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International Journal of Injury Control and Safety Promotion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nics20
Pedestrian injuries in the United Arab Emirates a
b
Ashraf F. Hefny , Hani O. Eid & Fikri M. Abu-Zidan a
cd
Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
b
Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates c
Trauma Group, Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates d
Department of Surgery, Al Ain Hospital, Al Ain, United Arab Emirates Published online: 10 Apr 2014.
Click for updates To cite this article: Ashraf F. Hefny, Hani O. Eid & Fikri M. Abu-Zidan (2014): Pedestrian injuries in the United Arab Emirates, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.884143 To link to this article: http://dx.doi.org/10.1080/17457300.2014.884143
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.884143
Pedestrian injuries in the United Arab Emirates Ashraf F. Hefnya, Hani O. Eidb and Fikri M. Abu-Zidanc,d* a
Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates; bDepartment of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; cTrauma Group, Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; dDepartment of Surgery, Al Ain Hospital, Al Ain, United Arab Emirates
Downloaded by [University of Waterloo] at 08:35 08 February 2015
(Received 26 August 2013; accepted 3 January 2014) We aimed to study the anatomical distribution, severity, and outcome of hospitalised trauma pedestrian patients in Al Ain, United Arab Emirates (UAE), so as to improve preventive measures. All pedestrian trauma patients who were involved with a road traffic collision and admitted to Al Ain Hospital for more than 24 hours or who died in the hospital were included in the study. Data were prospectively collected during March 2003–October 2007. Three hundred and eighteen patients were studied, 279 (87.7%) were males. Median (range) age was 31 (1–75) years. UAE nationals were significantly younger than non-nationals (median (range) age of 14 (2–75) years compared with 33 (1–75) years, p ¼ 0.001, Mann– Whitney U-test). The lower limb (57.2%) was the most common injured region followed by the head (46.9%). The median (range) Injury Severity Score of patients was 5 (1–45). The median (range) total hospital stay was 11.3 (1–130) days. Thirty patients died (overall mortality 9.4%). In conclusion, mortality of pedestrian injured patients in the UAE is high. Severe head injury was the main cause of death. Measures to improve pedestrian safety should be adopted so as to reduce morbidity and mortality. These include educating drivers and pedestrians on road safety and enforcement of traffic safety laws. Keywords: epidemiology; hospitalisation; injury; pedestrians; registry
1. Introduction Road traffic collision (RTC) is a leading cause of death worldwide. In 2002, 1.2 million people died in RTC, 90% of them in low- and middle-income countries (Peden et al., 2004). Compared with injured vehicle occupants, pedestrians are exposed to severe trauma and sustain more severe injuries and higher mortality (Brainard, Slauterbeck, Benjamin, Hagaman, & Higie, 1989). Pedestrian crashes are a major health problem especially in developing countries (Nantulya & Reich, 2002). In low-income countries, 45% of RTC mortality is due to pedestrian injuries compared with 18% in high-income countries (Naci, Chisholm, & Baker, 2009). The fast economical growth in the United Arab Emirates (UAE), which depends mainly on oil exports, was associated with increase in number of high buildings, streets, and modern fast cars. It was accompanied also by an increase in major supporting infrastructure projects that required employing many foreign workers (78% of the population) (United Arab Emirates Census, 2005). The majority of those workers have low income and may walk to their job location. Most of the published studies on pedestrian injuries focus on mortality-related issues (Naci et al., 2009; Nicaj, Wilt, & Henning, 2006). In contrast, papers covering the non-fatal injuries are less
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
common (Al-Shammari, Bendak, & Al-Gadhi, 2009; Arregui-Dalmases, Lopez-Valdes, & Segui-Gomez, 2010; Chakravarthy, Lotfipour, & Vaca, 2007). We aimed to study the anatomical distribution, severity, and outcome of hospitalised pedestrian injured patients in Al Ain City, UAE, so as to better understand pedestrian injuries in our community and to give recommendations regarding preventive measures.
2. Patients and methods Al Ain is the largest city in the eastern district of Abu Dhabi, with 463,000 inhabitants (Ministry of Health, 2007). During the study period, trauma patients who needed hospitalisation in our city were exclusively managed in two major hospitals (Al Ain and Tawam Hospitals). 80% of those were treated in Al Ain Hospital. All trauma pedestrian patients who were involved with RTC and were admitted to Al Ain Hospital for more than 24 hours or who died in the hospital after arrival were studied. Patient’s data were retrieved from Al Ain Hospital Trauma Registry which was prospectively collected during 4.5 years (March 2003–October 2007). Percentages of population by nationality and gender were retrieved from the United Arab Emirates Census (2005).
Downloaded by [University of Waterloo] at 08:35 08 February 2015
2
A.F. Hefny et al.
Demography of patients, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), anatomical body part(s) injured, and mortality were analysed. Nationality was categorised into UAE nationals and non-UAE nationals because traffic risks are different in these two groups (Abu-Zidan, Abbas, Hefny, Eid, & Grivna, 2012; Hefny, Barss, Eid, & Abu-Zidan, 2012). Severity was assessed by the Abbreviated Injury Scale (AIS), which divides the body into six anatomical regions and assigns each a severity including minor ¼ 1, moderate ¼ 2, serious ¼ 3, severe ¼ 4, critical ¼ 5, unsurvivable ¼ 6, and by the ISS. The maximum AIS of each region was used to measure the ISS. The ISS was calculated manually, using the Abbreviated Injury Scale Handbook, as the sum of squares of the three maximum AIS scores from different body regions (Association of the Advancement of Automotive Medicine, 1998).
2.1.
Statistical analysis
Non-parametric statistical methods were used. These included Fisher’s exact test for categorical data (gender, nationality, method of arrival, and mortality) for two independent groups and Mann–Whitney U-test for continuous data (age, length of hospital stay) or ordinal data (GCS, ISS) for two independent groups. A p-value of 0.05 was considered significant. Data were analysed with Predictive analytics softWare (PASW) Statistics 18, SPSS Inc.
3. Results The trauma registry included 1608 patients of RTC over 4.5 years duration. There were 318 (19.8%) pedestrian patients, 279 (87.7%) were males and 39 (12.3%) were females. The estimated annual incidence of hospitalised pedestrian injured patients was 12.2/100,000 population. Median (range) age was 31 (1–75) years. Seventy-one (22.7%) patients were less than 18 years of age and 14 (4.5%) were 60 years and above. Thirty-eight patients (11.9%) were UAE nationals. Patients from the Indian subcontinent were the most common injured patients (61.9%) (Table 1). UAE nationals were significantly younger than non-nationals (median (range) age of 14 (2–75) years Table 1. Nationality of injured patients. Nationality
Number
Pakistani Bangladeshi Indian UAE Egypt Others Total
111 43 43 38 20 63 318
% 34.9 13.5 13.5 11.9 6 19 100
Figure 1. Age of hospitalised road traffic collision pedestrian patients by nationality (UAE nationals ¼ broken line, non-UAE nationals ¼ solid line).
compared with 33 (1–75) years, p ¼ 0.001, Mann–Whitney U-test) (Figure 1). There were three peaks of increased injuries during the day: around 12 noon, 8 pm, and 12 midnight (Figure 2(a)). Injuries were higher on Wednesdays compared with other days (Figure 2(b)). The median (range) ISS was 5 (1–45) and the median (range) GCS was 15 (3–15). Lower limb injury was the most common injured body region (57.2%) followed by the head (46.9%) (Table 2). Two hundred (62.9%) patients had multiple injuries. Fifty-one patients (16%) were admitted to the intensive care unit (ICU) with a median (range) ICU stay of 4 (1– 39) days. Median (range) total hospital stay was 11.3 (1– 130) days. Thirty patients died (overall mortality 9.4%), 20 died in the Emergency Department, 9 in the ICU, and one patient died in the operating theatre. Our trauma registry, during the same period of the study, has shown that 54 patients with RTC died including 30 (55.6%) pedestrian patients. GCS was significantly less and ISS was significantly higher in those who died (p < 0.0001) (p < 0.0001) (Table 3). Pedestrians of 60 years old or more had significantly lower GCS and significantly higher mortality compared with patients of less than 60 years of age (median (range) GCS of 13.5 (3–15) compared with 15 (3–15), p ¼ 0.009, Mann–Whitney U-test; and mortality of 5/14 (35.7%) compared with 25/304 (8.2%), p ¼ 0.01, Fisher’s exact test). 4. Discussion Pedestrian injury rates are related to traffic flow and population density (Lascala, Gerber, & Gruenewald, 2000). In the recent years, there have been increasing efforts to promote walking as a way of increasing health and physical
Downloaded by [University of Waterloo] at 08:35 08 February 2015
International Journal of Injury Control and Safety Promotion
3
Figure 2. Time (a) and day (b) of road traffic collision pedestrian injuries.
Table 2. Injured anatomical regions. Region Head Face Neck Thorax Abdomen Spine Upper limb Lower limb
Number of patients (n ¼ 318) 149 73 3 92 34 23 105 182
% 46.9 23 0.9 28.9 10.7 7.2 33 57.2
Note: Patients may have more than one injured region.
fitness. Although, walking is difficult in most times of the year in the UAE because of hot weather, 19.8% of RTC patients in our study were pedestrians. This is higher than other high-income developed countries (Transport Canada, 2004). Our study has shown that only 11.9% of hospitalised injured patients were UAE nationals which is less than
Table 3. Comparison between patients who died and those who survived. Variable Median age years (range) Gender Male Female Nationality UAE Non UAE GCS median (range) ISS median (range) Methods of arrival Ambulance Private car Police car Others
Survived n ¼ 288
Died n ¼ 30
30 (1–75)
40 (2–75)
251 (87.2) 37 (12.8)
28 (93.3) 2 (6.7)
32 (11.1) 256 (88.9) 15 (3–15) 5 (1–45)
6 (20) 24 (80) 4 (3–14) 22 (9–43)
183 (63.5) 91 (31.6) 9 (3.1) 3 (1)
21 (70) 8(26.7) 1 (3.3) 0
p-value 0.08 0.57 0.15
International Journal of Injury Control and Safety Promotion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nics20
Pedestrian injuries in the United Arab Emirates a
b
Ashraf F. Hefny , Hani O. Eid & Fikri M. Abu-Zidan a
cd
Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates
b
Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates c
Trauma Group, Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates d
Department of Surgery, Al Ain Hospital, Al Ain, United Arab Emirates Published online: 10 Apr 2014.
Click for updates To cite this article: Ashraf F. Hefny, Hani O. Eid & Fikri M. Abu-Zidan (2014): Pedestrian injuries in the United Arab Emirates, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.884143 To link to this article: http://dx.doi.org/10.1080/17457300.2014.884143
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.884143
Pedestrian injuries in the United Arab Emirates Ashraf F. Hefnya, Hani O. Eidb and Fikri M. Abu-Zidanc,d* a
Department of Surgery, Al Rahba Hospital, Abu Dhabi, United Arab Emirates; bDepartment of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; cTrauma Group, Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates; dDepartment of Surgery, Al Ain Hospital, Al Ain, United Arab Emirates
Downloaded by [University of Waterloo] at 08:35 08 February 2015
(Received 26 August 2013; accepted 3 January 2014) We aimed to study the anatomical distribution, severity, and outcome of hospitalised trauma pedestrian patients in Al Ain, United Arab Emirates (UAE), so as to improve preventive measures. All pedestrian trauma patients who were involved with a road traffic collision and admitted to Al Ain Hospital for more than 24 hours or who died in the hospital were included in the study. Data were prospectively collected during March 2003–October 2007. Three hundred and eighteen patients were studied, 279 (87.7%) were males. Median (range) age was 31 (1–75) years. UAE nationals were significantly younger than non-nationals (median (range) age of 14 (2–75) years compared with 33 (1–75) years, p ¼ 0.001, Mann– Whitney U-test). The lower limb (57.2%) was the most common injured region followed by the head (46.9%). The median (range) Injury Severity Score of patients was 5 (1–45). The median (range) total hospital stay was 11.3 (1–130) days. Thirty patients died (overall mortality 9.4%). In conclusion, mortality of pedestrian injured patients in the UAE is high. Severe head injury was the main cause of death. Measures to improve pedestrian safety should be adopted so as to reduce morbidity and mortality. These include educating drivers and pedestrians on road safety and enforcement of traffic safety laws. Keywords: epidemiology; hospitalisation; injury; pedestrians; registry
1. Introduction Road traffic collision (RTC) is a leading cause of death worldwide. In 2002, 1.2 million people died in RTC, 90% of them in low- and middle-income countries (Peden et al., 2004). Compared with injured vehicle occupants, pedestrians are exposed to severe trauma and sustain more severe injuries and higher mortality (Brainard, Slauterbeck, Benjamin, Hagaman, & Higie, 1989). Pedestrian crashes are a major health problem especially in developing countries (Nantulya & Reich, 2002). In low-income countries, 45% of RTC mortality is due to pedestrian injuries compared with 18% in high-income countries (Naci, Chisholm, & Baker, 2009). The fast economical growth in the United Arab Emirates (UAE), which depends mainly on oil exports, was associated with increase in number of high buildings, streets, and modern fast cars. It was accompanied also by an increase in major supporting infrastructure projects that required employing many foreign workers (78% of the population) (United Arab Emirates Census, 2005). The majority of those workers have low income and may walk to their job location. Most of the published studies on pedestrian injuries focus on mortality-related issues (Naci et al., 2009; Nicaj, Wilt, & Henning, 2006). In contrast, papers covering the non-fatal injuries are less
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
common (Al-Shammari, Bendak, & Al-Gadhi, 2009; Arregui-Dalmases, Lopez-Valdes, & Segui-Gomez, 2010; Chakravarthy, Lotfipour, & Vaca, 2007). We aimed to study the anatomical distribution, severity, and outcome of hospitalised pedestrian injured patients in Al Ain City, UAE, so as to better understand pedestrian injuries in our community and to give recommendations regarding preventive measures.
2. Patients and methods Al Ain is the largest city in the eastern district of Abu Dhabi, with 463,000 inhabitants (Ministry of Health, 2007). During the study period, trauma patients who needed hospitalisation in our city were exclusively managed in two major hospitals (Al Ain and Tawam Hospitals). 80% of those were treated in Al Ain Hospital. All trauma pedestrian patients who were involved with RTC and were admitted to Al Ain Hospital for more than 24 hours or who died in the hospital after arrival were studied. Patient’s data were retrieved from Al Ain Hospital Trauma Registry which was prospectively collected during 4.5 years (March 2003–October 2007). Percentages of population by nationality and gender were retrieved from the United Arab Emirates Census (2005).
Downloaded by [University of Waterloo] at 08:35 08 February 2015
2
A.F. Hefny et al.
Demography of patients, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), anatomical body part(s) injured, and mortality were analysed. Nationality was categorised into UAE nationals and non-UAE nationals because traffic risks are different in these two groups (Abu-Zidan, Abbas, Hefny, Eid, & Grivna, 2012; Hefny, Barss, Eid, & Abu-Zidan, 2012). Severity was assessed by the Abbreviated Injury Scale (AIS), which divides the body into six anatomical regions and assigns each a severity including minor ¼ 1, moderate ¼ 2, serious ¼ 3, severe ¼ 4, critical ¼ 5, unsurvivable ¼ 6, and by the ISS. The maximum AIS of each region was used to measure the ISS. The ISS was calculated manually, using the Abbreviated Injury Scale Handbook, as the sum of squares of the three maximum AIS scores from different body regions (Association of the Advancement of Automotive Medicine, 1998).
2.1.
Statistical analysis
Non-parametric statistical methods were used. These included Fisher’s exact test for categorical data (gender, nationality, method of arrival, and mortality) for two independent groups and Mann–Whitney U-test for continuous data (age, length of hospital stay) or ordinal data (GCS, ISS) for two independent groups. A p-value of 0.05 was considered significant. Data were analysed with Predictive analytics softWare (PASW) Statistics 18, SPSS Inc.
3. Results The trauma registry included 1608 patients of RTC over 4.5 years duration. There were 318 (19.8%) pedestrian patients, 279 (87.7%) were males and 39 (12.3%) were females. The estimated annual incidence of hospitalised pedestrian injured patients was 12.2/100,000 population. Median (range) age was 31 (1–75) years. Seventy-one (22.7%) patients were less than 18 years of age and 14 (4.5%) were 60 years and above. Thirty-eight patients (11.9%) were UAE nationals. Patients from the Indian subcontinent were the most common injured patients (61.9%) (Table 1). UAE nationals were significantly younger than non-nationals (median (range) age of 14 (2–75) years Table 1. Nationality of injured patients. Nationality
Number
Pakistani Bangladeshi Indian UAE Egypt Others Total
111 43 43 38 20 63 318
% 34.9 13.5 13.5 11.9 6 19 100
Figure 1. Age of hospitalised road traffic collision pedestrian patients by nationality (UAE nationals ¼ broken line, non-UAE nationals ¼ solid line).
compared with 33 (1–75) years, p ¼ 0.001, Mann–Whitney U-test) (Figure 1). There were three peaks of increased injuries during the day: around 12 noon, 8 pm, and 12 midnight (Figure 2(a)). Injuries were higher on Wednesdays compared with other days (Figure 2(b)). The median (range) ISS was 5 (1–45) and the median (range) GCS was 15 (3–15). Lower limb injury was the most common injured body region (57.2%) followed by the head (46.9%) (Table 2). Two hundred (62.9%) patients had multiple injuries. Fifty-one patients (16%) were admitted to the intensive care unit (ICU) with a median (range) ICU stay of 4 (1– 39) days. Median (range) total hospital stay was 11.3 (1– 130) days. Thirty patients died (overall mortality 9.4%), 20 died in the Emergency Department, 9 in the ICU, and one patient died in the operating theatre. Our trauma registry, during the same period of the study, has shown that 54 patients with RTC died including 30 (55.6%) pedestrian patients. GCS was significantly less and ISS was significantly higher in those who died (p < 0.0001) (p < 0.0001) (Table 3). Pedestrians of 60 years old or more had significantly lower GCS and significantly higher mortality compared with patients of less than 60 years of age (median (range) GCS of 13.5 (3–15) compared with 15 (3–15), p ¼ 0.009, Mann–Whitney U-test; and mortality of 5/14 (35.7%) compared with 25/304 (8.2%), p ¼ 0.01, Fisher’s exact test). 4. Discussion Pedestrian injury rates are related to traffic flow and population density (Lascala, Gerber, & Gruenewald, 2000). In the recent years, there have been increasing efforts to promote walking as a way of increasing health and physical
Downloaded by [University of Waterloo] at 08:35 08 February 2015
International Journal of Injury Control and Safety Promotion
3
Figure 2. Time (a) and day (b) of road traffic collision pedestrian injuries.
Table 2. Injured anatomical regions. Region Head Face Neck Thorax Abdomen Spine Upper limb Lower limb
Number of patients (n ¼ 318) 149 73 3 92 34 23 105 182
% 46.9 23 0.9 28.9 10.7 7.2 33 57.2
Note: Patients may have more than one injured region.
fitness. Although, walking is difficult in most times of the year in the UAE because of hot weather, 19.8% of RTC patients in our study were pedestrians. This is higher than other high-income developed countries (Transport Canada, 2004). Our study has shown that only 11.9% of hospitalised injured patients were UAE nationals which is less than
Table 3. Comparison between patients who died and those who survived. Variable Median age years (range) Gender Male Female Nationality UAE Non UAE GCS median (range) ISS median (range) Methods of arrival Ambulance Private car Police car Others
Survived n ¼ 288
Died n ¼ 30
30 (1–75)
40 (2–75)
251 (87.2) 37 (12.8)
28 (93.3) 2 (6.7)
32 (11.1) 256 (88.9) 15 (3–15) 5 (1–45)
6 (20) 24 (80) 4 (3–14) 22 (9–43)
183 (63.5) 91 (31.6) 9 (3.1) 3 (1)
21 (70) 8(26.7) 1 (3.3) 0
p-value 0.08 0.57 0.15
