyang Military Command.
Provenance and peer review Not commissioned; externally peer reviewed.
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