the prevalence of surgical trauma as a public health 
 hazard in low - resource settings globally has been 
 severely neglected .
traditionally , surgery has been 
 viewed as a resource - intense intervention that does not 
 fit in with most effective public health models . 

however , surgery can provide solutions to diverse yet 
 common crises such as appendicitis or obstructed 
 labour , which constitute a large burden of global 
 morbidity ( 1 ) . specifically , the world health 
 organisation recognises accidents and injuries as a 
 rising cause of disability and mortality globally ( 2 ) .
burns , road accidents and domestic violence are all 
 common situations where surgical intervention may 
 prevent death or disability ( 3 ) . of these , the focus on 
 road accidents as a preventable cause of high mortality 
 and disability has become central .
estimates go as high 
 as 3000 people dying every day in road accidents 
 worldwide .
the very young , the very old , cyclists and 
 pedestrians are the most vulnerable ( 4 ) . as
societies 
 globally become more automated , increasing 
 congestion of motor transport has made this issue of 
 critical concern .
understanding the burden injury that could otherwise 
 be treated through simple trauma surgery places on 
 global health systems can not be accurately understood 
 without effective means to monitor its prevalence . 

furthermore , evaluating the capacity to respond to such 
 a burden also requires effective management of data . 
 as global capacity to provide emergency
surgical care develops , mechanisms to monitor and evaluate 
 outcomes also need to be instituted concomitantly . 

furthermore , using 
 trauma scores to analyse injury data can identify best 
 practices in treatment of injury by identifying where 
 outcomes are improved ( 1 ) .
. 
 however , many now aim to move beyond mere 
 epidemiological analysis towards managing responses 
 to such injuries .
developing tools that permit appropriate monitoring 
 and evaluation of burgeoning surgical capacity provides 
 a means to ensure that challenges are identified , and 
 successes are replicated , as demonstrated in iran ( 5 ) . 

this study showed that a standard trauma score , 
 developed in north america , had some capacity to 
 evaluate the care given to injury patients in the iranian 
 context , demonstrating where treatment of trauma there 
 was suboptimal to comparative injuries in north 
 america .
a larger study , also in iran , demonstrated that 
 a registry system provides valuable information 
 focusing attention on plausible public health 
 intervention for injury prevention , specific to local 
 contexts ( 6 ) .
similar studies have been done in costa 
 rica ( 7 ) and a study of occupational injuries from a 
 government database of such incidents was completed 
 in turkey ( 8) . in nigeria , a retrospective study of data 
 from hospital records focused on the specific issue of 
 peripheral artery injuries to better understand 
 prevention ( 9 ) .
however , correlating 
 the epidemiological data of a registry with the clinical 
 practice data from measurement of trauma severity 
 scores requires a further step . in north america ,
the trauma injury severity score 
 ( triss ) is the standard tool used in hospitals to 
 evaluate clinical performance in trauma wards .
standardised tool , comparisons of performance in order 
 to identify problems or best practices are thus possible 
 ( 10 ) .
however , triss can only be applied reliably in 
 the settings where the index has been validated , in the 
 high - resource settings of north america .
although 
 there have been minor studies done to evaluate the 
 adequacy of the scores in low - resource settings ( 5 ) , 
 more predictive efficacy could be reached by designing 
 an index specific to low - resource settings .
trauma surgeons in uganda and canada are already 
 developing a trauma severity index specific to east 
 african contexts ( 11 ) .
this index , the kampala trauma 
 score ( kts ) , was developed to be effective in areas 
 where access to certain indicators may be costly or 
 time - consuming .
thus , patient status is evaluated by taking four vital parameters into account : blood 
 pressure , respiratory rate , neurological status and 
 number of serious injuries sustained .
these relatively 
 easy measurements give a global overview of a patient 's 
 status , and in principle , can be correlated to the outcome 
 of the case , given interventions appropriate for the 
 patient 's status .
analysis of data from uganda 
 showed some degree of success in predicting outcome , 
 although evaluation of its efficacy as a triage tool 
 remains to be seen ( 12 ) .
this data from dar es salaam , 
 tanzania is the first time data has been collected 
 externally using this system of registry and trauma 
 indexing .
one round of data has already been evaluated 
 from this collection in dar es salaam ( 13 ) .
the data 
 presented in this round are the preliminary results from 
 the second round of data being collected in dar es 
 salaam , given the changes incorporated into the survey 
 after the first round .
research is required to evaluate 
 that data collection is standardised and consistent , in 
 order to improve the ability to monitor and plan trauma 
 management protocols specific to their context 
 effectively ( 14 ) .
regional reliability of trauma data has 
 become an increasing concern in the field , even in the 
 developed world , as populations become more mobile 
 and social systems more integrated ( 15 ) .
previous experiences in data collection from developing 
 country registries have showed variable consistency in 
 the recording of necessary data , requiring efforts to 
 systematise the data available in manageable ways ( 1 ) . 

however , 
 research in the developing world faces serious 
 difficulties in capacity ( 16 ) .
the transfer of research 
 capacity from national systems to global actors is an 
 issue , as well as the instability of political agendas to 
 support research in low- and middle - income countries . 

poor pay of research workers that require them to seek 
 opportunities elsewhere also has an impact on research 
 capacity in the developing world .
old models of 
 academic partnerships in and of themselves have 
 contributed to the degeneration of research capacity 
 globally , as local authority has been pre - empted by 
 external control of research agendas ( 17 ) . with this context in mind ,
this project thus sought to 
 accomplish three primary goals : to understand the 
 benefits maintaining a trauma registry can bring to the 
 tanzanian context , to describe the efficacy of the 
 kampala trauma score in monitoring injury in dar es 
 salaam , and finally to evaluate the challenges apparent 
 in the maintenance of such a registry for research 
 purposes in this context .
the data analysed in this paper comes from an initial 
 two - week collection of the second round of data from 
 tanzania .
this round of data collection is derived from 
 a survey instrument that has been modified to respond 
 to collection challenges encountered in the year - long 
 first round .
some data in this round had to be dismissed as data 
 collectors used the old tool for approximately twenty 
 cases .
the remaining data , involving 125 valid cases , 
 was analysed for data quality concerns , screened for 
 missing values and contradictory evidence .
interviews 
 were also conducted with three project managers in the 
 hospital administration to highlight some of the most 
 pressing challenges in trauma registry maintenance .
a 
 focus group with emergency department nurses who 
 served as data collectors at the dar es salaam site was 
 also conducted .
these data collectors were also 
 responsible for clinical nursing duties for patients 
 entering the emergency department , thus engaging in 
 acute care to ensure stabilisation of patients ' conditions .
therefore , it is important to note that they were not 
 primarily researchers steeped in the research questions 
 and methodology , their main interest being to ensure 
 appropriate care of the injured patient . while the data 
 they recorded would be pertinent to routine care , the 
 burden of filling out additional paperwork could come 
 into conflict with their clinical duties .
the data 
 collectors were however remunerated a nominal amount 
 for every score evaluation conducted .
a visit to a rural clinic at mkuranga , 80 km outside of 
 dar es salaam , where data collection has commenced as 
 part of a national process , provided additional 
 information on the nature of trauma registries in 
 tanzania , through interviewing the project coordinator 
 at that site .
initial findings from the second round of data 
 confirms the general understanding that men are 
 preponderantly susceptible to visit the emergency room , 
 involving 97 cases of the 125 .
. there were some 
 inconsistencies in recording of age , as some collectors 
 recorded year of birth rather than age . in three cases , 

simply  adult  was noted , and in four cases , age was 
 not recorded at all .
of anecdotal interest , on the initial 
 day of the visiting researcher 's stay at the hospital , all 
 four beds in the department devoted to serious injuries 
 were occupied by young men ( suffering head trauma 
 from road accidents ) .
certain parameters required to define the trauma 
 score on the kampala scale did not pose problems .
the 
 vast majority of cases came in with normal systolic 
 blood pressure , and this index was not scored in only 
 one instance ( see table i ) .
eleven cases came in with 
 poor respiratory rates , five of which were children , one 
 unknown .
two cases showed the poorest neurological 
 signs of no response to any stimuli whatsoever , one of 
 those cases being a child .
although in 
 interview , collectors seemed clear about what 
 constituted a serious injury  anything that required 
 surgical intervention 
these discrepancies came to light as 
 there was a repeated question on serious injury .
one 
 question , question 9 , asked the collector identify the 
 number of serious injuries .
another question , question 
 19 , asked the clinician to identify the site of serious 
 injuries .
table iv shows some of the findings of this 
 internal cross - checking , with figures of note in bold .
the table compares the initial reporting of serious 
 injury of the case under question 9 by the data collector , 
 against where they later record as the site of serious 
 injury under question 19 .
for instance , of the 47 
 patients who were initially described as having no 
 serious injuries , 8 were later noted to have the 
 head / neck as a site of serious injury , and 26 at the pelvis 
 or extremities . of the 55 who were initially noted to 
 have one site of serious injury , 1
was later described as 
 having no site of serious injury , 3 as multiple sites of 
 injury and 9 had no site recorded at all .
this inconsistency in data collection must naturally 
 lead to inaccuracies in calculating the total kts .
these 
 problems were compounded by simpler errors , where , 
 for example , clinicians provided a total score for four of 
 the twelve cases which had not been scored on the 
 serious injury scale .
the kts was not calculated in 
 eight cases but can be extrapolated from the component 
 scores , all of them at a stable 8 . in four cases where 
 there was no serious injury score ,
the data collector 
 nonetheless provided a kts score , all of them a stable 
 8 .
besides the problems with actual scoring , there were 
 other points to note on the data collection ( see table v ) . 
 in three cases of the total ,
otherwise , 58 cases were caused by road 
 accidents , 39 were caused by a fall , two were stabs or 
 cuts , two were blunt force and 21 were from other 
 causes .
however , when prompted , 14 of the cases in 
 this latter category were described as assaults , rather 
 than by the specific nature of the assault described in the 
 earlier categories . given the preponderance of road accidents , the 
 survey asked for further detail regarding the 
 circumstances of these injuries ( see table vi ) .
of the 58 
 road accidents , the highest proportion was those involving vehicles and pedestrians as counterparts  31 
 out of the 55 of the cases where the counterparts were 
 noted by data collectors in the survey .
important information regarding seatbelt 
 use ( or helmet use in the case of motorcycle or bicycle 
 accidents ) was quite well recorded where relevant ( see 
 table vii ) . gathering this data is essential to enhance 
 monitoring and implementation of public health 
 initiatives .
the most critical 
 lack of information comes from the two - week followup 
 ( see table viii ) .
of the 125 cases , only 31 had 
 information on the follow - up , of which 22 remained 
 discharged , two had died and the remainder were still 
 noted as remaining in hospital . of the 39 cases 
 originally noted as having been admitted to the hospital , 
 two - week follow - up was missing for 30 of them . 

interestingly , of the two who died , one had no kts 
 score noted and the other had come in scored as a stable 
 9 .
firstly , the ability to monitor data in an emergency 
 department provides valuable insight into the nature of 
 injuries that are prevalent in an area . as such , registries 
 may prove to be an effective tool for public health 
 interventions , in their capacity to direct resources 
 towards addressing the most serious concerns in 
 preventing accident and injury .
the data , although 
 preliminary , provides an overview of the injuries that place the most burden on an orthopaedic emergency 
 room in dar es salaam .
clearly , mimicking global 
 trends , road accidents are a major concern in the region . 

there is also particular concern for the health 
 status of young men . while this statistic may be due to 
 the enhanced risk - taking behaviours of men , it is also 
 plausible that women in dar es salaam are less likely to 
 seek formal care for injuries than men , thus presenting 
 less often to the emergency room
secondly , the leverage tool the registry provides in 
 order to launch public health interventions underscores 
 its importance .
this data can be used both by national 
 authorities in tanzania , as well as regionally and more 
 globally , to address pressing issues of road safety and accident awareness .
although human resources are 
 insufficient to devote to this work , the interviews with 
 hospital administration in dar es salaam underlined the 
 necessity of bringing this data to government authorities 
 to launch a campaign to limit the injury burden from 
 road accidents .
thirdly , the process of launching and maintaining the 
 registry at a national hospital in a low - resource setting 
 promotes the development of capacity to engage in 
 research in these contexts , which is direly needed in 
 order to make sure public health dollars are spent 
 effectively .
locally - led research ensures that funds are 
 not misdirected to concerns that are externally 
 determined . while these initiatives bring to light global 
 health concerns that need redress , they also enhance 
 global health equity in acknowledging the expertise of 
 researchers active in low - resource settings .
the hospital 
 administration in dar es salaam shows remarkable 
 commitment to the research process with little public 
 support , fuelled by the energy of a few individuals . 

overall , the relative completeness of the components 
 of the kampala trauma score collection shows that at 
 least the three initial parameters ( blood pressure , 
 respiratory rate , and neurological status ) are efficient 
 indicators to collect data in clinical contexts in 
 tanzania . whether they adequately describe patient 
 outcomes remains to be seen ,
although the analysis 
 done on the more extensive ugandan data suggests that 
 as the tanzanian data is more rigorously collected and analysed , there will be predictive capacity ( 12 ) . 

however , the results for the serious injury score in this 
 preliminary tanzanian data , for example , show some of 
 the most pressing concerns in data collection .
the interviews provided some nuance to the 
 questions where the most critical lapses occurred .
the 
 project managers noted that inadequate support for 
 research capacity requires that nurses undertake the 
 work .
the nurses in the emergency room , in return , 
 underlined that balancing the needs of the researcher 
 and clinician in a busy emergency room was difficult , 
 with the research needs suffering .
this reality was 
 particularly highlighted at the rural clinic , where the 
 data entries ( not analysed here ) were much more 
 nuanced and detailed , given the many fewer visits at 
 mkuranga .
while some of the difficulties could be ascribed to the 
 fact that this data collection occurred early on in the 
 round of data collection , it must be noted that the 
 hospital had conducted one full year s round of data 
 collection previously . introducing new data collectors to 
 the process can naturally cause difficulties , but 
 providing immediate feedback once these challenges 
 have been identified early on
is necessary to ensure 
 usable data arises in the long - term . in the meantime ,
a 
 stopgap measure of cross - checking data with hospital 
 records themselves may be instituted .
however , 
 devoting human resources to this task is also an 
 untenable drain on clinical work in the hospital . for future perspectives
, the two most important areas 
 where further improvement of data collection needs to 
 take place are in scoring serious injury , and in recording 
 outcomes in the two - week follow - up .
adequate 
 recording of this component is essential , as an accurate 
 calculation of the kts is dependent on it .
the former 
 can be a challenge given the possibilities of rapid 
 clinical evolution in emergency settings .
however , 
 refining the design of the survey in this regard may prove useful , requiring clinicians to list only the sites 
 where intervention was required .
the data analysers can 
 then total up this elementary information to assign a 
 serious injury score themselves , ensuring that there is 
 no repetition of the same data in the collection . in this 
 way
, the analysers can also do the work of calculating 
 the total kts , further relieving the burden from the data 
 collectors so they are required only to gather the most 
 elementary components of the data .
furthermore , clear 
 definitions of what constitutes a serious injury need to 
 be refined further , taking into account that surgical 
 intervention alone can not be the most reliable marker of 
 gravity of trauma .
it is conceivable that there is not 
 even a consensus amongst data collectors on what 
 constitutes a surgical intervention itself .
sustaining the collection of outcome data is critical to 
 harness the entire potential of a trauma registry , in order 
 to monitor the effectiveness of treatment in each setting . 
 in this consideration ,
the lack of capacity to undertake a 
 two - week follow - up , even as minimally required by this 
 survey instrument , was limited with the resources 
 available to the hospital .
even though most data 
 collected by the survey instrument was also 
 independently entered into the hospital records , there 
 was little time to cross - check this data with hospital 
 records , and certainly two - week follow - up was often 
 impossible by the emergency nurses even if the patient 
 remained in hospital . rather than research design , this 
 problem is a more structural issue in low - resource 
 settings of limited research capacity .
clearly , addressing this difficulty can not be resolved 
 within one project alone . in the long - term
, the registry 
 would ideally be integrated into routine care in the 
 emergency department across east africa , perhaps 
 incorporated into regular charting activities in order to 
 monitor the predicted outcomes and the course of 
 treatment of trauma patients .
however , much needs to 
 be done to verify the validity of the tool until then .
the establishment of research partnerships between highresource 
 settings and lower - resource contexts can be 
 helpful , only if there is a transfer of both financial and 
 human resources to local actors so that research 
 capacity within the society is enhanced .
control of 
 research agendas and projects needs also to remain 
 within the developing world .
firstly , the ability to monitor data in an emergency 
 department provides valuable insight into the nature of 
 injuries that are prevalent in an area . as such
, registries 
 may prove to be an effective tool for public health 
 interventions , in their capacity to direct resources 
 towards addressing the most serious concerns in 
 preventing accident and injury .
the data , although 
 preliminary , provides an overview of the injuries that place the most burden on an orthopaedic emergency 
 room in dar es salaam . clearly , mimicking global 
 trends , road accidents are a major concern in the region . 

there is also particular concern for the health 
 status of young men . while this statistic may be due to 
 the enhanced risk - taking behaviours of men , it is also 
 plausible that women in dar es salaam are less likely to 
 seek formal care for injuries than men , thus presenting 
 less often to the emergency room
secondly , the leverage tool the registry provides in 
 order to launch public health interventions underscores 
 its importance .
this data can be used both by national 
 authorities in tanzania , as well as regionally and more 
 globally , to address pressing issues of road safety and accident awareness .
although human resources are 
 insufficient to devote to this work , the interviews with 
 hospital administration in dar es salaam underlined the 
 necessity of bringing this data to government authorities 
 to launch a campaign to limit the injury burden from 
 road accidents .
thirdly , the process of launching and maintaining the 
 registry at a national hospital in a low - resource setting 
 promotes the development of capacity to engage in 
 research in these contexts , which is direly needed in 
 order to make sure public health dollars are spent 
 effectively .
locally - led research ensures that funds are 
 not misdirected to concerns that are externally 
 determined . while these initiatives bring to light global 
 health concerns that need redress , they also enhance 
 global health equity in acknowledging the expertise of 
 researchers active in low - resource settings .
the hospital 
 administration in dar es salaam shows remarkable 
 commitment to the research process with little public 
 support , fuelled by the energy of a few individuals . 

overall , the relative completeness of the components 
 of the kampala trauma score collection shows that at 
 least the three initial parameters ( blood pressure , 
 respiratory rate , and neurological status ) are efficient 
 indicators to collect data in clinical contexts in 
 tanzania . whether they adequately describe patient 
 outcomes remains to be seen ,
although the analysis 
 done on the more extensive ugandan data suggests that 
 as the tanzanian data is more rigorously collected and analysed , there will be predictive capacity ( 12 ) . 

however , the results for the serious injury score in this 
 preliminary tanzanian data , for example , show some of 
 the most pressing concerns in data collection .
the interviews provided some nuance to the 
 questions where the most critical lapses occurred .
the 
 project managers noted that inadequate support for 
 research capacity requires that nurses undertake the 
 work .
the nurses in the emergency room , in return , 
 underlined that balancing the needs of the researcher 
 and clinician in a busy emergency room was difficult , 
 with the research needs suffering .
this reality was 
 particularly highlighted at the rural clinic , where the 
 data entries ( not analysed here ) were much more 
 nuanced and detailed , given the many fewer visits at 
 mkuranga .
while some of the difficulties could be ascribed to the 
 fact that this data collection occurred early on in the 
 round of data collection , it must be noted that the 
 hospital had conducted one full year s round of data 
 collection previously . introducing new data collectors to 
 the process can naturally cause difficulties , but 
 providing immediate feedback once these challenges 
 have been identified early on
is necessary to ensure 
 usable data arises in the long - term . in the meantime , a 
 stopgap measure of cross - checking data with hospital 
 records themselves may be instituted .
however , 
 devoting human resources to this task is also an 
 untenable drain on clinical work in the hospital . for future perspectives
, the two most important areas 
 where further improvement of data collection needs to 
 take place are in scoring serious injury , and in recording 
 outcomes in the two - week follow - up .
adequate 
 recording of this component is essential , as an accurate 
 calculation of the kts is dependent on it .
the former 
 can be a challenge given the possibilities of rapid 
 clinical evolution in emergency settings .
however , 
 refining the design of the survey in this regard may prove useful , requiring clinicians to list only the sites 
 where intervention was required .
the data analysers can 
 then total up this elementary information to assign a 
 serious injury score themselves , ensuring that there is 
 no repetition of the same data in the collection . in this 
 way
, the analysers can also do the work of calculating 
 the total kts , further relieving the burden from the data 
 collectors so they are required only to gather the most 
 elementary components of the data .
furthermore , clear 
 definitions of what constitutes a serious injury need to 
 be refined further , taking into account that surgical 
 intervention alone can not be the most reliable marker of 
 gravity of trauma .
it is conceivable that there is not 
 even a consensus amongst data collectors on what 
 constitutes a surgical intervention itself .
sustaining the collection of outcome data is critical to 
 harness the entire potential of a trauma registry , in order 
 to monitor the effectiveness of treatment in each setting . 
 in this consideration
, the lack of capacity to undertake a 
 two - week follow - up , even as minimally required by this 
 survey instrument , was limited with the resources 
 available to the hospital .
even though most data 
 collected by the survey instrument was also 
 independently entered into the hospital records , there 
 was little time to cross - check this data with hospital 
 records , and certainly two - week follow - up was often 
 impossible by the emergency nurses even if the patient 
 remained in hospital . rather than research design , this 
 problem is a more structural issue in low - resource 
 settings of limited research capacity .
clearly , addressing this difficulty can not be resolved 
 within one project alone . in the long - term
, the registry 
 would ideally be integrated into routine care in the 
 emergency department across east africa , perhaps 
 incorporated into regular charting activities in order to 
 monitor the predicted outcomes and the course of 
 treatment of trauma patients .
however , much needs to 
 be done to verify the validity of the tool until then .
the establishment of research partnerships between highresource 
 settings and lower - resource contexts can be 
 helpful , only if there is a transfer of both financial and 
 human resources to local actors so that research 
 capacity within the society is enhanced .
control of 
 research agendas and projects needs also to remain 
 within the developing world .
the current process of data collection in tanzania 
 provides very interesting descriptive data on the nature 
 of injury in a particular setting , which provides 
 evidence upon which to build public health 
 interventions .
however , to improve clinical outcomes , 
 further refinements in the data collection process need 
 to be instituted through modifications to the survey tool , 
 and particularly , further resource allocation to bolster 
 clinical research capacity in emergency rooms in the 
 country .
once this capacity to monitor outcomes is 
 developed , further research into the correlation of 
 patient status and outcome , depending on interventions 
 used , needs to be undertaken in order to develop an 
 analysis of the clinical capacity to respond to trauma in 
 this context .
the ultimate goal is , after all , to refine 
 practice to improve patient outcome .
especially given 
 the increasingly high burden injuries are placing on 
 global health systems given the advent of motorised 
 traffic worldwide , this work is becoming imperative to 
 protect those most vulnerable to these accidents . 

however , the process requires a solid base of evidence 
 upon which to design both treatment and prevention 
 interventions .
these challenges can not be overcome 
 unless there is serious investment in clinical research in 
 low- and middle - income countries .
 the prevalence of surgical trauma as a global public health hazard has been severely 
 neglected . 
 trauma surgeons in uganda and canada have developed the kampala trauma score ( kts ) , 
 a trauma severity index specific to east african contexts . 
 hospitals in tanzania have begun to use this 
 tool to measure their own trauma management protocols in order to measure the validity of this index 
 regionally . 
 this study sought to enhance analysis of data collected through the kts , by highlighting 
 the efficacy and the lacunae of this registry through evaluation of the data quality of one ongoing round 
 of data collection at an orthopaedic emergency room in dar es salaam , tanzania . 
 the data was 
 screened for missing values that would have impact on prediction of clinical evolution and also analysed 
 for contradictory evidence . 
 interviews were conducted with data collectors on the main challenges 
 involved in data gathering and analysis for this project . 
 analysis of the initial round of data collection 
 confirms road accidents cause the most trauma in dar es salaam , with pedestrians being particularly 
 vulnerable . 
 however , critical sources of information such as serious injury scores and two - week followup 
 were inconsistently recorded , thereby limiting outcome measurement . the lack of research 
 resources , both financial and human , had a major impact on the ability to sustain the data collection . 
 while the results of this study demonstrate the public health value of having a mechanism to record 
 trauma , research capacity must be supported in low - resource settings in order to enhance clinical care 
 to accident and injury patients . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
The Epidemiology of Injury
The Power of Evidence
The Challenges of Capacity
CONCLUSION