Epidemiology of major injury in the population of Friuli Venezia Giulia—Italy

Abstract

Objective: To provide reliable and comparable information on major injury (MIJ) (Injury Severity Score (ISS)>15) by establishing a comprehensive and Utstein-style compliant registry of all occurrences in a defined geographical area. Methods: Prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia (FVG). Deliberate self-harm was excluded. Results: The total number of MIJ cases was 627, the resulting incidence 522 per million per year. Trauma was mostly blunt (98.4%). Young (15–44 years) adults (54.8%) and males (78.6%) were most affected. Leading mechanisms of injury were traffic accidents (81%) and falls (9.1%). Most events occurred in rural (80.9%) areas despite one third of the regional population living in major urban centres. Summer and weekends carried the highest frequency. The mean ISS (n=455) was 30.0, median 25. On-scene vital parameters were often subnormal, e.g. 53.9%, GCS<14. The Emergency Medical System was nearly always activated (98.4%). The time intervals were within standards although in part susceptible of improvement. The percentage of direct triage to the definitive hospital was 79.8%. Overall mortality was 45.6% or 238 per million per year. Most fatalities were found already dead (171/300) and no trimodal distribution was verified. Only 1.5% of the patients found alive died outside hospital. Mean GOS was 4.4±1 (S.D.), median 5. Conclusion: A considerable amount of information on MIJ in FVG has been gathered, of both local and general interest because it can help to assess the local trauma system and also, given the relative scarcity of prospective, population-based information on MIJ, contribute to scientific research.

Introduction

Trauma has been a significant cause of death and disability throughout history and in recent years has become one of the most serious public health problems not only in developed societies, but also in intermediate and low-income countries. One of the most authoritative and recent publications on the subject¹⁴ states that “It is estimated that 5.8 million people died world-wide from injuries in 1998”; “Injuries are the leading causes of death in all age groups”; “Five of the top 10 causes of death in the world for persons aged 15–44 years are the result of injury” and “Road traffic and self-inflicted are the leading causes of injury-related deaths world-wide.”

Detailed epidemiological information is the basis for planning the control and prevention of disease in communities. Several studies concerning the epidemiology of major injuries have been published, albeit not always homogeneous and comparable. A main limitation in the past has been the lack of clear and accepted definitions. For example the Ontario Trauma Registry¹⁶ included patients with Injury Severity Score (ISS) >12 while other data banks used the threshold of 15.² Uniformity and standardisation in trauma studies are however expected to show a considerable improvement after the publication of the Utstein-style Recommendations for uniform reporting in trauma¹⁰ in 1999.

The heterogeneity of their designs is another limitation on the accuracy and comparability of studies on trauma. For example, “The major trauma outcome study”,⁵ published in 1990 and still one of the largest data banks on trauma, considers only the patients admitted alive, ignoring any information concerning the prehospital phase. The failure to consider this type of information may leave an important part of trauma care unexplored and even hinder any subsequent comparison with other sets of data collected elsewhere. If, for instance, the criterion used in the Ontario Trauma Registry of excluding the patients that arrive at hospital already sedated and intubated were applied to the Italian region Friuli Venezia Giulia (FVG), more than 80% of trauma victims with ISS>25 would be missed. Population-based data are therefore strongly advisable to draw reliable inferences.

Population-based studies on major trauma that take into account also the prehospital phase have been already published. Analysing a population of more than 3.2 million in Wales and north-east England, Gorman et al.¹² found an incidence of 340 major injury (MIJ) cases per million per year. Regrettably, this study after demonstrating that most deaths occur outside the hospital, made no distinction among patients found dead, dead at scene and dead on arrival at hospital. This distinction is important because it can help identify the best prevention strategies as shown by another study²² that found that 25% of prehospital fatalities occurred during the rescue and transport procedures.

Based on the above considerations, we attempted to establish a regional registry of all major (ISS>16) injury occurrences—except self-inflicted—that included comprehensive demographic, prehospital, hospital and outcome information. The registry’s main findings are presented in an Utstein-compliant fashion with the aim of providing reference information in a field where prospective, population-based and comparable data are still scarce, contributing to evaluate the appropriateness of the local trauma system and helping to identify critical points and develop strategies for improvement. Although this study has been published in a preliminary form²¹ and its database has been used for more specific publications,8., 9. it had not yet been presented integrally.