Opportunities for health system strengthening to reduce preventable trauma deaths in the Western Cape Province, South Africa: Findings from an expert panel review
DOI:
https://doi.org/10.7196/Keywords:
Trauma, inter-personal violence, preventable trauma death review, health system improvement, injury, injury deathAbstract
Background. Injuries are a leading cause of death and disability worldwide, and disproportionately affect young persons (aged 15 - 49 years) residing in low- and middle-income countries. Panel reviews of trauma deaths are an effective way to identify areas for improvement within a health system.
Objectives. To assess the preventability of trauma deaths that had contact with the health system, and the associated panellists’ recommendations for improvements.
Methods. A comprehensive review of injury-related deaths identified by an epidemiological study was conducted in the Western Cape Province of South Africa in April 2022. Panellists identified contributing factors and opportunities for improvement for each case. Investigators assigned a thematic code to each opportunity for improvement, and codes were categorised and mapped into a matrix organised according to the applicable level of the health system and the descriptive category for improvement.
Results. Twenty-three multidisciplinary expert panellists reviewed 90 injury deaths that occurred in 2021. The largest proportion of deaths was from firearms (30%), and 41 (45%) of the 90 cases were found to be preventable or potentially preventable. The median time from injury to death was 41.4 hours for rural injuries, compared with 12.9 hours for urban injuries.
Conclusion. Key recommendations from the panel included training in basic trauma resuscitation, and increased access to patient monitoring, operating theatres, radiology and intensive care beds. Panellists further recommended implementation of injury primary prevention strategies in the community.
References
1. James SL, Abate D, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990 - 2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1789- 1858. https://doi.org/10.1016/s0140-6736(18)32279-7
2. World Health Organization. Injuries and violence. Geneva: WHO, 2021. https://www.who.int/news- room/fact-sheets/detail/injuries-and-violence (accessed 6 February 2025).
3. Norman R, Matzopoulos R, Groenewald P, Bradshaw D. The high burden of injuries in South Africa. Bull World Health Organ 2007;85(9):695-702. https://doi.org/10.2471/blt.06.037184
4. Matzopoulos R, van Niekerk A, Marais S, Donson H. A profile of fatal injuries in South Africa: Towards a platform for safety promotion: Original contribution. Afr Safety Promot 2002;1(1):16-23.
5. Sukhai A, van Niekerk A. Transport-related deaths. A profile of fatal injuries in South Africa 2001: Third annual report of the National Injury Mortality Surveillance System (NIMSS). Cape Town: Medical Research Council and University of South Africa, 2000.
6. Zaidi AA, Dixon J, Lupez K, et al. The burden of trauma at a district hospital in the Western Cape Province of South Africa. Afr J Emerg Med 2019;9:S14-S20. https://doi.org/10.1016/j.afjem.2019.01.007 7. Slabbert J, Smith W. Patient transport from rural to tertiary healthcare centres in the Western Cape: Is there room for improvement? Afr J Emerg Med 2011;1(1):11-16. https://doi.org/10.1016/j.
afjem.2011.04.001
8. Gonzalez RP, Cummings G, Mulekar M, Rodning CB. Increased mortality in rural vehicular trauma: Identifying contributing factors through data linkage. J Trauma 2006;61(2):404-409. https://doi. org/10.1097/01.ta.0000229816.16305.94
9. Grossman DC, Kim A, Macdonald SC, Klein P, Copass MK, Maier RV. Urban-rural differences in prehospital care of major trauma. J Trauma 1997;42(4):723-729. https://doi.org/10.1097/00005373- 199704000-00024
10. Kong VY, Bruce JL, Sartorius B, et al. Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients. Euro J Trauma Emerg Surg 2019;45(1):145-150. https://doi.org/10.1007/s00068-017-0800-z
11. Lee B, Kong V, Cheung C, et al. The association between rural or urban setting and outcomes in geriatric trauma patients in South Africa: A retrospective cohort study. Surg Pract Sci 2023;14:100184. https://doi.org/10.1016/j.sipas.2023.100184
12. World Health Organization. Guidelines for trauma quality improvement programmes. Geneva: WHO, 2009. https://www.who.int/publications/i/item/guidelines-for-trauma-quality-improvement- programmes (accessed 6 February 2025).
13. Dixon J, de Vries S, Fleischer C, et al. Preventable trauma deaths in the Western Cape of South Africa: A consensus-based panel review. PLoS Glob Pub Health 2024;4(5):e0003122. https://doi.org/10.1371/ journal.pgph.0003122
14. South Africa. Inquests Act No. 58 of 1959; as amended 1996.
15. Suresh K, Dixon JM, Patel C, et al. The epidemiology and outcomes of prolonged trauma care (EpiC)
study: Methodology of a prospective multicenter observational study in the Western Cape of South Africa. Scand J Trauma Resusc Emerg Med 2022;30(1):55. https://doi.org/10.1186/s13049-022-01041-1
16. Vindrola-Padros C, Johnson GA. Rapid techniques in qualitative research: A critical review of the literature. Qual Health Res 2020;30(10):1596-1604. https://doi.org/10.1177/1049732320921835
17. Losonczy LI, Papali A, Kivlehan S, et al. White paper on early critical care services in low resource settings. Ann Glob Health 2021;87(1):105. https://doi.org/10.5334/aogh.3377
18. Tenner AG, Sawe HR, Amato S, et al. Results from a World Health Organization pilot of the basic emergency care course in sub Saharan Africa. PLoS ONE 2019;14(11):e0224257. https://doi. org/10.1371/journal.pone.0224257
19. Stewart BT, Quansah R, Gyedu A, et al. Serial assessment of trauma care capacity in Ghana in 2004 and 2014. JAMA Surg 2016;151(2):164-171. https://doi.org/10.1001/jamasurg.2015.3648
20. Den Hollander D, Albertyn R, Ambler J. Palliation, end-of-life care and burns; concepts, decision- making and communication – a narrative review. Afr J Emerg Med 2020;10(2):95-98. https://doi. org/10.1016/j.afjem.2020.01.003
21. Owolabi EO, Ferreira K, Nyamathe S, et al. Social determinants of seeking and reaching injury care in South Africa: A community-based qualitative study. Ann Glob Health 2023;89(1):5. https://doi. org/10.5334/aogh.4003
22. Ataguba JE, Day C, McIntyre D. Explaining the role of the social determinants of health on health inequality in South Africa. Glob Health Action 2015;8(1):28865. https://doi.org/10.3402/gha.v8.28865
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Copyright (c) 2026 J Dixon, S de Vries, S Bhaumik, C Dymond, M Ross, J Finn, H Geduld, E Steyn, H Lategan, L Hodsdon, J Verster, S Mukonkole, K Doubell, N-K Mould-Millman
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