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World Journal of Surgery
Official Journal of the International
Society of Surgery/Société
Internationale de Chirurgie
ISSN 0364-2313
World J Surg
DOI 10.1007/s00268-012-1889-1
An Assessment of the Hospital Disease
Burden and the Facilities for the In-hospital
Care of Trauma in KwaZulu-Natal, South
Africa
Timothy C.Hardcastle, Candice Samuels
& David J.Muckart
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An Assessment of the Hospital Disease Burden and the Facilities
for the In-hospital Care of Trauma in KwaZulu-Natal,
South Africa
Timothy C. Hardcastle •Candice Samuels •
David J. Muckart
ÓSocie
´te
´Internationale de Chirurgie 2012
Abstract
Background Trauma is a significant cause of morbidity and
mortality in South Africa. The present study was designed to
review the hospital trauma disease burden in light of the
facilities available for the care of the injured in KwaZulu-
Natal (KZN), South Africa’s most populous province.
The primary outcomes were the annual hospital burden of
trauma in KZN, determined through data extrapolation, and
evaluation of the data in light of available hospital facilities
within the province of KZN, a developing province. The
data were obtained through review of the trauma load in
relation to all emergency cases at all levels of hospitals.
Methods Hospital administrators in KZN were requested
to submit trauma caseloads for the months of March and
September 2010. Caseloads were reviewed to determine
the trauma load for the province per category using two
extrapolation methods to determine the predicted range of
annual incidence of trauma, intentional versus non-inten-
tional trauma ratios and population-related incidence of
trauma. The results were GIS mapped to demonstrate
variations across districts. Hospital data were obtained
from assessments of structure, process, and personnel
undertaken prior to a major sporting event. These were
compared to the ideal facilities required for accreditation of
trauma care facilities of the Trauma Society of South
Africa and other established documents.
Results Data were obtained from 36 of the 47 public
hospitals in KZN that manage acute emergency cases. The
predicted annual trauma incidence in KZN ranges from
124,000 to 125,000, or 12.9 per 1,000 population. This
would imply a national public hospital trauma load on the
order of at least 750,000 cases per year. Most hospitals are
required to treat trauma; however, within KZN many
hospitals do not have adequate personnel, medical equip-
ment, or structural integrity to be formally accredited as
trauma care facilities in terms of existing criteria.
Conclusions There is a significant trauma load that con-
sumes vital emergency center resources. Most hospitals
will need extensive upgrading to provide appropriate care
for trauma. An inclusive trauma system needs to be for-
malized and funded, especially in light of the planned
National Health Insurance for South Africa
Introduction
South Africa has a legacy of political turmoil and inter-
personal violence. Since the transition to democracy the
focus of health care in South Africa has shifted from
hospital-centered care to primary care [1]. KwaZulu-Natal
(KZN) (Image 1) is South Africa’s most populous prov-
ince, with a population of almost 11 million persons [2].
Trauma varies in scale and mechanism from minor injury,
suitably treated at the community hospital level, through to
major trauma requiring intensive care and surgical
T. C. Hardcastle (&)
Department of Surgery (Trauma), Inkosi Albert Luthuli Central
Hospital, University of KwaZulu-Natal, PostNet 27, Private Bag
X05, Malvern 4055, South Africa
e-mail: timothyhar@ialch.co.za; hardcastle@ukzn.ac.za
C. Samuels
GIS Unit, Provincial Department of Health, Natalia Building,
Pietermaritzburg, South Africa
e-mail: Candice.samuels@kznhealth.gov.za
D. J. Muckart
Department of Trauma and Critical Care, Inkosi Albert Luthuli
Central Hospital, University of KwaZulu-Natal, KwaZulu-Natal,
South Africa
e-mail: Davidmuc@ialch.co.za
123
World J Surg
DOI 10.1007/s00268-012-1889-1
Author's personal copy
intervention. It is known, however, that most trauma
patients will be in need of medical care, and thus nurse-led
clinics are generally an inappropriate care-level for this
disease entity, as even simple suturing is outside the
nursing scope of practice [3].
There have been a number of studies over the years
examining the mortality burden of trauma in South Africa
[4–9], as well as some older studies looking at the overall
disease burden [10–13]. To date, however, there have been
no recent large-scale studies of the trauma disease burden
of live patients admitted to government hospitals providing
an overview of these patients generally. Additionally, there
are limited data on how well hospitals are equipped,
staffed, and prepared for dealing with major trauma,
despite national standards existing for the primary care
environment.
Aim
The goal of the present study was to review the overall
trauma burden of disease in KZN and the facilities avail-
able at hospitals in the province as a precursor to the design
and establishment of a definitive care trauma system within
the province. With such information, the study aimed to
place the trauma burden into a national perspective and to
provide insights into the adaptations needed prior to the
implementation of the planned National Health Insurance,
which will need to fund the care of trauma patients.
Methods
A questionnaire was sent to all 47 government hospitals
in KZN that treat trauma cases. The questionnaire was
designed to obtain data regarding the trauma caseload,
specifically in terms of gunshot wounds, stab wounds,
motor vehicular trauma, and other blunt injury for the
months of March and September 2010. Drownings, other
medical emergencies, and snake bites were excluded.
These months were chosen as they represented a ‘‘normal’’
month outside the holiday season (December–January) and
outside the FIFA World Cup period (June–July), when no
major school vacations occur, thus providing a reasonable
average spread of injuries. The data were extrapolated to
predicted annual figures (trauma range) by two calculation
methods (average of 2 months 912 and the total sum of
the 2 months 96), extended to national figures, and
compared to the overall emergency case-census as pro-
vided by the Provincial Health Head Office. These results
were Geographic Information System (GIS) mapped where
relevant. Facilities were physically assessed by a team of
specialist trauma and emergency professionals prior to the
FIFA 2010 Soccer World Cup (the lead author of this
article being one of the members of the team), which took
place in June–July 2010. These assessments were com-
pared to the Essential Trauma Care Guidelines (EsTC), the
Trauma Society of South Africa Trauma Centre Accredi-
tation criteria (TSSA) recently published by the society,
and the expected district service delivery standards of the
Department of Health for the accreditation of hospital
facilities [14–16]. Based on these results, a proposal will be
formulated for the establishment of an inclusive Afrocen-
tric trauma system.
Results
Responses were received from 36 of the 47 hospitals in
KZN (77 %). The raw data are summarized in Table 1.
Based on the calculations, the range of trauma per annum
was between 124,908 and 125,652 cases as a minimum for
the hospitals represented. Converting this to an expected
case load for all hospitals would yield approximately
160,000 cases per year. This equates to an annual trauma
load of 12.9 per 1,000 population, or one in every 77
members of the population. Figure 1is the Geographical
Information System (GIS) map of the overall hospital
burden per district. This means that trauma constitutes at
least 17.8 % of the overall emergency cases treated in the
province (total provincial emergency head count for 2010
was 706,346). Of these trauma patients, 44 % were treated
at urban hospitals, 12 % at rural regional hospitals, and
44 % at rural district hospitals. Extrapolating these data to
the national population equates to over 750,000 trauma
cases per year requiring hospital level healthcare.
The total trauma load included 65 % from intentional
trauma and only 35 % from unintentional injuries (this
Image 1 Map demonstrating the location of KwaZulu-Natal within
the borders of South Africa
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Table 1 Raw data for the district and regional hospital trauma burden in KwaZulu-Natal
March September Per
district
Per district
Region Hospital Stab GSW MVA Assault Blunt
a
Burn Total
March
Stab GSW MVA Assault Blunt
a
Burn Total
Sep
Total
Averages
Simple
tot 2-mo
Rate
per year
Rate per
1,000
Population
count
Amajuba 1 120 9 98 3 230 209 8 62 0 279 255 509 Amajuba
2 40 0 75 34 149 30 2 138 46 216 183 365 5,244 10.8 48,4673
Total 160 9 173 37 239 10 200 46 438 874
eThikweni 1 119 10 337 344 810 108 13 236 332 689 689 750 1,499
2 105 50 210 130 495 98 31 191 149 469 482 964
3 43 12 139 41 235 32 4 83 39 158 197 393
4 153 26 364 315 858 26 199 303 337 865 862 1,723
5 330 26 536 1274 89 2,255 243 19 387 843 61 1,553 1,904 3,808
6 38 1 56 199 294 23 1 88 160 272 285 566 eThikweni
Total 788 125 1642 2303 530 267 1,288 1,860 4,480 8,953 53,718 16.8 3,199,944
Ilembe 1 160 22 77 86 345 144 9 86 62 301 323 646
2 2 3 30 38 73 9 4 34 44 91 82 164 Ilembe
Total 162 25 107 124 153 13 120 106 405 810 4,860 8.4 580,307
Sisonke 1 5 1 5 2 13 5 0 1 36 42 27 55 Sisonke
2 12 1 78 103 194 12 1 88 120 221 208 415
Total 17 2 83 105 17 1 89 156 235 470 2,820 9.1 308,999
Umkhanyakude 1 7 2 20 32 59 14 3 26 23 66 64 125 Umkhanyakude
2 12 1 3 8 24 12 1 3 8 24 24 48
3 3 3 16 4 26 5 0 37 13 55 41 81
4 13 1 28 43 85 26 3 14 70 113 99 198
5 7 4 33 31 68 143 7 0 12 50 22 91 117 234
Total 42 11 100 118 64 7 92 164 345 686 4,116 6.9 593,718
Ugu 1 16 3 26 53 6 104 24 7 44 73 10 158 131 264
2 10 172 328 510 8 137 316 461 485 971
3 4 0 25 64 93 23 4 50 79 156 125 249 Ugu
Total 30 3 223 117 55 11 231 152 741 1484 8,904 12.2 729,052
uMgungundlovo 1 10 2 10 32 54 9 0 11 35 55 55 109
2 64 10 66 85 225 71 8 91 79 249 238 474
34122 93 040 7 8 16
4 53 1 27 42 123 5 1 41 74 121 122 244 uMgungundlovo
Total 131 14 105 161 88 9 147 188 423 843 5,058 5.3 960,819
uMzinyathi 1 23 0 76 44 0 0 143 23 0 112 39 0 0 174 159 317
2 0 26 26 3 7 10 18 36
3 8 4 26 55 93 9 3 38 45 95 94 188 uMzinyathi
Total 31 4 128 99 32 6 157 84 271 541 3,246 6.9 472,682
uThukela 1 18 6 46 33 103 18 7 45 33 103 103 206
2 44 8 127 156 335 45 16 163 161 385 360 720 uThukela
Total 62 14 173 189 63 23 208 194 463 926 5,556 8.2 680,333
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Table 1 continued
March September Per
district
Per district
Region Hospital Stab GSW MVA Assault Blunt
a
Burn Total
March
Stab GSW MVA Assault Blunt
a
Burn Total
Sep
Total
Averages
Simple
tot 2-mo
Rate
per year
Rate per
1,000
Population
count
uThungulu 1 2 1 0 0 3 1 0 0 0 1 2 4
2 22 31 21 16 90 59 18 31 29 137 114 227
3 15 30 252 263 560 560 560 1,120
4 4 2 10 32 48 6 1 12 53 72 60 120 uThungulu
Total 43 64 283 311 66 19 43 82 736 1,471 8,826 9.6 917,451
Zululand 1 5 0 21 44 70 5 0 36 46 87 79 157
2 297 108 459 621 1,485 297 108 459 621 1,485 1,485 2,970
3 118 5 90 193 406 107 5 68 154 334 370 740 Zululand
Total 420 113 570 858 10,768 409 113 563 821 10,155 1,934 3,867 23,202 27.9 833,037
Total
20,925
Total averages
10,471 20,925
X6 =
125,550
Total averages
X12 =125,652
a
Blunt indicates unintentional blunt injury
GSW gun shot wound; MVA motor vehicle accident
World J Surg
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being the motor vehicle collisions [MVC] and ‘‘other’’
groups). Of the intentional trauma admissions, 35 % were
due to penetrating injury, either stab wounds or gunshot
wounds. Figure 2illustrates the distribution of the pene-
trating trauma across the districts, showing that most dis-
tricts averaged between 21 and 48 % penetrating injuries.
When comparing the urban spectrum of injury to the rural
environment, there was no distinct variation when exam-
ined in context of the population distribution. The ratio of
gunshots to stab wounds in the group of penetrating trauma
was noted as 1:4. Motor vehicle accidents were the greatest
contributor to the trauma burden. Overall, 36 % of all
trauma admissions were due to vehicular trauma (Fig. 3
demonstrates the variation in incidence across the health
districts). Other mechanisms (blunt or penetrating non-
intentional injuries, burns, and falls constituted the rest of
the trauma burden (Fig. 4demonstrates the variation in
incidence across the health districts). The need for appro-
priate assessment facilities, with appropriate imaging, is
therefore essential, as is the need for surgical capability.
The data from the hospitals used for the facility
assessments were physically corroborated by the medical
expert teams undertaking hospital preparations for the
Soccer World Cup event. When comparing the facility
Fig. 1 Total distribution of
Trauma Burden per 1,000
population across
KwaZulu-Natal
health districts
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assessments to the Essential Trauma Care (EsTC) and
Trauma Society of South Africa (TSSA) criteria [14,15],
only one hospital met all the criteria for level 1 status,
whereas most regional hospitals (66 %) met the criteria for
level two status. Even within these facilities, however, only
three hospitals had a formal trauma service, with the rest
using the general surgical service. Four had inadequate
access to emergency operation facilities for trauma and
were competing with other emergencies, including cesar-
ean sections, for operating room time. There was a shortage
of intensive care unit (ICU) facilities at these regional
hospitals, and the imaging services were variable in
availability (some only daytime full service; head scans
only after hours). Quality assurance programs were docu-
mented for only seven of these regional facilities.
Regarding specific criteria, an average of 41 % (range:
12.5–80 %) of staff were Advanced Life Trauma Support
(ATLS) [17] trained, and 53 % (range: 10–74 %) had
medical resuscitation training. Only 46 % (range:
12.5–75 %) had training in disaster management, such as
the one-day hospital major incident medical management
& support (HMIMMS) course offered free of charge to all
health care providers in preparation for the recent Soccer
World Cup event [18]. Further challenges include the lack
Fig. 2 Penetrating trauma
distribution per 1,000
population across
KwaZulu-Natal
health districts
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of a uniform trauma registry, limited access to computer-
ized databases—both of which lead to concerns regarding
data accuracy—and a distinct shortage of designated space
for emergency care within the already overloaded hospital
system. The limited trauma data have been addressed
partially through the introduction of mandatory injury data
reporting to the Provincial Head office Epidemiology Unit,
and this, we hope, will mature into a proper Provincial
Trauma Registry.
Most district hospitals would be expected to meet level
three trauma unit status; however, deficiencies were noted
in at least 50 %, such that the commitment to establishing
an effective trauma system appears to be lacking at the
regional and national government level. For example, 54 %
of district facilities assessed had inadequate resuscitation
area facilities, none had in-house CT-scanners, and only
62.5 % had emergency mobile X-ray units, and 58 % did
not have access to an emergency operating room. Only
25 % of district hospitals had an emergency observation
ward, despite the need to hold many patients awaiting
transfer to a higher level of care. Sixty-two percent of
medical staff had no formal trauma training, and 50 % of
the hospitals had inadequate helicopter landing facilities,
despite the rural nature of many hospitals. Only 12.5 % of
Fig. 3 Motor vehicle trauma
distribution per 1,000
population across
KwaZulu-Natal
health districts
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district hospitals had documented trauma or emergency
quality assurance programs. This is highly relevant in a
country where public transport incidents involving buses,
minibus-taxi, and heavy duty vehicles are an everyday
occurrence, and many of these district hospitals are the first
‘‘port of call’’ for trauma victims.
Discussion
Injuries in low and middle income countries (LMIC),
which include South Africa, are acknowledged to
contribute significantly to death and disability, as well as
loss of life-years [4]. In an effort to address the high
mortality and morbidity, it is essential to work on estab-
lishing systems of care that are cost efficient, functional,
and show a long-term outcome improvement [14,19]. The
challenge is that most governments want to see instant
results; however, a number of recent studies have shown
that it may take as long as 10 years before a significant
mortality reduction becomes evident [20–22]. Most of the
relevant reports, however, come from developed high
income countries with large healthcare budgets. Africa and
other developing regions suffer from the financial burdens
Fig. 4 Blunt and domestic
trauma per 1,000 population
across the KwaZulu-Natal
health districts
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that make establishing such systems more difficult. It was
for this reason that the World Health Organization and the
International Association for trauma Surgery and Intensive
Care (IATSIC) group formulated the Essential Trauma
Care Guidelines [14], which have been widely adopted or
implemented in various forms within LMIC across a
number of continents [23–25].
When comparing the current KZN predicted injury
burden determined in the present study with previous
publications from South Africa and elsewhere in the world,
it is noted that the incidence of 1,290 per 100,000 popu-
lation is far higher than the trauma burden in the developed
world, with rates around 13–20 per 100,000, although it
seems to have been reduced from the initial studies in 1999
that suggested a figure closer to 66 per 1,000 population
[26–28]. The results compare most strikingly to an epide-
miological study from Canada, where the categories ‘‘fall’’
and ‘‘other’’ injury were the highest, at a combined rate of
420 per 100,000, while penetrating injury was only 9.5 per
100,000. The overall rate of all injuries in Canada requiring
hospital treatment was 5.34 per 1,000 of the population,
half the rate in KZN, and included categories not reviewed
in the present study [29]. The difference with the study
from 1999 is that it included not only injuries treated in
hospitals but also minor injuries treated at community
clinics, or by general practitioners and traditional healers,
whereas the current study examined hospital admissions at
district and regional facilities only and excluded any case
remotely unclear as being due to trauma. In contrast, the
former study included a category of ‘‘other trauma’’ that
may have included a number of conditions (such as
drowning, animal bites, or poisoning) not included in the
present study. Using the extrapolation method described in
the study by Matzopoulos et al. [26] would estimate the
current injury burden at about 1.5 million cases per year
(about 34/1,000) at a minimum for the entire country,
which is still less than previous estimates, although closer
to their one estimate of 40/1,000 of the population.
It is interesting that when comparing the South African
data to that from other parts of Africa there are stark
contrasts, with interpersonal violence contributing a much
higher percentage of the injury burden in South Africa
(35 %), whereas motor vehicle collisions predominate in
other parts of Africa, following a distant second to human
immunodeficiency virus (HIV) and other communicable
diseases [30–35]. Even the study from a rural district
hospital in KZN [36] showed that almost 13 % of patients
transported there by ambulance as ‘‘walking wounded’’
were considered by the treating doctor to have an ‘‘urgent-
care’’ traumatic injury.
The system of care theoretically in operation within
South African health facilities has been described in detail
in previous publications [37,38]. The concern is that these
articles generally focus on urban facilities and academic
medical establishments. The broader scenario is far from
ideal, with the physical facilities not meeting national core
standards [16], not to mention the EsTC or TSSA criteria
[14,15]. There is slow uptake and apparent lack of interest
in available short-courses for further training [38]. The
national district hospital core standards, for example,
require that doctors at district hospitals are able to perform
emergency surgery for trauma, yet most of the district
hospitals in KZN (58 %) do not even have access to an
operating room in emergencies. Where these are present
the resources compete with emergency cesarean section
and other urgent operations. Across the country facilities
are crumbling for lack of maintenance; computerized
tomography scanners break down and repairs are delayed,
necessitating multiple transfers of patients to receive nee-
ded care [39].
This is of particular concern as the National Department
of Health is planning to embark on a comprehensive
National Health Insurance initiative over the next few years
[40]. Of importance is that the current plan does not spe-
cifically address trauma care or other emergency medical
problems, despite mentioning in the preamble the fourfold
problem of HIV-AIDS, maternal and child-health, diseases
of lifestyle, and injuries [40]. Additionally, it is widely
acknowledged that there is a major shortage of health care
providers of all grades in South Africa [37,41,42]. This is
compounded throughout Africa. The first step the govern-
ment can take is to invest in human capital, through
funding training of staff across the spectrum to better
manage the trauma patient. This is especially important
given the fact that around 30 % of rural practitioners do not
feel competent to undertake emergency trauma surgery
(laparotomy) independently [43].
To realistically determine the injury burden to the
country it would be prudent to establish a national trauma
registry, collecting a limited data set that can guide system
development and confirm the disease severity and average
length of stay in hospital enabling costing to be performed
[14,15]. A simple Department of Health trauma registry
has recently been designed for KZN and is in the initial
stages of data collection. The next step is the upgrading of
all health facilities to at least the minimal standards
expected by national and international norms [14–16].
If one compares the facilities in Africa to the American
system [44] it would take most of the specialists within an
entire country to staff one major trauma center meeting
American standards. This is impractical and thus it is
essential that Afrocentric solutions are designed for Afri-
can systems. Combined with the need for simple solutions
is the limited availability of critical care services in Africa,
which form an essential component of care for severe
trauma [45,46]. It will indeed take a strong political will to
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change the situation for the benefit of all of the people of
South and Sub-Saharan Africa [47]. The need is great, yet
funding is finite and limited, but to reduce mortality from
injury, all levels of care should meet the basic standards,
whether in terms of functional equipment, access to sur-
gical services, a basic staffing norm, or rapid transfer to
higher levels of care. An established system is better than
islands of excellence within a sea of indifference, where
the care is provided in a haphazard fashion [19].
In Africa one should consider the role of a ‘‘trauma
center’’ as a specialist hospital, with not only multiple
subspecialist disciplines present, but providing an over-
arching leadership role within the greater system, working
with the single goal of mortality reduction. This has cer-
tainly worked in the UK, where mortality has been reduced
through direct access to a dedicated facility for severely
injured patients [48]. In Africa the need for such centers is
no less, but thoughtful planning is required to locate these
lead facilities in a manner to enable optimal access without
overloading the health budget. Using the EsTC guidelines
and the TSSA criteria will enable the Department of Health
to devise suitable patient flow pathways and bypass sys-
tems so that the most severely injured patient can gain
access to a suitable level of care without undue delay.
These centers should not be for ‘‘all comers,’’ but for the
small severely injured subgroup, but they should provide
outreach and retrieval teams, thus offloading the other
facilities of major cases and providing guidance and lead-
ership of the overall system. It is proposed that one such
center should cater to a population of some 2–3 million
persons in high trauma regions and 4–5 million in lower
trauma regions of the continent.
For a population as dispersed and with the geographic
layout of rural KZN (and typical of much of rural Africa), the
ideal system would thus entail the expansion of the ambu-
lance services and a referral system to bypass smaller facil-
ities and transport the severely injured directly to the regional
facilities where surgical capacity and ancillary service s exist.
Upgrading the number of regional facilities and regionaliz-
ing certain specialist disciplines (e.g., neurosurgery) would
reduce the time to surgical intervention. It would also enable
rational use of the limited number of CT scanning facilities,
thus allowing timely care. A recent letter in World Journal of
Surgery has highlighted the limited role that specialist sur-
geons are able play at district level hospitals because of the
need for ancillary services [49]. This system should, at least,
be generalizable to the rest of South Africa, because the
geography and relative population densities are similar
throughout the country, and from previous studies [26] the
trauma distribution appears to be relatively comparable. The
country has one health registration authority and one set of
national prehospital treatment protocols, so improving
access to the system should be generalizable as well.
It has been shown that, even within institutions caring
for major trauma in KZN, the care is variable and incon-
sistent, which corroborates the findings of the facility audit
[50]. This often results in missed injury and unnecessary
morbidity or even mortality [51]. To prevent these adverse
outcomes, the hospitals participating in the trauma system
need to be inspected by an independent non-governmental
organization and be formally accredited, have quality
improvement programs in place, and have a lead authority
with government-endorsed executive authority [14–16,19].
This way the currently unmet needs of surgical disease in
general may be partially addressed [52]. This is especially
true in light of the high injury burden (12,9/1,000), which is
higher than the 1,6/1,000 reported from Uganda [53].
Finally, the remaining challenge to the establishment of
trauma systems in Africa is the distinct lack of rehabilita-
tion facilities, especially residential step-down rehabilita-
tion facilities, thus leading to much lower levels of return
to gainful employment. This is so although rehabilitation is
recognized in both the EsTC and TSSA guidelines as
essential for a trauma care system. Unfortunately, reha-
bilitation is not seen as an integral part of the trauma care
process, which results in bed-blockages to the acute care
hospital system and prolongs recovery times considerably.
This is not a new problem and not one isolated to South
Africa, with similar problems reported from Ghana [54,
55]. At least South Africa has dedicated physiotherapists
and occupational therapists who attempt to rehabilitate
rural patients against trying odds and while facing ethical
dilemmas [56].
Trauma costs money; however, litigation costs the
country far more! Appropriate care of trauma has been
demonstrated to be cost-effective in numerous studies
[57–59], with sustained cost-saving over time with efficient
system design of approximately $36,000 per life-year
saved. In a national study from the USA published in 2010
[59] it was found that although trauma centers are more
expensive (especially the initial care), the benefits in terms
of lives saved and quality of life-years gained outweigh the
costs, particularly for the most severely injured patients.
The costs of trauma care vary from around 6,396 ZAR
($540) to 25,000 ZAR ($2,200) per patient for gunshot
wounds, depending on the calculation method used
[60–62], whereas for traffic injuries the cost approximates
3,886 ZAR ($300) per patient per day [60]. It is, however,
important to look at the ‘‘real’’ cost of traffic collisions,
which approximate R11 million ($800,000) per day when
all costs (policing, medical, repair, rehabilitation, and legal
aspects) and not simply medical expenses are included,
applying the model of the Council for Scientific and
Industrial Research. It should also be noted that pedestrian
injuries account for up to half of the medical costs! [63].
Optimizing the transfer of patients, provision of
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appropriate equipment, staffing, and other resources at the
correct levels of care should result in overall cost savings.
These cost savings are further enhanced through multi-
sectorial prevention initiatives [19,64].
Limitations
The present study is limited by the fact that the patient data
were retrieved from casualty records collected by ward
clerks, thus limiting reliability. In addition, the data were
re-interpreted by one person (T.H.), who excluded anything
that appeared to be non-trauma, thus potentially reducing
the overall numbers. The totals may thus be a significant
underestimation of the true trauma burden; however, they
do reflect at least a minimum trauma burden. Further, the
hospital assessments were significantly different when self-
reported (by local hospital managers) compared to the
inspection teams. Some of the TSSA criteria [15] were not
specifically included in the hospital assessments, thus
reducing the direct applicability of the local criteria.
Conclusions
Trauma, particularly interpersonal intentional violence and
motor vehicular collisions, constitute a major health care
burden on the South African public health system, consti-
tuting 18 % of the emergency care burden. The current
primary-care focused referral pathways and hospital
equipment norms are not suitable for dealing with major
trauma. A national trauma registry capturing basic data
would ensure that the true trauma burden is recorded.
Upgrading facilities to meet minimum national standards is
essential prior to establishing and formalizing trauma sys-
tems, or instituting the proposed National Health Insurance
plan across South Africa. Any trauma system that is
implemented will require a central government funding
buy-in from all parties and continuous performance
improvement programs to ensure compliance and improve
patient outcomes, with legislative and political support.
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