A Year of Trauma at the Emergency Department of

National Referral Hospital in Bhutan: An

Observational Study
Sherab Wangdi (  sherabw1989@gmail.com )
Khesar Gyalpo University of Medical Sciences of Bhutan
Melanie Watts
Khesar Gyalpo University of Medical Sciences of Bhutan (Adjunct) & Geisel School of Medicine
Shankar LeVine
Khesar Gyalpo University of Medical Sciences of Bhutan (Adjunct) & Geisel School of Medicine
Ugyen Tshering
Jigme Dorji Wangchuk National Referral Hospital

Research Article

Keywords:

Posted Date: January 4th, 2023

DOI: https://doi.org/10.21203/rs.3.rs-2413132/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License

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Abstract
Background
Trauma and related injuries are one of the top ten causes of disability in the world. With the lack of proper
baseline data, this study was conducted to improve the understanding of types, modes and outcomes
related to trauma visiting the emergency department of national referral hospital in Bhutan.

Methods
An observational study of all the trauma cases admitted to the Emergency Department over a one year
period detailing the mechanism of injury, types of injuries sustained and patient outcomes was carried
out. Case record form was used for data collection and Epidata analysis was done for descriptive
analysis.

Results
A total of 820 participants were included during the study period. The sample consisted of 71.6% males
and 28.4% females. The median age was 32 years with more than half of the patients (51.4%) belonging
to the age range from 26 to 60 years. The top three occupations that experienced trauma were farmers
(23.2%), followed by office workers (20.7%) and students (16.9%). Pre-hospital transport was primarily by
ambulance (66%) followed by private vehicle (33%). Accidental injury accounted for 91.9% of the injured
patients, followed by interpersonal assault (4.8%) and self-harm 3.3%. Fall injuries accounted for 46.2%
of the trauma among the study participants, followed by occupational injury (19.1%) and motor vehicle
collision injury (19.0%). Extremity injuries were the most common anatomical site comprising of nearly
half of all trauma. Majority were admitted to the orthopedic ward 68.2% (n = 391) followed by the surgical
ward (n = 91 15.8%). Around sixty five percent (64.9%) were admitted to general ward, 28% of the patients
were discharged from ER, 5% were admitted to the ICU and ED mortality was 1.3%.

Conclusion
This study provides a clinical trauma profile at the national referral hospital in Bhutan where injury-related
presentations are common. It highlights the importance of emergency department in managing and
evaluation of trauma cases. It also shows the need of further studies to better understand the country’s
trauma distribution and development of a robust trauma surveillance system to better provide effective
prehospital care and standardized timely hospital care.

Introduction

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Traumatic injuries are one of the growing health concerns in the developing world affecting both the
individuals and the health resources of a country. According to the Global Burden of Disease 2019 study
done in 204 countries, road traffic accidents and other injuries were in the top 10 cause of disability for
the year 2019. [1] The main global causes were motor vehicle collisions (MVC), self-harm, falls and
interpersonal violence which is consistent with findings in South Asian countries as well. [2–6]

Bhutan is a landlocked primarily agrarian country in the Himalayas, made up by 20 districts. Each district
offers different levels of medical care varying from Basic Health Units (BHUs), clinics to district hospitals.
In the most rural areas, BHUs which are staffed by either community health workers or nonspecialized
doctors are the closest point of access to care after a trauma has occurred. There are a total of 28 district
hospitals, are staffed by a mix of medical officers and some specialists in internal medicine, pediatrics,
OBGYN, general surgery or orthopedics, scattered throughout the country which are and serve as a
common access point for patients who have experienced traumatic injuries and where trauma patients
from BHUs are initially transferred.

Nationwide there are currently 3 regional referral centers with the option of advanced imaging for trauma:
computed tomography (CT): Gelephu to the south, Mongar to the east and Thimphu covering the
north/west. Patients requiring CT imaging or higher level of care are transferred to these centers. Jigme
Dorji Wangchuck National Referral Hospital (JDWNRH) in the capital, Thimphu, acts both as the western
regional referral hospital and the national referral hospital for all critical trauma cases. Trauma seen or
referred to Gelephu and Monggar, the other 2 regional referral hospitals, are often transferred to JDWNRH
as this hospital houses all specialized services for trauma in the country, including, but not limited to
neurosurgery, pediatric surgery, spine surgery, urology and general surgeons with greater experience in
trauma in Bhutan. [7]

Most referrals to JDWNRH are transported via ground ambulances and often accompanied by an
available medical staff member from the referring hospital. The geographical distribution of injuries,
mountainous terrain and road conditions often contribute to long transport times. Bhutan recently
graduated its first class of an Emergency Medical Responder (EMR) program – a 3-year diploma course
to train prehospital providers in August of 2020. There scope of practice is between an advanced EMT
and paramedic compared to the US system and, having recently joined the workforce, they are often
caring for field and referred trauma patients. Based on clinical and geographical criteria some trauma
patients are transported by the Bhutan Emergency Aeromedical Retrieval (BEAR) team, for expedited
arrival and care. Referral criteria for BEAR team activation is based on physiologic, anatomic, mechanism
of injury factors and a variety of other special consideration such as extremes of age, anticoagulation or
geographical distance. For ground transportation, the criteria vary given that different district hospitals,
based on the resources at a given time, have slightly different capacity to care for different injuries
therefore all injuries outside of their current capacity are transferred.

Throughout Bhutan, despite seeing many cases of trauma, the burden and types of these injuries has
largely been under-reported in the Emergency Departments (EDs) due to limited human and technical

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resources, the lack of consistency in reporting, case burdens, and lack of follow-up. [8, 9] Although
accurately capturing the nationwide burden of trauma given the many rural centers would not be practical
currently, given the referrals to JDWNRH of all trauma cases requiring specialized services and all critical
trauma, a profile of trauma at this hospital is a helpful step to understand the nationwide burden of
trauma. This study was conducted to provide a comprehensive profile of injured patients admitted to the
ED including patterns, types and forms on injury, severity and outcomes associated with these injuries.
Currently the severity of the trauma on presentation is assessed using the International Committee of the
Red Cross (ICRC)-World Health Organization (WHO) based triage scale, however no further standardized
scoring system is currently used.

Methodology
Methods
Study Design
An observational study was conducted among all trauma patients who was admitted to the emergency
department of national referral hospital in Bhutan. The study was done over a 1-year duration, between
March 2020 and February 2021

Study Setting
The study recruited all trauma patients admitted in the ED, both adult and pediatric. The department cares
for all the emergency medical and trauma cases from the local catchment area as well as all critical
referred cases from across the country. JDWNRH is one of the three hospitals with a CT machine and the
only center with specialized surgeons (including neurosurgeon, pediatric surgeon, spine surgeon and
urologist), most trauma patients requiring their services are referred to this hospital. The department has
4 resuscitation beds and 14 acute care bed with provision to expand using extra trolleys if situation
demands.

Sampling And Recruitment

The study was designed as a census and included all trauma patients admitted to emergency department
during the study period. The inclusion criteria were all patients who had sustained trauma from falls,
MVC, work-related, assaults, self-harm, and animal related injuries. Injuries related to burns, patients
brought in dead and minor injuries which didn’t require ED observation and admission were not included
in the study. Due to limited prehospital data and trauma severity scoring tools requiring initial vitals,
patient brought in dead, were excluded. Burns scores severity based on amount of surface area and
thickness, so burn injury was excluded from the study due to concerns regarding consistent assessments
by a variety of provider. Minor injuries usually included those patients with scratches and bruises which

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didn’t require ED admission and observation were sent to general outpatient department (OPD) after
undergoing triage using a triage tool based on ICRC-WHO by the triage nurses therefore were excluded
from this study.

Patients who met the criteria were approached for inclusion in the study. Informed written consent was
obtained from all patients above the age of 18 who had the capacity to consent, and from primary care
giver whose age was less than 18 or those who could not give consent. The enrolled participants were
informed about the study and detailed were explained to the patient or the care giver in the language they
understood. Failure to consent to the study did not have any compromise on patient care.

Data Collection

Data collection was done using a case record form, which was based on WHO trauma surveillance form
and inputs from co- authors. This form was tested among the potential participants before finalizing the
working version.

Patients’ demographic details, mode and form of injury, time of injury and triage vital signs were
recorded. The severity of injury was calculated based on the information gathered and the trauma score.

Patients’ physiological vitals were noted on presentation and based on these data, severity of the trauma
were predicted based on four trauma scores. The trauma severity scores we used in the study to classify
severity were the Revised Trauma Score (RTS), MGAP (Mechanism, GCS, Age, Systolic Arterial Pressure),
and the simplified version without mechanism, GAP and New Trauma Score (NTS) which are based on
patients’ initial physiological variables. All the trauma scores were based on the physiological values at
presentations. Similarly scores based on anatomy were not included due to concerns regarding provider
variability in anatomical assessments and the need for consistent further imaging facility for accurate
scoring which was not consistently possible.

Data Management And Analysis

All data was double entered in Epidata version 3.1 (Epidata Association, Odense, Denmark) and analyzed
in Epidata analysis (version 2.2.2. 183). Normally distributed continuous variables were summarized by
reporting the mean and standard deviation and continuous variables that were not normally distributed
were presented by reporting the median with minimum to maximum ranges. Categorical variables were
reported as frequencies and proportions.

Results
During the one year period, 864 trauma patients were admitted to the emergency department which
constituted 15.4% of all ED admission. After excluding 2 brought dead and 42 with missing data, 820
patients [94.0%] were included in the analysis as shown in Fig. 1.

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Patients’ characteristics

The age of the patients ranged from 1 year to 93 years with a median age of 32 years. 71.6% of the
patients were male (n = 587) and 28.4% female (n = 233). It was observed that young adults (aged
between 26–40 years) were affected more compared to other age groups. The top three occupations that
experienced trauma were farmers (23.2%), followed by office workers (20.7%) and then students (16.9%)
(Table 1).

Of the 820 cases, 54.6% (n = 448) were referred from the district hospitals. Pre-hospital transport was
primarily by ambulance (66% n = 536) with 55% (n = 448) being referral cases and 11% (n = 88)
transported by a Emergency Medical Responder (EMR). Other pre-transport was by private vehicle (33%)
and by police (1%)

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 Table 1
Demographic Characteristics of Injured patient
Characteristics Number (n) Percentage (%)

Sex

Male 587 71.6

Female 233 28.4

Age a (Median 32, Min = 1, Max = 93)

< 15 years 169 20.5

15–25 years 128 15.5

26–40 years 242 29.5

41–60 years 180 21.9

> 60 years 101 21.9

Occupation b

Farmers 191 23.2

Officer workers 170 20.7

Student 137 16.7

Unemployed 121 14.8

Others 106 12.9

Industrial workers/laborers 69 8.5

Driver 14 1.7

Armed force 12 1.5

Manner of Presentation c

Referral 448 54.6

Self-presentation 270 33

Emergency medical service (EMS) 88 10.7

Others 14 1.7

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 Characteristics Number (n) Percentage (%)

Sex

a
Age: This classification was included to risk stratify injury based on age. Children were < 15 years,
young people (15–25 years) and young adults (26–40 years) were most economically active group.
Middle age (41–60 years) and elderly (> 60 years)
b
Occupation: Others included occupation like businessman, monks/nuns, mason and age < 5 years.
Unemployed were those who were at economically active age but were unemployed. Student were
those more than 5 years who were attending school.
c Manner of presentation: Others included those brought in by Police and law enforcing personals

Injury Pattern

Accidental injuries accounted for 91.9% of patients with self-harm and interpersonal assault accounting
for 3.3% and 4.8% respectively. Fall injuries accounted for 46.2% of the trauma among the study
participants, followed by occupational injuries (19.1%) and motor vehicle collision injury (19.0%). Fall
injuries were seen more among the older (> 60 years) and the younger populations (< 15 years) compared
to the adult population (Tables 2 and 3).

The most common anatomical area of sustained injuries were lower extremities (25%), multiple sites
(22.3%) and upper extremities (19.8%)

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 Table 2
Injury Pattern of Trauma Patients
Injury pattern Number (n) Percentages (%)

Intent of injury

Accidental 754 91.9

Interpersonal 39 4.8

Self-harm 27 3.3

Mechanism of injury

Fall injury 379 46.2

Occupational injury 157 19.1

Motor vehicle collision 156 19.0

Others a 42 5.1

Assault 39 4.8

Self-harm 27 3.3

Sports injury 20 2.4.

Type of injury

Blunt injury 780 95.2

Penetrating injury 40 4.8

Site on injury

Lower extremities 205 25

Poly trauma (multiple site) b 183 22.3

Upper extremities 162 19.8

Head/scalp 131 16

Abdomen 32 3.9

Face c 31 3.7

Back 27 3.3

Neck 26 3.2

Chest 23 2.8

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 Injury pattern Number (n) Percentages (%)

Intent of injury

a
Others included accidental cut injury and penetrating eye injury
b poly trauma included multiple sites rather than isolated injury
c
face also included injury to eye, ear and nose

Table 3
Mechanism of Injuries in Different Age Groups -n (%)
Age (in MVC* Assault Fall Self- Occupation Sports Othersa
years) harm

< 15 17 2 129 1 4 5 11 169(20.5)

15–25 33 7 34 13 28 4 8 127(15)

26–40 58 16 81 8 60 8 12 243(30)

41–60 44 13 64 4 48 3 8 180(22)

> 60 8 1 71 1 17 0 3 101(12.5)

156 39(4.8) 379(46.2) 27(3.3) 157(19.1) 20(2.4) 42(5.1) 820

(19)

a
Others included accidental cut injury and penetrating eye injury

*MVC: Motor vehicle collision

Trauma Scores
Patients’ physiological vitals were noted on presentation. The vital signs were pulse rate (PR), systolic
blood pressure (SBP), diastolic blood pressure (DBP), respiratory rate(RR), saturation (SPO2) and
Glascow coma score (GCS). Based on these data, severity of the trauma were predicted based on the four
trauma scores (Table 4).

Trauma scores are used to predict severity and mortality based on the injury score. In our study, four
trauma score were calculated namely RTS (revised trauma score), GAP score, MGAP score and NTS (New
trauma score). The median score of RTS was 7.84 with a maximum score of 7.84 and minimum of 0.733.
Lower the score, higher the mortality risk and score < 4 predicts very high severity and the need for
management in a trauma center and ICU. The median for GAP, MGAP and NTS in our study were 23, 27
and 22 respectively. All four of the scores has higher median values and grouped most of the injury into
low risk category and has better prognosis. This data is illustrated in Table 5.

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 Table 4
Characteristics of patients’ physiological variables and trauma scores
Median (IQR) Min- Max Mean (SD)

Vital signs

Respiratory rate (RR) 18(17–20) 0–40 19.20 (3.94)

Oxygen Saturation (SPO2) 95(93–97) 10–100 93.37(8.36)

Pulse Rate (PR) 90 (78–108) 0-190 93.53(22.52)

Systolic Blood Pressure(SBP) 124 (110–140) 10–224 125(25.53)

Diastolic Blood Pressure (DBP) 79.5 (68–90) 10–150 78.85(18.34)

GCS 15(15–15) 3–15 14.55(2.04)

Trauma scores*

Revised Trauma Score (RTS)a 7.84 (7.84–7.84) 0.73–7.84 7.64 (0.78)

GAP scoreb 23( 23–25) 8–25 23.05 (2.78)

MGAP scorec 27(27–29) 11–29 26.85(2.90)

New trauma score (NTS)d 22(21–23) 3–23 21.51 (2.79)

*Trauma scores allows appropriate triage and classification and found to reduced mortality and
morbidity related to injury
a
RTS: calculate based on patients GCS, SBP and RR
b
GAP: GCS, age and SBP
c
MGAP: mechanism (blunt or penetrating, GCS, age and SBP
d NTS: GCS, SBP and SPO2

Table 5
Mortality Risk According To Different Trauma Score n (%)
Trauma score Moderate - high mortality (%)* Low mortality (%)

RTS 36 (4.3) 784 ( 95.7)

GAP 47(5.7) 773 (94.3)

MGAP 49(5.9) 771 (94.1)

NTS 37(4.5) 783 (95.5)

*Moderate- high mortality patient should be managed in trauma centers where there is ICU and
trauma surgeon
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Outcomes
After assessment and intervention in the ED, 69.9% (n = 973) of the patients were admitted to the hospital,
out of which 5% (n = 41) of them was admitted to the ICU, 28% (n = 230) of the patients were discharged
from ER and 1.3% (n = 10) died in the ED (Table 6).

A total of 572 patients were admitted, the majority were admitted to the orthopedic ward 68.2% (n = 391),
followed by the surgical ward (n = 91 15.8%) (Fig. 2).

Table 6
Patient’s Disposition from ED
Outcomes Number(n) Percentage (%)

Disposition

Admitted to general ward a 532 64.9

Discharged from ER 230 28.0

Admitted to ICU b 41 5.0

Died in ER 10 1.3

Others c 7 0.8

a General ward included surgical, orthopedics, ENT, dental wards

b ICU included both pediatric and adult ICU.
c
6 left against medical advice and 1 was referred to India for higher care

Patients spent from minimum of 4 min to 47 hours 15 minutes in the ER during their visit with a median
time range of 5 hours 13 minutes. Mean time for different wards are shown in Table 7.

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 Table 7
Length of ED stay by different wards
Length of Stay in ER (in hr. : min) Mean SD Min- Max

For all Patients 5:13 ± 6:06 0:04–47:15

Surgical Ward 9:33 ± 8:24 0:27–43:42

Expired patients a 8:27 ± 15:25 0:04–47:15

ICU 6:58 ± 7:20 0:40–32:30

Dental Ward 6:40 ± 12:57 0:13–29:51

ENT 6:22 ± 4:35 1:25–30:45

Discharged patients b 5:42 ± 6:11 0:21–30:45

Eye ward 3:51 ± 4:55 0:05–20:13

Orthopedics 3:40 ± 4:48 0:12–28:21

a are those who died in ED following trauma

b
are those who are discharged from ED after observation

Discussion
Although trauma contributes to significant morbidity and mortality globally, within Bhutan there is a lack
of published data, which this one-year prospective observational profile of trauma patients seen at
Bhutan’s national referral hospital attempts to address. This profile reveals there are significant
similarities to other southern Asian countries in the population most affected by traumatic injuries. This
study’s findings that 71.6% of the trauma patients were male with a median age of 32 and nearly a third
of all patients within the ages of 26–40 is similar to other regional studies. [5, 10, 11, 12] The 26–40 age
group accounts of a quarter of Bhutan’s overall population. [13]

Bhutan is primarily an agrarian society with nearly 50% of Bhutanese self-describing their primary
occupation within agriculture according to the 2021 Labor Force Survey. [14] Therefore it is not surprising
that among occupations, farmers were the most affected (23.2%) followed by office workers (20.7%) and
students (16.7%). This is also similar to findings in studies from neighboring countries [5].

In terms of the most common types of injuries, blunt trauma is consistently the most common
mechanism in Bhutan and neighboring countries. However, in studies of other regional countries the most
common mechanism is consistently motor vehicle collisions (MVCs) by significant margin with some
regional studies demonstrating 65% in India and 67–79% in Pakistan of the trauma from MVCs. [5, 6, 15]
However, in this study we found that fall injuries accounted for 46.2% of the cases followed by
occupational injuries (19.1%) and MVCs (19%). These falls were more common among the middle age to
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older (> 40) and younger (< 15) populations accounting for 15.7% and 16.4% respectively. In older
population (> 60years), falls accounted for 70.2% (n = 71) of all injuries at that age group. In contrast,
MVCs primarily affected the adult populations 26–40 and 41–60 accounting for 37.1% (n = 58) and
28.2% (n = 44) respectively. The comparatively lower rate of MVCs in Bhutan is likely multifactorial; even
though the number of vehicles and traffic have increased recently in Bhutan, it is still significantly less
compared to neighboring countries like India and Nepal where rapid motorization, crowded streets and
poor road condition led to increased MVC injuries.

Pre-hospital trauma care is one of the key components in reducing trauma related mortality. [16] It is
usually provided by the trained paramedics and emergency responders. [3, 8] In Bhutan, the prehospital
care is still in its early stages of development, as discussed in the introduction. Our study demonstrated
that only 10.7% of the trauma patients were brought in by EMS limiting our ability to comment on
prehospital care. With 33% of the traumas arriving to the ER in private vehicle and 55% by ambulance
without an EMR there is limited information around prehospital deaths and prehospital care. The lack of
a method to collect reliable data was the primary reason that patients who were dead on arrival or at the
scene were excluded from the study. This likely contributes to the low ED mortality rate of 1.2% (n = 10)
succumbing to their injuries.

Regional studies from India and Pakistan demonstrated higher ED mortality rates of 4.1% and 2.9%
respectively.[6, 12, 15] The lower mortality rate in our study may reflect that patients were only included
who arrived to the ED alive and in our rural environment with long transport times the prehospital
mortality (not captured in this study) may be higher.

Within emergency medicine the importance of the golden hour of trauma care has been well-documented,
however providing this timely care to trauma patients in Bhutan meets a number of challenges, many of
which are observed in this study. One of the main challenges is the time from injury to treatment at an
appropriate medical facility. The country is currently working on a number of ways of addressing this
problem. Our first class of 20 EMR students joined the work force towards the end of 2020 and thereafter
20 more graduate annually to join the workforce to bolster prehospital care. Bhutan’s Ministry of Health
(MOH) is actively working on a plan to establish 10 Emergency and Trauma Centers across the country
which will improve the proximity to an appropriate level of care facility. [17]

Different scoring system are developed to predict trauma and injury severity, each with their own
advantages and disadvantages. [18] Currently in our emergency department, we do not have a particular
scoring system in place to grade the severity of injuries. We triage the patients based on one or two
variables according to the WHO Triage scale. A standardized score system is based on multiple patients’
variables and it allows for appropriate triage and classification.[18] In countries like the USA and Canada,
improvement and organization in trauma care including the use of trauma score systems have resulted in
significant reductions in mortality related to injury. [19]

A study in Japan showed mean (+ SD) of RTS, GAP and MGAP of 6.9 (+ 2), 19.4 (+ 5) and 23.5 (+ 5.5)
which was lower compared to our study. [20] Rahmani F et al, in his report when comparing GAP and
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MGAP scores also had lower means compared to our study at 20.53 (+ 5.08) and 24.36 (5.08). [21] We
postulated that the patterns of injury are different in their study as compared to ours with their high
penetrating injury and more MVCs which lowered their mean trauma scores. The study done in Japan
was carried out over the period of 5 years with more than 35000 participants which could also have
contributed to difference in the scores.

In all four of our scoring systems, more than 94% were labelled as low mortality risk which was less than
2% mortality. RTS labelled 4.3%, GAP score 5.7% (n = 47), MGAP 5.9% (n = 49) and NTS 4.5% (37) as
moderate-high mortality. A comparison study done in Japan validating the GAP score saw RTS labelled
92% of admitted patients as low - moderate risk and 7.6% in the high risk group. The same study revealed
MGAP scores risked 68% as low risk, 21% as moderate and 10% into high risk groups. [20] The reason for
this difference is not clear but it could be due to different nature of injuries where penetrating injury, which
has high severity scores, is more common in their sample compared to our sample population (10% vs.
4.8%).

The ED-LOS (length of stay) is the total time from the first documented time after arrival in the ED to the
time the patient is discharged or admitted and leaves the ED. It is well documented that longer ED LOS
results in overcrowding which put strain on ED resources, delays patient care and diagnosis, increases
error risk and reduces patient satisfaction. [45] ED-LOS more than 2 hours in trauma patients was found
to be associated with increased risk of infection, longer ICU and hospital stay and greater 30 day
mortality risk. [22]

The mean ED length of stay for trauma patients was found to be 5 hours 14 minutes (+ 6:06) hours with
maximum of 47 hours 15 minutes and minimum of 4 minutes. Fragmenting ED-LOS by different
departments shows that surgery patients had the longest ED stay with a mean of 9 hours 33 minutes. ICU
patients had a mean LOS 6:58 hours and orthopedic patients had a mean LOS of 3.40 hours. With this
information, solutions for reducing ED LOS, ways for better bed management and early admission can be
looked into.

Conclusion
This study provides an initial glimpse into the clinical trauma profile in Bhutan. It reveals many
similarities to neighboring countries in terms of the most at risk populations and predominant injuries
due to blunt mechanisms of injury. A couple of notable differences in frequency of blunt mechanisms of
injury are Bhutan seeing a smaller proportion of trauma related to MVCs and a higher portion of falls.

In Bhutan, there are significant challenges to trauma patients receiving timely treatment often related to
the geographic distribution and long transportation to appropriate trauma centers. The need to build the
prehospital care and equip more hospitals in a broader distribution for trauma care is evident. With
numerous limitations, this study primarily reveals the need for further studies of trauma care in Bhutan at
the regional and district hospitals. Potentially preventable injuries like occupational injuries and falls in

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elderly are high in our study. We recommend the need for another study to better understand possible
reasons to see if preventive measures can be established.

Prehospital care is essential for good trauma outcomes and lack of consistent care demonstrates the
need for more EMRs in the field and to further EMR training programs. This study is a further
demonstration of the ubiquitous nature of traumatic injuries and provides some data which can be used
to improve clinical care through targeted interventions and trainings.

Limitations
Our study had certain limitations. It is a single center observational study. The study only included
participants who presented in the emergency department and did not include trauma cases seen in the
ED or other outpatient departments (OPDs). Outcomes used were disposition from ED and participants
were not followed through to discharge after admission to the hospital. Comorbidities such as diabetes,
hypertension and COPD were not included when considering patient outcomes which may have affected
the initial vital signs abnormalities and contributed to patient outcomes. The trauma scores used were
only based on patient physiology and did not include scores based on anatomy. Anatomy scores are
mostly rater dependent and also need imaging facility for accurate scoring.

The timeline for the study had been established long before and the study began prior to the first case of
COVID-19 being diagnosed in Bhutan in March of 2020. The subsequent lockdowns, school closures,
border closures would have reduced the number of cars on the road and numerous construction projects
came to a halt – both significant contributors to trauma. Additionally, due to hospital testing and travel
restrictions there may have been less referrals to JDWNRH. The full extent of the resulting changes in
people’s behavior and activities due to COVID would be difficult to predict, however it seems likely that
due to the timing of COVID coinciding with the study period the study may underreport the trauma burden
when compared to other years.

Abbreviations
BP Blood pressure

DBP Diastolic blood pressure

ED Emergency Department

ED LOS Emergency Department length of stay

EMR Emergency medical responder

ENT Ear, nose and throat

GAP GCS, age and pressure (systolic)

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GCS Glasgow coma scale

ICU Intensive care unit

JDWNRH Jigme Dorji Wangchuck National Referral Hospital

KGUMSB Khesar Gyalpo University of Medical Sciences of Bhutan

MGAP Mechanism, GCS, age and pressure (systolic)

MoH Ministry of Health

MVCs Motor vehicle collisions

NTS New trauma scale

OPD Outpatient department

REBH Research Ethics Board of Health

RR Respiratory rate

RTS Revised trauma score

SBP Systolic blood pressure

SPO2 Oxygen saturation

WHO World Health Organization

Declarations
Ethic Declaration

The thesis protocol was reviewed by the Department of Emergency Medicine and forwarded to the Thesis
Review committee of the Faculty of Post graduate Medicine for approval. Administrative clearance was
obtained from the JDWNRH Administration and the policy and Planning Division (PPD), Ministry of
Health. Ethical clearance was sought from the Research Ethics Board of Health (REBH). Research
proposed was approved by the ethical review committee of REBH Ref. No. REBH/Approval/2019/060.
Written informed consent was obtained from the participants or the primary care giver. . It is specified in
this consent that all information that can identify or correlate to the person will be anonymized to
guarantee their confidentiality.

Consent for publication

Not applicable
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Availability of data and material

The dataset used and analyzed during the study are available from the corresponding author on request

Competing interest

The authors declare that they have no competing interest

Funding

Ministry of Health, Royal Government of Bhutan

Author information

1. Affiliation

1. Sherab Wangdi (S.W), Khesar Gyalpo university of Medical Sciences of Bhutan, Thimphu, Bhutan

2. Shankar LeVine (S.L), Dartmouth Geisel School of Medicine, Hanover, USA

3. Melanie Watts (M.W), Dartmouth Geisel School of Medicine, Hanover, USA

4. Ugyen Tshering (U.T), Jigme Dorji Wangchuk National Referral Hospital, thimphu , BHutan

2. Contributions

S.W collected, entered and analyzed the data. S.W, M.W, S.L and U.T interpreted the data. S.W and S.L
wrote the manuscript. All authors reviewed and approved the manuscript.

3. Corresponding Author

Sherab Wangdi, sherabw1989@gmail.com

Acknowledgement

Special Thanks to Ms Kinley Yangdon and Mr. Tshering Choeda for their guidance during data analysis

References
1. Institute for Health Metrics and Evaluation, Global burden of 369 diseases and injuries in 204
countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study
2019, Lancet 2020; 396: 1204–22
2. Haagsma JA, Graetz N, Bolliger I, The global burden of injury: Incidence, mortality, disability-adjusted
life years and time trends from the global burden of disease study 2013. Inj Prev. 2016; 22 (1):3–18.

Page 18/21
 3. Institute for Health Metrics and Evaluation, Human Development Network, the World Bank. The
Global Burden of Disease: Generating Evidence, Guiding Policy – South Asia Regional Edition.
Seattle, WA: IHME, 2013.
4. Peden M, McGee K, Sharma G. The Injury Chart book: a graphical overview of the global burden of
injuries. Geneva, World Health Organization, 2002.
5. Rastogi D, Meena S, Sharma V, Singh GK. Epidemiology of patients admitted to a major trauma
centre in northern India. Chinese Journal of Traumatology 2014; 17(August 2008):103–107.
6. Abhilash KPP, Chakraborthy N, et al. Profile of trauma patients in the emergency department of a
tertiary care hospital in South India. J Family Med Prim Care 2016; 5:558–563.
7. Annual health bulletin 2018, Health Management & Information System, Policy & Planning Division
Ministry of Health, Thimphu, Bhutan
8. Morris SC, Manice N, Nelp T, Tenzin T. Establishing a trauma registry in Bhutan: Needs and process.
Springerplus. 2013; 2 (1):1–5. doi:10.1186/2193-1801-2-231
9. Holder Y, Peden M, Krug E, et al. Injury surveillance guidelines, Geneva, World Health Organization,
2001.
10. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health. 2000; 90 (4):523–
526.
11. DiMaggio CJ, Avraham JB, Lee DC, Frangos SG,Wall SP.The Epidemiology of Emergency Department
Trauma Discharges in the United States Acad Emerg Med. 2017 October; 24(10): 1244–1256
12. Puri P, Goel S, Gupta AK, Verma P, Management of polytrauma patients in emergency department: An
experience of a tertiary care health institution of northern India. World J Emerg Med, Vol 4, No 1, 2013
15
13. National Statistics Bureau, Royal Government of Bhutan, Bhutan living standard survey report, 2017,
14. National Statistics Bureau, Royal Government of Bhutan; Labour Force Survey Report,2021,
www.nsb.gov.bt
15. Hyder AA, HE S, Zafar W, Mir MU, Razzak JA. One hundred injured patient a day: Multicenter
emergency room surveillance of trauma in Pakistan, Public Health Volume 148, July 2017, pages
88–95.
16. Bedard AF, Mata LV, Dymond C, Moreira F, Dixon J et al. A scoping review of worldwide studies
evaluating the effects of prehospital time on trauma outcomes. International Journal of Emergency
Medicine (2020) 13:64
17. Emergency Medical Services Division, Guideline for Establishing Emergency Medical and Trauma
Centers; 1st edition (2020), Department of Medical Services Ministry of Health, Bhutan
18. Kim JY, Injury severity scoring systems: a review of application to practice. Nurs Crit Care May-June
2012;17(3):138–50
19. Feldhaus I, Carvalho M, Waiz G, Igu J, Matthay Z, et al. The feasibility, appropriateness, and
applicability of trauma scoring systems in low and middle-income countries: a systematic review.

Page 19/21
 Trauma Surg Acute Care Open 2020; 5: e000424
20. Kondo Y, Abe T, Kohshi K, Tokuda Y Cook EF and Kukita I. Revised trauma scoring system to predict
in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood
Pressure score Critical Care 2011, 15:R191.
21. Rahmani F, Bakhtavar HE, Vahdati SS, Hosseini M and Esfanjani RM. Evaluation of MGAP and GAP
Trauma Scores to Predict Prognosis of Multiple-trauma Patients; Trauma Monthly: International
Journal in the Fields of Trauma and Emergency Medicine; 2017May;22(3):e3324
22. Mowery NT, Dougherty SD, Hildreth AM, Holmes JH, Chang MC,et al. Emergency Department Length
of Stay Is an Independent Predictor of Hospital Mortality in Trauma Activation Patients. J Trauma.
2011; 70: 1317–1325

Figures

Figure 1

Flow chart showing the number of patients enrolled and analyzed in the study.

*Missing data includes those with incomplete data collecting form.

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Figure 2

Number of Patients Admitted to Different Wards

Supplementary Files
This is a list of supplementary files associated with this preprint. Click to download.

WHOintegradedtraigetool.docx
traumascores.docx

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