Abstract
Background
Road traffic injuries (RTIs) are a leading cause of mortality in low and middle-income countries. The study aimed to assess the magnitude of RTIs, determine the length of stay (LoS) for RTI patients and identify factors associated with prolonged LoS.
Methods
A retrospective study was conducted at the Addis Ababa Burn, Emergency and Trauma Hospital in Addis Ababa, Ethiopia. Data were extracted from medical records for the period between 1 April 2021 and 30 March 2022, using a structured data collection form. Descriptive statistics were used to summarize patient and injury characteristics, and Poisson regression model with robust variance was applied to identify factors associated with prolonged LoS in the emergency department (ED).
Results
Over the 1 year, 2693 RTI patient records were reviewed, accounting for 38.5% (95% CI 37.4% to 39.7%) of all injury cases. Of these, 2661 patients’ data were included in the analysis. The majority of patients were male (n=1932, 72.6%) and 1031 (38.7%) were aged 18–29 years. The most frequently affected body region was the head (n=966, 36.3%), and fracture was the most common injury (n=991, 37.2%). Overall, 59 (2.2%) patients died, and 780 (29.0%; 95% CI 27.6 to 31.0) experienced a LoS exceeding 24 hours. The identified factors associated with prolonged LoS included: residence outside Addis Ababa (adjusted prevalence ratio (APR)=1.41; 95% CI (1.24 to 1.60)), being in the age group of 18–29 years (APR=0.78; 95% CI (0.63 to 0.95), neck injuries (APR: 1.75; 95% CI 1.17 to 2.65), trunk injuries (APR: 1.43; 95% CI 1.09 to 1.89) and outcome of fractures (APR: 4.34; 95% CI 2.66 to 7.00); and contusions and crushing injuries (APR: 3.81; 95% CI 2.33 to 6.21).
Conclusions
The magnitude of RTI was substantially high compared with previous studies in Ethiopia. One-third of RTI patients’ LoS in the ED exceeded the country’s health system standard. The study highlights the need for enhanced road safety and healthcare resource allocation to manage RTIs effectively.
Level of evidence
III
Keywords: injuries; Length Of Stay; Accidents, Traffic; Emergency Treatment
WHAT IS ALREADY KNOWN ON THIS TOPIC
Studies in Ethiopia report a significant number of road traffic injury (RTI) patients presenting at hospitals. However, the burden of these injuries at the emergency department (ED), particularly in trauma hospitals, and the length of stay (LoS) are not addressed.
WHAT THIS STUDY ADDS
RTIs constitute a significant portion of all injury cases in ED of trauma hospitals and RTI patients exceeded LoS in the ED, indicating a gap in trauma care. This highlights the critical need for dedicated strategies to manage the high volume of trauma cases stemming from RTIs and urgent attention in emergency care services.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The study could lead to improved emergency care practices, targeted research on the trauma care system, policy enhancements to trauma care capacity and the implementation of injury prevention and road safety strategies.
Introduction
In 2021, road traffic injuries were responsible for approximately 1.9 million deaths globally, 92% of whom died in low and middle-income countries.1 Ethiopia has recently experienced significant motorization, with the number of registered vehicles exceeding 1.4 million in 2024.2 Ethiopia maintains one of the lowest motor vehicle-to-population ratios, with approximately nine vehicles per 1000 people.3 However, RTIs remain the leading cause of mortality in the country, with around 400 traffic deaths per 10 000 vehicles per year, accounting for about 27 deaths per 100 000 people in 2016.3 4
Recent studies in Ethiopia indicate that RTIs account for a pooled prevalence of 31.5% among trauma patients, with the highest rate was reported in region previously known as the Southern Nations, Nationalities and Peoples Region (58.3%), followed by Addis Ababa (33.3%).5 Other studies on mortality at six health and demographic surveillance system sites showed that RTIs contributed to about 18% of all cause deaths.6
The hospital in Ethiopia provides 24/7 emergency medical services. Emergency services include triage, resuscitation, stabilization, medical emergency management (obstetric, gynecologic, pediatric, surgical, orthopedic, psychiatric, and poisoning emergencies), diagnostic, and ambulance.7
The Ethiopian Hospital Services Transformation Guideline states that patients should not stay in the ED for more than 24 hours. If necessary, arrangements should be made for the patient’s transfer to a ward for inpatient admission.8 However, previous studies on LoS reported a 63.67% pooled prevalence of exceeding 24 hours among ED patients.9 The identified reasons for LoS in EDs include patients’ rural residence, delayed diagnostic services, inadequate diagnostic instruments, the severe nature for injuries, unavailability of beds in admission areas or shortage of beds in inpatient wards, and delays in senior clinicians’ decisions and investigations.10,12
While previous efforts to analyze the epidemiology and outcomes of trauma using hospital-based data have proven beneficial,13,15 such data remain scarce in low-income countries. Hospital-based trauma registries have emerged as an essential strategy to address the challenges of accessing trauma data and outcomes, thereby enhancing trauma care and preventive measures.16 17 Despite the inadequate surveillance system in Sub-Saharan Africa, trauma registries are feasible and valuable tools for injury studies.1 15 16 18
The trauma registries provide large longitudinal databases for analysis and policy improvement. Currently, there are limited trauma registries in Ethiopia for collecting and analyzing RTI data. Such limitations hamper the understanding and improvement of RTI care in the country. Moreover, previous studies in Ethiopia have inadequately addressed the magnitude of RTI patients among trauma patients and the LoS in the ED, highlighting a critical gap in understanding their characteristics and injury outcomes.1119,21 This study aimed to bridge this gap by analyzing and characterizing RTIs, assessing their LoS, and identifying factors associated with prolonged LoS in the ED of a trauma hospital.
Methods
Study setting
This study was conducted at the Addis Ababa Burn, Emergency, and Trauma (AaBET) hospital, a public hospital affiliated with St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia.22 Addis Ababa is the country’s largest and capital city with an estimated population of more than 5.7 million in 2024.23
The AaBET hospital is the largest trauma hospital in Ethiopia, with 250 patient beds (14 in intensive care and 60 in ED beds). The hospital provides specialized and subspecialized care to patients presenting directly as well as those referred from other healthcare facilities in Addis Ababa and other parts of the country. The ED provides 24-hour emergency and critical care services. During the study period, there were 12 physicians, 8 interns, and 24 nurses during the daytime; and 8 physicians, 3 interns, and 24 nurses at night. More than 500 trauma patients were treated in the hospital’s ED monthly.
Hospital patient triage system
The ED triage system is organized into color-coded zones based on the severity of illness or injury and the level of care required. This triage system consists of three treatment and support areas based on the triage scale, which aligns with the increasing severity indicated by the yellow/green, orange and red zones.15 Those patients who are stable or have mild to minor severity are triaged to yellow/green, and those with moderate severity are assigned to the orange zone for urgent management and care. The red zone is designated for seriously ill patients requiring immediate treatment and resuscitation.
Hospital data recording and management
The triage officers assessed patients on their arrival and admitted them to the ED zones based on severity. Data recording begins when a patient is given medical charts with a folder in the ED. All patient records are kept in a folder with charts for documenting each step of the treatment process. When the patient is referred between ED zones or other departments in the hospital, the patient’s folder stays with them.
Subsequently, as part of the health management information system (HMIS), nurses in the ED entered all information from the chart into the patient logbook. The logbook contains essential information such as medical registration number, arrival time, name, age, sex, region, date of admission, diagnosis, mechanism of injury, injured body part, injury nature, transfers between zones and departments; disposition status, and date. The HMIS personnel then transferred the data from the logbooks into HMIS database.22 24
Study population
The study population was all patients who presented in the ED with evidence of clinically confirmed RTI. To avoid data duplication, patients who had repeat visits to the ED for the same injury were excluded, and only data from their initial visits were considered. However, RTI patients who had previously visited another healthcare facility or were referred to AaBET hospital were included in the study.
Data collection tool and procedure
Data were collected through a retrospective review of medical records for all trauma patients who visited the ED over 12 months, from 1 April 2021 to 30 March 2022. Then, data were collected for all RTI patients using a structured data collection form to extract relevant information. The HMIS personnel extracted patients’ demographic information, site of the injured body region, nature of the injury, admission date, disposition date, disposition status and outcomes during the ED stay. In cases where the HMIS database lacked complete information, patient charts were retrieved and reviewed to supplement the data. Records were excluded if key variables such as age, sex or disposition status were missing. Each patient’s data were then assigned a unique study identifier and subsequently sent to the first author.
Definition and assessment criteria
RTIs were defined as ‘fatal or non-fatal injuries resulting from a road traffic crash’. The classifications of injury body regions were based on the effect of the accident on specific bodily locations at the head, neck (including throat and cervical vertebrae), trunk (comprising the abdomen, chest, back and pelvis), upper limb, lower limb and general or unspecified areas.25 Various body regions were more commonly affected by RTI accidents. In cases where patients sustained injuries to multiple body regions, only the region with the most severe injury was considered for classification and analysis to avoid duplication.26 The injuries were classified based on their nature, such as fractures, amputations, dislocations, sprains, strains, concussions, internal injuries and soft tissue injuries.25 26
The LoS was the total time patients spent in the ED, calculated as the difference between their arrival time to the ED and their ED discharge or departure time.10 27 A 1-day LoS means a patient stayed ≤24 hours or was discharged from an ED on the same calendar day.14 The guideline for the reform of hospital services in Ethiopia has stated that patients’ LoS in the ED should not exceed 24 hours, otherwise, the patients should be transferred to an inpatient for appropriate admission.8 So, a case of a patient’s LoS that exceeded 24 hours was considered as prolonged LoS.10 27 The deaths included RTI patients who were alive on arrival at the triage stage or admitted for treatment in the ED but unfortunately passed away.
Data quality control
Every effort was made to ensure the accuracy and veracity of the data through verification and validation with triangulated data from HMIS and patient charts. The data retrieval and extraction procedures were progressively conducted on weekdays, thus minimizing the risk of backlogging and medical record loss. In cases where major variables were missed, efforts were made to retrieve the information from medical records.
Data analysis
The Microsoft Excel worksheet data were imported to SPSS V.21.0 for further cleaning and STATA V.17 was used for statistical analysis. Descriptive statistics including frequencies, percentages, medians, mean, SD and range were calculated. The magnitudes of RTI and LoS were described using proportions and 95% CIs. Bivariate and multivariable Poisson regression models with robust variance were used to estimate the relationship between LoS and the risk of prolonged LoS with prevalence ratio (PR). This approach provides interpretable and reliable estimates in cross-sectional studies, especially when the outcome is common.28 The collinearity test was assessed via collinearity diagnostics and one of the correlated variables was removed from the multivariable regression model. Goodness-of-fit was evaluated using the Deviance statistic and Pearson χ2 test. A p value of < 0.05 was considered to indicate statistical significance.
Results
Magnitude of RTI and triage characteristics
A total of 6991 injury patient records were reviewed. Among all mechanisms of injury, 2693 (38.5%, 95% CI 37.4 to 39.7) were due to RTIs within 1 year. However, 32 RTI patients’ data were excluded due to incomplete major information, resulting in 2661 patients’ data being included in the current analysis. On average, 222 RTI patients visited per month, with a peak of 279 in May 2021 and drop to 195 in June 2021. The majority of RTI patients was male (n=1932, 72.6%), with a mean age of 31.8 years (SD=16.1; range: 1–95). Most patients were between 18 and 29 years old (n=1031, 38.7%), and nearly half were from Addis Ababa (n=1240, 46.6%) (table 1).
Table 1. Distribution of RTI patients by triage category.
| Characteristics | Total, n (%) | Triage zone, n (%) | ||
|---|---|---|---|---|
| Yellow/green | Orange | Red | ||
| Sex | ||||
| Male | 1932 (72.6) | 1465 (71.3) | 260 (77.8) | 207 (76.4) |
| Female | 729 (27.4) | 591 (28.7) | 74 (22.2) | 64 (23.6) |
| Age group (year) | ||||
| 0–4 | 51 (1.9) | 39 (1.9) | 4 (1.2) | 8 (3.0) |
| 5–17 | 311 (11.7) | 233 (11.3) | 37 (11.1) | 41 (15.1) |
| 18–29 | 1031 (38.7) | 834 (40.6) | 120 (35.9) | 77 (28.4) |
| 30–44 | 722 (27.2) | 554 (26.9) | 92 (27.5) | 76 (28.0) |
| 45–59 | 306 (11.5) | 231 (11.2) | 43 (12.9) | 32 (11.8) |
| ≥ 60 | 240 (9.0) | 165 (8.0) | 38 (11.4) | 37 (13.7) |
| Median (IQR) | 28 (22,40) | |||
| Regional residence | ||||
| Addis Ababa | 1240 (46.6) | 1044 (50.8) | 111 (33.2) | 85 (31.4) |
| Oromia | 1192 (44.8) | 857 (41.7) | 181 (54.2) | 154 (56.8) |
| Amhara | 146 (5.5) | 97 (4.7) | 26 (7.8) | 23 (8.5) |
| Other* | 83 (3.1) | 58 (2.8) | 16 (4.8) | 9 (3.3) |
| Total | 2661(100) | 2056 (77.3) | 334 (12.6) | 271 (10.2) |
Other includes Afar, Benishangul-Gumuz, Dire Dawa, Gambella, Harari, SNNPR, Somali regions and military.
RTI, road traffic injury.
Characteristics of injury
The yellow/green zone had the highest percentage of triaged RTI patients (n=2056, 77.3%) during the study period. Across all demographics, head injuries were consistently the most common (n=966, 36.3%), followed by lower limb injuries (n=553, 20.8%). Patients in the red zone had the highest proportion of head injury cases (n=203, 74.9%) (table 2).
Table 2. Injured body region by patient characteristics and triage zone.
| Characteristics | Injured body regions, n (%) | Total | |||||
|---|---|---|---|---|---|---|---|
| Head | Neck | Upper limb | Trunk | Lower limb | Unspecified body region * | ||
| Sex | |||||||
| Male | 729 (37.7) | 47 (2.4) | 186 (9.6) | 152 (7.9) | 416 (21.5) | 402 (20.8) | 1932 |
| Female | 237 (32.5) | 12 (1.6) | 75 (10.3) | 76 (10.4) | 137 (18.8) | 192 (26.3) | 729 |
| Age in years | |||||||
| 0–4 | 22 (43.1) | 1 (2.0) | 1 (2.0) | 0 (0.0) | 11 (21.6) | 16 (31.4) | 51 |
| 5–17 | 124 (39.9) | 1 (0.3) | 22 (7.1) | 19 (6.1) | 55 (17.7) | 90 (28.9) | 311 |
| 18–29 | 366 (35.5) | 18 (1.7) | 100 (9.7) | 106 (10.3) | 208 (20.2) | 232 (22.5) | 1031 |
| 30–44 | 255 (35.3) | 24 (3.3) | 70 (9.7) | 63 (8.7) | 155 (21.5) | 155 (21.5) | 722 |
| 45–59 | 101 (33.0) | 10 (3.3) | 50 (16.3) | 26 (8.5) | 62 (20.3) | 57 (18.6) | 306 |
| ≥ 60 | 97 (40.4) | 5 (2.1) | 18 (7.5) | 14 (5.8) | 62 (25.8) | 44 (18.3) | 240 |
| Triage zone | |||||||
| Yellow/green | 552 (26.8) | 29 (1.4) | 250 (12.2) | 174 (8.5) | 512 (24.9) | 539 (26.3) | 2056 |
| Orange | 211 (63.2) | 24 (7.2) | 8 (2.4) | 37 (11.1) | 28 (8.4) | 26 (7.8) | 334 |
| Red | 203 (74.9) | 6 (2.2) | 3 (1.1) | 17 (6.3) | 13 (4.8) | 29 (10.7) | 271 |
| Total | 966 (36.3) | 59 (2.2) | 261 (9.8) | 228 (8.6) | 553 (20.8) | 594 (22.3) | 2661 (100%) |
Unspecified body region was the category under the ICD 10 diagnosis code.
Overall, fractures were the most common injuries (n=991, 37.2%), followed by concussions and other internal injuries (n=830, 31.2%). The proportion of fractures was the highest among patients aged ≥60 years (43.3%) compared with other age groups and injuries. The highest percentage of concussions and internal injuries was also observed in this group (34.6%). Regarding triage zones, fractures were most common in the yellow/green zone (n=860, 41.8%), while concussions and internal injuries predominated in the red zone (n=202, 74.5%) and orange zone (n=188, 56.3%) (table 3).
Table 3. Nature of RTI cases by patients’ characteristics and triage zone.
| Characteristics | Nature of RTI, n (%) | Total | ||||
|---|---|---|---|---|---|---|
| Fracture | Concussion and other internal injury | Soft tissue injury | Contusions and crushing | Sprain, strain or dislocation | ||
| Sex | ||||||
| Male | 732 (37.9) | 617 (31.9) | 425 (22.0) | 94 (4.9) | 64 (3.3) | 1932 |
| Female | 259 (35.5) | 213 (29.2) | 191 (26.1) | 34 (4.7) | 32 (4.4) | 729 |
| Age group (years) | ||||||
| 0–4 | 18 (35.3) | 15 (29.4) | 16 (31.4) | 1 (2.0) | 1 (2.0) | 51 |
| 5–17 | 99 (31.8) | 104 (33.4) | 93 (29.9) | 9 (2.9) | 6 (1.9) | 311 |
| 18–29 | 367 (35.6) | 320 (31.0) | 245 (23.8) | 56 (5.4) | 43 (4.2) | 1031 |
| 30–44 | 281 (38.9) | 222 (30.7) | 158 (21.9) | 37 (5.1) | 24 (3.3) | 722 |
| 45–59 | 122 (39.9) | 86 (28.1) | 65 (21.2) | 18 (5.9) | 15 (4.9) | 306 |
| ≥ 60 | 104 (43.3) | 83 (34.6) | 39 (16.3) | 7 (2.9) | 7 (2.9) | 240 |
| Triage zone | ||||||
| Yellow/green | 860 (41.8) | 440 (21.4) | 592 (28.8) | 71 (3.5) | 93 (4.5) | 2056 |
| Orange | 88 (26.3) | 188 (56.3) | 19 (5.7) | 38 (11.3) | 1 (0.3) | 334 |
| Red | 43 (15.9) | 202 (74.5) | 5 (1.8) | 19 (7.0) | 2 (0.7) | 271 |
| Total | 991 (37.2) | 830 (31.2) | 616 (23.1) | 128 (4.8) | 96 (3.6) | 2661 (100%) |
RTI, road traffic injury.
Length of stay in the ED
Of all RTI patients who presented to the ED, 780 (29.0%; 95% CI 27.6 to 31.0) experienced an LoS exceeding 24 hours. Among these patients, the median ED stay was 5 days with an IQR of 3–10, and 288 (36.9%) stayed in the ED for more than a week. Regarding injury type, soft tissue injuries resulted in the shortest stays, with 93.3% of such patients discharged within 24 hours (table 4).
Table 4. Length of stay in the emergency department by RTI patient characteristics.
| Characteristics | Length of stay, n (%) | Total | |||
|---|---|---|---|---|---|
| ≤ 24 hours | 2–7 days | 8–14 days | > 14 | ||
| Sex | |||||
| Male | 1335 (69.1) | 132 (6.8) | 368 (19.0) | 97 (5.0) | 1932 |
| Female | 546 (74.9) | 124 (17.0) | 36 (4.9) | 23 (3.2) | 729 |
| Age group (years) | |||||
| 0–4 | 39 (76.5) | 6 (11.8) | 4 (7.8) | 2 (3.9) | 51 |
| 5–17 | 224 (72.0) | 57 (18.3) | 19 (6.1) | 11 (3.5) | 311 |
| 18–29 | 754 (73.1) | 180 (17.5) | 57 (5.5) | 40 (3.9) | 1031 |
| 30–44 | 506 (70.1) | 135 (18.7) | 43 (6.0) | 38 (5.3) | 722 |
| 45–59 | 203 (66.3) | 63 (20.6) | 24 (7.8) | 16 (5.2) | 306 |
| ≥ 60 | 155 (64.6) | 51 (21.3) | 21 (8.8) | 13 (5.4) | 240 |
| Severely injured body part | |||||
| Head | 623 (64.5) | 220 (22.8) | 75 (7.8) | 48 (5.0) | 966 |
| Neck | 26 (44.1) | 24 (40.7) | 5 (8.5) | 4 (6.8) | 59 |
| Upper limb | 194 (74.1) | 45 (17.2) | 13 (5.0) | 9 (3.4) | 261 |
| Trunk | 134 (58.3) | 58 (25.4) | 18 (7.9) | 18 (9.8) | 228 |
| Lower limb | 363 (65.6) | 110 (19.9) | 46 (8.3) | 34 (6.1) | 553 |
| Unspecified body region | 541 (91.1) | 35 (5.9) | 11 (1.9) | 7 (1.2) | 594 |
| Nature of RTIs | |||||
| Fracture | 633 (63.9) | 223 (22.5) | 75 (7.6) | 60 (6.1) | 991 |
| Concussion and other internal injury | 535 (64.5) | 183 (22.0) | 65 (7.8) | 47 (5.7) | 830 |
| Soft tissue injury | 575 (93.3) | 30 (4.9) | 10 (1.6) | 1 (0.2) | 616 |
| Contusions and crushing | 63 (49.2) | 44 (34.4) | 11 (8.6) | 10 (7.8) | 128 |
| Sprain, strain, or dislocation | 75 (78.1) | 12 (12.5) | 7 (7.3) | 2 (2.1) | 96 |
| Triage zones | |||||
| Yellow/green | 1595 (77.6) | 289 (14.1) | 109 (5.3) | 63 (3.1) | 2056 |
| Orange | 162 (48.5) | 118 (35.3) | 29 (8.7) | 25 (7.5) | 334 |
| Red | 124 (45.8) | 85 (31.4) | 30 (11.1) | 32 (11.8) | 271 |
| Total | 1881 (70.7) | 492 (18.5) | 168 (6.3) | 120 (4.5) | 2661 (100%) |
RTI, road traffic injury.
Disposition of RTI patients
A total of 1789 (67.2%) patients were discharged home. Among the types of injuries, soft tissue injuries had the highest discharge rate to home. During the study period, 59 (2.2%) RTI patients died in the ED. The majority of deaths (78%) occurred in the red zone, and 71.1% were males. The leading cause of death was head injury (66.1%), followed by concussions and other internal injuries (64.4%). Of the RTI patients in the ED, 691 (26.0%) were transferred to other departments within the hospital for either inpatient admission or outpatient care (table 5).
Table 5. Disposition from the ED according to RTI patient characteristics.
| Characteristics | Disposition from the ED, n (%) | Total | ||||
|---|---|---|---|---|---|---|
| Discharged home | Linked to other departments in the hospital | Referred to other hospital | Left against medical advice | Died | ||
| Sex | ||||||
| Male | 1258 (65.1) | 536 (27.7) | 53 (2.7) | 43 (2.2) | 42 (2.2) | 1932 |
| Female | 531 (73.9) | 155 (21.6) | 16 (2.2) | 10 (1.4) | 17 (2.3) | 729 |
| Age group (year) | ||||||
| 0–4 | 34 (66.7) | 17 (33.3) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 51 |
| 5–17 | 208 (66.9) | 87 (28.0) | 8 (2.6) | 2 (0.6) | 6 (1.9) | 311 |
| 18–29 | 721 (69.9) | 249 (24.2) | 20 (1.9) | 21 (2.0) | 20 (1.9) | 1031 |
| 30–44 | 492 (68.0) | 173 (24.0) | 21 (2.9) | 18 (2.5) | 18 (2.5) | 722 |
| 45–59 | 198 (64.7) | 82 (26.8) | 12 (3.9) | 6 (2.0) | 8 (2.6) | 306 |
| ≥ 60 | 136 (56.7) | 83 (34.6) | 8 (3.3) | 6 (2.5) | 7 (2.9) | 240 |
| Severely injured body part | ||||||
| Head | 527 (54.6) | 354 (36.6) | 35 (3.6) | 11 (1.1) | 39 (4.0) | 966 |
| Neck | 31 (52.2) | 17 (28.8) | 5 (8.5) | 2 (3.4) | 4 (6.8) | 59 |
| Upper limb | 181 (69.3) | 63 (24.1) | 5 (1.9) | 11 (4.2) | 1 (0.4) | 261 |
| Trunk | 152 (66.7) | 55 (24.1) | 7 (3.1) | 7 (3.1) | 7 (3.1) | 228 |
| Lower limb | 375 (67.7) | 148 (26.8) | 13 (2.4) | 16 (2.9) | 1 (0.2) | 554 |
| Unspecified body region | 523 (88.0) | 54 (9.1) | 4 (0.7) | 6 (1.0) | 7 (1.2) | 594 |
| Nature of RTI | ||||||
| Fracture | 635 (64.0) | 279 (28.2) | 32 (3.2) | 34 (3.4) | 11 (1.1) | 991 |
| Concussion and other internal injury | 443 (53.2) | 315 (38.0) | 26 (3.1) | 8 (1.0) | 38 (4.6) | 830 |
| Soft tissue injury | 565 (91.7) | 41 (6.7) | 5 (0.8) | 5 (0.8) | 0 (0.0) | 616 |
| Contusions and crushing | 71 (55.5) | 39 (30.5) | 5 (3.9) | 3 (2.3) | 10 (7.8) | 128 |
| Sprain, strain or dislocation | 75 (78.1) | 17 (17.7) | 1 (1.0) | 3 (3.1) | 0 (0.0) | 96 |
| Triage zone | ||||||
| Yellow/green | 1656 (80.5) | 310 (15.1) | 41 (2.0) | 48 (2.3) | 1 (0.0) | 2056 |
| Orange | 123 (36.6) | 170 (50.9) | 24 (7.2) | 5 (1.5) | 12 (3.6) | 334 |
| Red | 10 (3.7) | 211 (77.9) | 4 (1.5) | 0 (0.0) | 46 (17.0) | 271 |
| Regional residence | ||||||
| Addis Ababa | 909 (73.2) | 260 (21.0) | 28 (2.3) | 23 (1.9) | 20 (1.6) | 1240 |
| Oromia | 752 (63.1) | 352 (29.5) | 36 (3.0) | 22 (1.8) | 30 (2.5) | 1192 |
| Amhara | 79 (54.1) | 52 (35.6) | 4 (2.7) | 4 (2.7) | 7 (4.8) | 146 |
| Other | 49 (59.0) | 27 (32.5) | 1 (1.2) | 4 (4.8) | 2 (2.4) | 83 |
| Total | 1789 (67.2) | 691 (26.0) | 69 (2.6) | 53 (2.0) | 59 (2.2) | 2661 (100) |
ED, emergency department; RTI, road traffic injury.
Factors associated with the LoS in the ED
The candidate variables were selected for the final model after assessment with a bivariate Poisson regression model with robust variance and collinearity diagnosis (table 6). Then, a multivariate Poisson regression model with robust variance was employed to evaluate the association between prolonged LoS and the predictor variables. The results indicated that patients aged 18–29 years had a 22% lower prevalence of prolonged LoS compared with those aged 60 and above (APR=0.78; 95% CI 0.63 to 0.95). A significantly higher prevalence of prolonged stay in ED among patients from outside Addis Ababa compared with residents in Addis Ababa (APR=1.41; 95% CI 1.24 to 1.60). Furthermore, among patients with neck injuries (APR=1.75; 95% CI 1.17 to 2.65) and those with trunk injuries (APR=1.43; 95% CI 1.09 to 1.89) had a higher prevalence of prolonged stay compared with those with upper extremity injury. Additionally, patients with fractures (APR=4.34; 95% CI 2.66 to 7.00); and contusions and crushing injuries (APR=3.81; 95% CI 2.33 to 6.21) had about four times higher prevalence of prolonged LoS compared with soft tissue injuries.
Table 6. Bivariate and multivariable Poisson regression models with robust variance.
| Characteristics | Length of stay | CPR (95% CI) |
APR (95% CI) |
|
|---|---|---|---|---|
| ≤ 24 hours | > 24 hours | |||
| Sex | ||||
| Male | 1335 (69.1) | 597 (30.9) | 1.23 (1.07 to 1.42)* | 1.15 (1.00 to 1.31) |
| Female | 546 (74.9) | 183 (25.1) | 1 | 1 |
| Age group (year) | ||||
| 0–4 | 39 (76.5) | 12 (23.5) | 0.66 (0.39 to 1.12)* | 0.75 (0.47 to 1.20) |
| 5–17 | 224 (72.0) | 87 (28.0) | 0.78 (0.62 to 0.93)* | 0.86 (0.67 to 1.09) |
| 18–29 | 754 (73.1) | 277 (26.9) | 0.75 (0.62 to 0.93)* | 0.78 (0.63 to 0.95)* |
| 30–44 | 506 (70.1) | 216 (29.9) | 0.85 (0.69 to 1.03) | 0.85 (0.69 to 1.03) |
| 45–59 | 203 (66.3) | 103 (33.7) | 0.95 (0.75 to 1.19) | 0.96 (0.76 to 1.20) |
| ≥ 60 | 155 (64.6) | 85 (35.4) | 1 | 1 |
| Regional residence | ||||
| Addis Ababa | 970 (78.2) | 270 (21.8) | 1 | 1 |
| Not Addis Ababa | 510 (36.0) | 911 (64.0) | 1.65 (1.45 to 1.87)† | 1.41 (1.24 to 1.60)† |
| Severely injured body part | ||||
| Head | 623 (64.5) | 343 (35.5) | 1.38 (1.10 to 1.72)* | 1.37 (1.04 to 1.81)* |
| Neck | 26 (44.1) | 33 (55.9) | 2.17 (1.60 to 2.96)† | 1.75 (1.17 to 2.65)† |
| Upper limb | 194 (74.3) | 67 (25.7) | 1 | 1 |
| Trunk | 134 (58.8) | 94 (41.2) | 1.61 (1.24 to 2.08)* | 1.43 (1.09 to 1.89)* |
| Lower limb | 363 (65.6) | 190 (34.4) | 1.33 (1.06 to 1.69)* | 1.28 (1.00 to 1.62) |
| Unspecified body region | 363 (65.6) | 190 (34.4) | 0.35 (0.25 to 0.48)* | 1.04 (0.67 to 1.62) |
| Nature of injury | ||||
| Fracture | 633 (63.9) | 358 (36.1) | 5.42 (3.99 to 7.38)† | 4.34 (2.66 to 7.00)† |
| Concussion and other internal injury | 535 (64.5) | 295 (35.5) | 5.34 (3.91 to 7.28)† | 3.81 (2.33 to 6.21)† |
| Sprain, strain or dislocation | 75 (78.1) | 21 (21.9) | 3.29 (2.03 to 5.31)† | 2.94 (1.63 to 5.27)† |
| Contusions and crushing | 63 (49.2) | 65 (50.8) | 7.63 (5.42 to 10.73)† | 4.69 (2.82 to 8.72)† |
| Soft tissue injury | 575 (93.3) | 41 (6.7) | 1 | 1 |
Significant association at P ≤ 0.05.
P ≤ 0.01.
APR, adjusted prevalence ratio; CPR, crude prevalence ratio.
Discussion
The study found that 38.5% of injury patients were RTI cases, predominantly male (72.6%) and between 18 and 44 years old (65.9%). Injuries commonly involved the head and fracture nature, with about one-third of patients staying in the ED for more than 24 hours. Among those with prolonged stays, the median length of stay was 5 days. Factors significantly associated with prolonged ED stay were geographical location and the nature of the injuries.
The magnitude of RTI
The magnitude of RTI in the current study is higher than the previous studies in Ethiopia15 19 29 30 and is consistent with findings of other researches in Ethiopia.31 32 However, it is lower than the rates reported in another study in Ethiopia22 and in Uganda.33 These variations could be due to differences in hospital types, data collection periods and approaches. The specialization of the current hospital for trauma centers may have also contributed to the high number of injury patients due to the referral system from different parts of the country.
Furthermore, males RTI visited the ED more than females, particularly within the age group of 18–44 years. These findings are consistent with the previous studies conducted in Ethiopia,1934,37 Uganda,33 Brazil38 and Nepal.39 The possible preseason might be the men are widely known to be more prone to taking risks and have poorer adherence to safety measures compared with women.40 41 Moreover, men and individuals of economically active age groups are often breadwinners in Ethiopia.42 These people tend to travel frequently for work and daily activities, increasing their vulnerability to road traffic accidents.43
The current study revealed that head injuries were the most prevalent among patients, followed by lower limb injuries, which aligns with previous research conducted in Ethiopia, Uganda, Nepal and Latin America.33 34 36 38 39 Furthermore, fractures were the most frequently encountered injury, followed by concussions and other internal injuries. The reason for this could be attributed to the fact that road traffic is known to produce severe outcomes, including fractures and organ damage.37
The mortality rate among patients with RTIs presenting to the ED in this study was 2.2%, which is lower than that reported in previous studies conducted in Ethiopia (8.8%–12.9%)44 45 and Uganda (4.0%).33 This disparity may be attributed to differences in the quality of care, availability of specialized services and the level of preparedness among hospitals.46 The specialized nature of AaBET Hospital as a trauma referral center may contribute to more timely and effective management of severe injuries, thereby improving survival rates. Another possible explanation might be the implementation of trauma care system improvement programs since 2020, which may have enhanced emergency response and clinical outcomes.7 47
RTI patients’ LoS and associated factors
In the current study, 29% (95% CI 27.6 to 31.0) of patients stayed in the ED for more than 24 hours. This proportion is lower than those reported in previous studies conducted in Ethiopia, which ranged from 38.4% to 91.5%.9,1127 One possible explanation for this difference might be the services and the relatively high level of hospital preparedness at AaBET Hospital. In contrast, previous studies often cited overcrowded hospital wards, delays in receiving laboratory and radiological results and limited inpatient bed availability as key contributors to prolonged ED stays. However, the ED LoS serves as a healthcare quality indicator in the country.8
The patients residing outside of Addis Ababa were found to have a higher prevalence of prolonged LoS. This finding is consistent with prior studies conducted at the same hospital among trauma patients, where patients from Oromia, Amhara and other distant regions were significantly more likely to experience extended ED stays.24 This may be partly explained by patients referred from regional hospitals outside Addis Ababa, typically arriving at the ED with more severe injuries, likely due to delays in reaching definitive care. These patients often experience prolonged ED stays while awaiting the necessary clinical interventions, inpatient bed availability, or logistical support. Furthermore, the hospital’s location in Addis Ababa means that patients from more remote areas may remain in the ED longer while awaiting transportation arrangements for their return home.
Injuries to the head, neck, trunk and lower limbs increased the risk of prolonged stays in the ED compared with the upper limbs. Similarly, previous studies in Iran have shown that patients with injuries to the face or head tend to have slightly longer stays compared with those with injuries to other parts of the body.48 49 This could be due to the complexity of management, diagnostic challenges and inadequate diagnostic instruments, which lead to patients waiting in the ED for the right services to address their injuries.10 27 50
Patients who suffered from fractures, concussions/internal injuries, sprains, strains/dislocations, contusions and crush injuries were at more risk of experiencing a prolonged LoS than those who had soft tissue injuries. This finding aligns with researches conducted in Iran.48 49 The reason for such relationships might be that patients with soft tissue injuries may not require as much care as those with other injuries. Fractures, head injuries and internal injuries require more complex evaluation and often might need specialist input or imaging. Moreover, compared with soft tissue injuries, the above-mentioned injuries may require more emphasis due to their severity or the need for longer care at the ED.49
Implications of the findings
This study offers a unique contribution by examining the magnitude of RTI and ED stays in Ethiopia’s only dedicated trauma center during the study period. Unlike previous studies conducted in general or regional hospitals, the setting of this study provides advanced diagnostic and specialist care, such as CT scans, MRIs, orthopedic, neurosurgical and trauma surgical consultations. Paradoxically, the availability of such resources may prolong ED stay patients remain in the ED while awaiting access to these services. This suggests that prolonged ED stay in specialized centers may be a marker of higher complexity care. Understanding these distinctions is critical for interpreting ED length of stay as a quality indicator, and for planning future referral systems, patient flow models and resource allocation strategies in trauma care across the country.
Limitation
This study has several limitations. It relied on secondary data, which may be prone to incomplete or inaccurate documentation, and excluded cases with missing key variables. Injury classification may underestimate polytrauma severity. Furthermore, this study, based on ED data, did not include patient information after transfer to other wards in hospital, which may not represent the broader population of RTI patients or other types of hospitals in Ethiopia. Nevertheless, the results of this study are based on large data and contribute valuable insights into the characteristics of RTIs and LoS in ED, particularly in countries facing data scarcity.
Conclusion
The study identified a high magnitude of RTIs, particularly among males, aged 15–44 years, with head injuries and fractures outcomes. About one-third of RTI patients’ LoS in the ED exceeded the country’s health system guidelines, influenced by residence, injured body region and nature of injuries. Although not directly measured in this study, the literature and logical inferences strongly suggest that prolonged LoS can harm patient outcomes and ED efficiency. The study’s findings can inform hospital administrations and policymakers on strategies to improve emergency care efficiency and enhance patient outcomes. Furthermore, addressing why patients from remote areas might stay in the ED might reduce the strain on emergency services. The authors suggested conducting prospective studies on LoS in RTI patients to gather real-time data, which is crucial for understanding patient flow and care processes.
Acknowledgements
The authors would like to thank the clinical and HMIS staff at AaBET hospital for providing the necessary technical and logistical support for this study. We also like to thank everyone who works in the medical record-keeping room.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Patient consent for publication: Not applicable.
Ethics approval: Ethical clearance for this study was obtained from the Institutional Review Board (IRB) of the Ethiopian Public Health Association (Number EPHA/06/039/21). Since the data were collected by reviewing injured patients’ cards and HMIS data, and there was no direct contact with patients, consent to participate was waived (deemed unnecessary) by the Ethiopian Public Health Association IRB. Furthermore, permission to conduct this study was obtained from the chairs of departments/units and the hospitals’ management board. The review of records adhered to relevant guidelines and regulations. After the data were extracted, patient names were deleted from the Microsoft Excel worksheet, and all deidentified data were kept confidential. The authors had no access to the information that could identify patients. This study also complies with the Declaration of Helsinki.
Provenance and peer review: Not commissioned; externally peer-reviewed.
Data availability free text: Data are available with the corresponding author (HM) and will be available on request at the following e-mail: hailumary464@gmail.com
Data availability statement
Data are available upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are available upon reasonable request.