A retrospective analysis of data obtained from the Qatar National Trauma Registry at HTC was conducted. This is a mature database that participates in both the National Trauma Data Bank and Trauma Quality Improvement Program of Committee on Trauma of the American College of Surgeons (TQIP-ACS). The study received ethical approval from the Institutional Review Board (IRB) of Hamad Medical Corporation (#MRC-01-18-189). The HTC is the only level 1 trauma center in Qatar which sees and treats moderate to severely injured patients across the country including referrals from other hospitals. Each year, a trauma code (Level I, II or III Trauma Criteria) is activated for nearly 2500 patients. Of these patients, an average of 1500-1800 require hospital admission at the HTC, 500-700 patients receive treatment at the ED without need for hospitalization and an average of 80 patients die before arrival as a consequence of their injuries. This study included all patients admitted to the level 1 HTC for violence related (IPV and self-inflicted) injuries from 1 June 2010 to 30 June 2017. Patients brought in ‘dead on arrival’ to the hospital and patients who did not require hospital admission were excluded from the final analysis. Patients were categorized into two groups based on the type of violence (interpersonal and self-inflicted) and their demographics, injury characteristics, management and in-hospital outcomes were analyzed and compared.
Data extracted and analyzed included: age, gender, nationality, mechanism of injury, Glasgow Coma Scale (GCS), Ethanol level (blood alcohol concentration), injured regions, injury severity score (ISS), major procedures and outcome. The Glasgow Coma Scale (GCS) is a neurological scale with scores that range from 3 to 15 to assess consciousness in which GCS < 8 severe, 9-12 moderate and ≥ 13 minor head injuries [11]. The term “alcohol” denotes “ethyl alcohol or ethanol”. Blood alcohol concentration (BAC) was reported as millimoles of ethanol per liter of blood (mmol/L). Any BAC level above zero mmol/L was reported as BAC-positive; levels 0.1–10.9 were “less intoxicated”; 10.9–21.7 were “intoxicated”, and >21.7 were “very intoxicated” (or at CNS depression levels) [12].
The Abbreviated Injury Scale (AIS) refers to severity of injuries in different body regions; scores range from 1-6, representing minor, moderate, serious, severe, critical and non-survivable injuries respectively [13,14]. Three most severely injured body region AIS scores are squared and added together to estimate the Injury Severity Score (ISS) in order to provide an overall score for polytrauma [13,14]. ISS ranges from zero to 75 where 0-9 is minor; 10-15 moderate; 16-24 severe; and >25 is critical [13]. Data elements are abstracted concurrently. Injury details are obtained from the final radiology reports, operative notes as well as physician and nursing documentations. The abstracted injury data are used for the AIS and ISS calculation during the patient’s hospitalization.
The study patients were grouped by nationality: Arabs, South Asians, Africans and Westerners. The population data were obtained from the website of the Ministry of Development, Planning and Statistics in Qatar [15], from which mid-year population was used for estimating the average annual incidence rate of violence related hospital admission.
Patients were identified from the Qatar national trauma registry which refers to the electronic medical records, reviews patient history, searches for police documentation, social worker notes and referrals to the Women and Child Protection Team for the confirmation of a violent event. The trauma registry utilizes the Classification of External Cause of Injury and Poisoning (E-Codes) of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) in the study period. The E-codes for suicide and self-inflicted injury (E950-E959) included: injuries in suicide and attempted suicide, self-inflicted injuries specified as intentional. The codes for homicide and injury purposely inflicted by other persons (E960-E969) included: injuries inflicted by another person with intent to injure or kill, by any means. The codes for legal intervention (E970-E978) included: injuries inflicted by police or other law enforcing agents. Each patient record was given a unique study number, and patient anonymity was maintained throughout the study. The trauma registry data validation is done internally and externally and on regular basis. This manuscript adheres to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines (Suppl table) [16].
Statistical analysis:
Descriptive and bivariate analysis of trauma registry data were carried out based on the inclusion and exclusion criteria in the study period. Data were summarized in form of proportions for categorical variables and, mean (±standard deviation) and median (range) for continuous variables. Categorical variables were compared using Chi-square test and Fisher exact test depending on the size of the data set. Independent student t-test was used for continuous variables. Multivariate analysis models for predictors of the type of violence and predictors of mortality were performed using the relevant and significant variables such as age , sex , nationality , mechanism and type of injury, injury severity score, admission GCS, and alcohol consumption (BAC status) and data were expressed as odds ratios (OR) and 95% confidence intervals (CI). The Hosmer and Lemeshow test was used for goodness of fit for logistic regression models. A two-tailed P value of < 0.05 was statistically significant. All data analyses were carried out using the Statistical Package for the Social Sciences, version 18 (SPSS, Inc., Chicago, IL).