the prevalence of surgical trauma as a public health 
 hazard in low - resource settings globally has been 
 severely neglected . traditionally , surgery has been 
 viewed as a resource - intense intervention that does not 
 fit in with most effective public health models . however , surgery can provide solutions to diverse yet 
 common crises such as appendicitis or obstructed 
 labour , which constitute a large burden of global 
 morbidity ( 1 ) . specifically , the world health 
 organisation recognises accidents and injuries as a 
 rising cause of disability and mortality globally ( 2 ) . burns , road accidents and domestic violence are all 
 common situations where surgical intervention may 
 prevent death or disability ( 3 ) . of these , the focus on 
 road accidents as a preventable cause of high mortality 
 and disability has become central . estimates go as high 
 as 3000 people dying every day in road accidents 
 worldwide . the very young , the very old , cyclists and 
 pedestrians are the most vulnerable ( 4 ) . as societies 
 globally become more automated , increasing 
 congestion of motor transport has made this issue of 
 critical concern . understanding the burden injury that could otherwise 
 be treated through simple trauma surgery places on 
 global health systems can not be accurately understood 
 without effective means to monitor its prevalence . furthermore , evaluating the capacity to respond to such 
 a burden also requires effective management of data . 
 as global capacity to provide emergency surgical care develops , mechanisms to monitor and evaluate 
 outcomes also need to be instituted concomitantly . furthermore , using 
 trauma scores to analyse injury data can identify best 
 practices in treatment of injury by identifying where 
 outcomes are improved ( 1 ) . . 
 however , many now aim to move beyond mere 
 epidemiological analysis towards managing responses 
 to such injuries . developing tools that permit appropriate monitoring 
 and evaluation of burgeoning surgical capacity provides 
 a means to ensure that challenges are identified , and 
 successes are replicated , as demonstrated in iran ( 5 ) . this study showed that a standard trauma score , 
 developed in north america , had some capacity to 
 evaluate the care given to injury patients in the iranian 
 context , demonstrating where treatment of trauma there 
 was suboptimal to comparative injuries in north 
 america . a larger study , also in iran , demonstrated that 
 a registry system provides valuable information 
 focusing attention on plausible public health 
 intervention for injury prevention , specific to local 
 contexts ( 6 ) . similar studies have been done in costa 
 rica ( 7 ) and a study of occupational injuries from a 
 government database of such incidents was completed 
 in turkey ( 8) . in nigeria , a retrospective study of data 
 from hospital records focused on the specific issue of 
 peripheral artery injuries to better understand 
 prevention ( 9 ) . however , correlating 
 the epidemiological data of a registry with the clinical 
 practice data from measurement of trauma severity 
 scores requires a further step . in north america , the trauma injury severity score 
 ( triss ) is the standard tool used in hospitals to 
 evaluate clinical performance in trauma wards . standardised tool , comparisons of performance in order 
 to identify problems or best practices are thus possible 
 ( 10 ) . however , triss can only be applied reliably in 
 the settings where the index has been validated , in the 
 high - resource settings of north america . although 
 there have been minor studies done to evaluate the 
 adequacy of the scores in low - resource settings ( 5 ) , 
 more predictive efficacy could be reached by designing 
 an index specific to low - resource settings . trauma surgeons in uganda and canada are already 
 developing a trauma severity index specific to east 
 african contexts ( 11 ) . this index , the kampala trauma 
 score ( kts ) , was developed to be effective in areas 
 where access to certain indicators may be costly or 
 time - consuming . thus , patient status is evaluated by taking four vital parameters into account : blood 
 pressure , respiratory rate , neurological status and 
 number of serious injuries sustained . these relatively 
 easy measurements give a global overview of a patient 's 
 status , and in principle , can be correlated to the outcome 
 of the case , given interventions appropriate for the 
 patient 's status . analysis of data from uganda 
 showed some degree of success in predicting outcome , 
 although evaluation of its efficacy as a triage tool 
 remains to be seen ( 12 ) . this data from dar es salaam , 
 tanzania is the first time data has been collected 
 externally using this system of registry and trauma 
 indexing . one round of data has already been evaluated 
 from this collection in dar es salaam ( 13 ) . the data 
 presented in this round are the preliminary results from 
 the second round of data being collected in dar es 
 salaam , given the changes incorporated into the survey 
 after the first round . research is required to evaluate 
 that data collection is standardised and consistent , in 
 order to improve the ability to monitor and plan trauma 
 management protocols specific to their context 
 effectively ( 14 ) . regional reliability of trauma data has 
 become an increasing concern in the field , even in the 
 developed world , as populations become more mobile 
 and social systems more integrated ( 15 ) . previous experiences in data collection from developing 
 country registries have showed variable consistency in 
 the recording of necessary data , requiring efforts to 
 systematise the data available in manageable ways ( 1 ) . however , 
 research in the developing world faces serious 
 difficulties in capacity ( 16 ) . the transfer of research 
 capacity from national systems to global actors is an 
 issue , as well as the instability of political agendas to 
 support research in low- and middle - income countries . poor pay of research workers that require them to seek 
 opportunities elsewhere also has an impact on research 
 capacity in the developing world . old models of 
 academic partnerships in and of themselves have 
 contributed to the degeneration of research capacity 
 globally , as local authority has been pre - empted by 
 external control of research agendas ( 17 ) . with this context in mind , this project thus sought to 
 accomplish three primary goals : to understand the 
 benefits maintaining a trauma registry can bring to the 
 tanzanian context , to describe the efficacy of the 
 kampala trauma score in monitoring injury in dar es 
 salaam , and finally to evaluate the challenges apparent 
 in the maintenance of such a registry for research 
 purposes in this context . the data analysed in this paper comes from an initial 
 two - week collection of the second round of data from 
 tanzania . this round of data collection is derived from 
 a survey instrument that has been modified to respond 
 to collection challenges encountered in the year - long 
 first round . some data in this round had to be dismissed as data 
 collectors used the old tool for approximately twenty 
 cases . the remaining data , involving 125 valid cases , 
 was analysed for data quality concerns , screened for 
 missing values and contradictory evidence . interviews 
 were also conducted with three project managers in the 
 hospital administration to highlight some of the most 
 pressing challenges in trauma registry maintenance . a 
 focus group with emergency department nurses who 
 served as data collectors at the dar es salaam site was 
 also conducted . these data collectors were also 
 responsible for clinical nursing duties for patients 
 entering the emergency department , thus engaging in 
 acute care to ensure stabilisation of patients ' conditions . therefore , it is important to note that they were not 
 primarily researchers steeped in the research questions 
 and methodology , their main interest being to ensure 
 appropriate care of the injured patient . while the data 
 they recorded would be pertinent to routine care , the 
 burden of filling out additional paperwork could come 
 into conflict with their clinical duties . the data 
 collectors were however remunerated a nominal amount 
 for every score evaluation conducted . a visit to a rural clinic at mkuranga , 80 km outside of 
 dar es salaam , where data collection has commenced as 
 part of a national process , provided additional 
 information on the nature of trauma registries in 
 tanzania , through interviewing the project coordinator 
 at that site . initial findings from the second round of data 
 confirms the general understanding that men are 
 preponderantly susceptible to visit the emergency room , 
 involving 97 cases of the 125 . . there were some 
 inconsistencies in recording of age , as some collectors 
 recorded year of birth rather than age . in three cases , simply  adult  was noted , and in four cases , age was 
 not recorded at all . of anecdotal interest , on the initial 
 day of the visiting researcher 's stay at the hospital , all 
 four beds in the department devoted to serious injuries 
 were occupied by young men ( suffering head trauma 
 from road accidents ) . certain parameters required to define the trauma 
 score on the kampala scale did not pose problems . the 
 vast majority of cases came in with normal systolic 
 blood pressure , and this index was not scored in only 
 one instance ( see table i ) . eleven cases came in with 
 poor respiratory rates , five of which were children , one 
 unknown . two cases showed the poorest neurological 
 signs of no response to any stimuli whatsoever , one of 
 those cases being a child . although in 
 interview , collectors seemed clear about what 
 constituted a serious injury  anything that required 
 surgical intervention these discrepancies came to light as 
 there was a repeated question on serious injury . one 
 question , question 9 , asked the collector identify the 
 number of serious injuries . another question , question 
 19 , asked the clinician to identify the site of serious 
 injuries . table iv shows some of the findings of this 
 internal cross - checking , with figures of note in bold . the table compares the initial reporting of serious 
 injury of the case under question 9 by the data collector , 
 against where they later record as the site of serious 
 injury under question 19 . for instance , of the 47 
 patients who were initially described as having no 
 serious injuries , 8 were later noted to have the 
 head / neck as a site of serious injury , and 26 at the pelvis 
 or extremities . of the 55 who were initially noted to 
 have one site of serious injury , 1 was later described as 
 having no site of serious injury , 3 as multiple sites of 
 injury and 9 had no site recorded at all . this inconsistency in data collection must naturally 
 lead to inaccuracies in calculating the total kts . these 
 problems were compounded by simpler errors , where , 
 for example , clinicians provided a total score for four of 
 the twelve cases which had not been scored on the 
 serious injury scale . the kts was not calculated in 
 eight cases but can be extrapolated from the component 
 scores , all of them at a stable 8 . in four cases where 
 there was no serious injury score , the data collector 
 nonetheless provided a kts score , all of them a stable 
 8 . besides the problems with actual scoring , there were 
 other points to note on the data collection ( see table v ) . 
 in three cases of the total , otherwise , 58 cases were caused by road 
 accidents , 39 were caused by a fall , two were stabs or 
 cuts , two were blunt force and 21 were from other 
 causes . however , when prompted , 14 of the cases in 
 this latter category were described as assaults , rather 
 than by the specific nature of the assault described in the 
 earlier categories . given the preponderance of road accidents , the 
 survey asked for further detail regarding the 
 circumstances of these injuries ( see table vi ) . of the 58 
 road accidents , the highest proportion was those involving vehicles and pedestrians as counterparts  31 
 out of the 55 of the cases where the counterparts were 
 noted by data collectors in the survey . important information regarding seatbelt 
 use ( or helmet use in the case of motorcycle or bicycle 
 accidents ) was quite well recorded where relevant ( see 
 table vii ) . gathering this data is essential to enhance 
 monitoring and implementation of public health 
 initiatives . the most critical 
 lack of information comes from the two - week followup 
 ( see table viii ) . of the 125 cases , only 31 had 
 information on the follow - up , of which 22 remained 
 discharged , two had died and the remainder were still 
 noted as remaining in hospital . of the 39 cases 
 originally noted as having been admitted to the hospital , 
 two - week follow - up was missing for 30 of them . interestingly , of the two who died , one had no kts 
 score noted and the other had come in scored as a stable 
 9 . firstly , the ability to monitor data in an emergency 
 department provides valuable insight into the nature of 
 injuries that are prevalent in an area . as such , registries 
 may prove to be an effective tool for public health 
 interventions , in their capacity to direct resources 
 towards addressing the most serious concerns in 
 preventing accident and injury . the data , although 
 preliminary , provides an overview of the injuries that place the most burden on an orthopaedic emergency 
 room in dar es salaam . clearly , mimicking global 
 trends , road accidents are a major concern in the region . there is also particular concern for the health 
 status of young men . while this statistic may be due to 
 the enhanced risk - taking behaviours of men , it is also 
 plausible that women in dar es salaam are less likely to 
 seek formal care for injuries than men , thus presenting 
 less often to the emergency room secondly , the leverage tool the registry provides in 
 order to launch public health interventions underscores 
 its importance . this data can be used both by national 
 authorities in tanzania , as well as regionally and more 
 globally , to address pressing issues of road safety and accident awareness . although human resources are 
 insufficient to devote to this work , the interviews with 
 hospital administration in dar es salaam underlined the 
 necessity of bringing this data to government authorities 
 to launch a campaign to limit the injury burden from 
 road accidents . thirdly , the process of launching and maintaining the 
 registry at a national hospital in a low - resource setting 
 promotes the development of capacity to engage in 
 research in these contexts , which is direly needed in 
 order to make sure public health dollars are spent 
 effectively . locally - led research ensures that funds are 
 not misdirected to concerns that are externally 
 determined . while these initiatives bring to light global 
 health concerns that need redress , they also enhance 
 global health equity in acknowledging the expertise of 
 researchers active in low - resource settings . the hospital 
 administration in dar es salaam shows remarkable 
 commitment to the research process with little public 
 support , fuelled by the energy of a few individuals . overall , the relative completeness of the components 
 of the kampala trauma score collection shows that at 
 least the three initial parameters ( blood pressure , 
 respiratory rate , and neurological status ) are efficient 
 indicators to collect data in clinical contexts in 
 tanzania . whether they adequately describe patient 
 outcomes remains to be seen , although the analysis 
 done on the more extensive ugandan data suggests that 
 as the tanzanian data is more rigorously collected and analysed , there will be predictive capacity ( 12 ) . however , the results for the serious injury score in this 
 preliminary tanzanian data , for example , show some of 
 the most pressing concerns in data collection . the interviews provided some nuance to the 
 questions where the most critical lapses occurred . the 
 project managers noted that inadequate support for 
 research capacity requires that nurses undertake the 
 work . the nurses in the emergency room , in return , 
 underlined that balancing the needs of the researcher 
 and clinician in a busy emergency room was difficult , 
 with the research needs suffering . this reality was 
 particularly highlighted at the rural clinic , where the 
 data entries ( not analysed here ) were much more 
 nuanced and detailed , given the many fewer visits at 
 mkuranga . while some of the difficulties could be ascribed to the 
 fact that this data collection occurred early on in the 
 round of data collection , it must be noted that the 
 hospital had conducted one full year s round of data 
 collection previously . introducing new data collectors to 
 the process can naturally cause difficulties , but 
 providing immediate feedback once these challenges 
 have been identified early on is necessary to ensure 
 usable data arises in the long - term . in the meantime , a 
 stopgap measure of cross - checking data with hospital 
 records themselves may be instituted . however , 
 devoting human resources to this task is also an 
 untenable drain on clinical work in the hospital . for future perspectives , the two most important areas 
 where further improvement of data collection needs to 
 take place are in scoring serious injury , and in recording 
 outcomes in the two - week follow - up . adequate 
 recording of this component is essential , as an accurate 
 calculation of the kts is dependent on it . the former 
 can be a challenge given the possibilities of rapid 
 clinical evolution in emergency settings . however , 
 refining the design of the survey in this regard may prove useful , requiring clinicians to list only the sites 
 where intervention was required . the data analysers can 
 then total up this elementary information to assign a 
 serious injury score themselves , ensuring that there is 
 no repetition of the same data in the collection . in this 
 way , the analysers can also do the work of calculating 
 the total kts , further relieving the burden from the data 
 collectors so they are required only to gather the most 
 elementary components of the data . furthermore , clear 
 definitions of what constitutes a serious injury need to 
 be refined further , taking into account that surgical 
 intervention alone can not be the most reliable marker of 
 gravity of trauma . it is conceivable that there is not 
 even a consensus amongst data collectors on what 
 constitutes a surgical intervention itself . sustaining the collection of outcome data is critical to 
 harness the entire potential of a trauma registry , in order 
 to monitor the effectiveness of treatment in each setting . 
 in this consideration , the lack of capacity to undertake a 
 two - week follow - up , even as minimally required by this 
 survey instrument , was limited with the resources 
 available to the hospital . even though most data 
 collected by the survey instrument was also 
 independently entered into the hospital records , there 
 was little time to cross - check this data with hospital 
 records , and certainly two - week follow - up was often 
 impossible by the emergency nurses even if the patient 
 remained in hospital . rather than research design , this 
 problem is a more structural issue in low - resource 
 settings of limited research capacity . clearly , addressing this difficulty can not be resolved 
 within one project alone . in the long - term , the registry 
 would ideally be integrated into routine care in the 
 emergency department across east africa , perhaps 
 incorporated into regular charting activities in order to 
 monitor the predicted outcomes and the course of 
 treatment of trauma patients . however , much needs to 
 be done to verify the validity of the tool until then . the establishment of research partnerships between highresource 
 settings and lower - resource contexts can be 
 helpful , only if there is a transfer of both financial and 
 human resources to local actors so that research 
 capacity within the society is enhanced . control of 
 research agendas and projects needs also to remain 
 within the developing world . firstly , the ability to monitor data in an emergency 
 department provides valuable insight into the nature of 
 injuries that are prevalent in an area . as such , registries 
 may prove to be an effective tool for public health 
 interventions , in their capacity to direct resources 
 towards addressing the most serious concerns in 
 preventing accident and injury . the data , although 
 preliminary , provides an overview of the injuries that place the most burden on an orthopaedic emergency 
 room in dar es salaam . clearly , mimicking global 
 trends , road accidents are a major concern in the region . there is also particular concern for the health 
 status of young men . while this statistic may be due to 
 the enhanced risk - taking behaviours of men , it is also 
 plausible that women in dar es salaam are less likely to 
 seek formal care for injuries than men , thus presenting 
 less often to the emergency room secondly , the leverage tool the registry provides in 
 order to launch public health interventions underscores 
 its importance . this data can be used both by national 
 authorities in tanzania , as well as regionally and more 
 globally , to address pressing issues of road safety and accident awareness . although human resources are 
 insufficient to devote to this work , the interviews with 
 hospital administration in dar es salaam underlined the 
 necessity of bringing this data to government authorities 
 to launch a campaign to limit the injury burden from 
 road accidents . thirdly , the process of launching and maintaining the 
 registry at a national hospital in a low - resource setting 
 promotes the development of capacity to engage in 
 research in these contexts , which is direly needed in 
 order to make sure public health dollars are spent 
 effectively . locally - led research ensures that funds are 
 not misdirected to concerns that are externally 
 determined . while these initiatives bring to light global 
 health concerns that need redress , they also enhance 
 global health equity in acknowledging the expertise of 
 researchers active in low - resource settings . the hospital 
 administration in dar es salaam shows remarkable 
 commitment to the research process with little public 
 support , fuelled by the energy of a few individuals . overall , the relative completeness of the components 
 of the kampala trauma score collection shows that at 
 least the three initial parameters ( blood pressure , 
 respiratory rate , and neurological status ) are efficient 
 indicators to collect data in clinical contexts in 
 tanzania . whether they adequately describe patient 
 outcomes remains to be seen , although the analysis 
 done on the more extensive ugandan data suggests that 
 as the tanzanian data is more rigorously collected and analysed , there will be predictive capacity ( 12 ) . however , the results for the serious injury score in this 
 preliminary tanzanian data , for example , show some of 
 the most pressing concerns in data collection . the interviews provided some nuance to the 
 questions where the most critical lapses occurred . the 
 project managers noted that inadequate support for 
 research capacity requires that nurses undertake the 
 work . the nurses in the emergency room , in return , 
 underlined that balancing the needs of the researcher 
 and clinician in a busy emergency room was difficult , 
 with the research needs suffering . this reality was 
 particularly highlighted at the rural clinic , where the 
 data entries ( not analysed here ) were much more 
 nuanced and detailed , given the many fewer visits at 
 mkuranga . while some of the difficulties could be ascribed to the 
 fact that this data collection occurred early on in the 
 round of data collection , it must be noted that the 
 hospital had conducted one full year s round of data 
 collection previously . introducing new data collectors to 
 the process can naturally cause difficulties , but 
 providing immediate feedback once these challenges 
 have been identified early on is necessary to ensure 
 usable data arises in the long - term . in the meantime , a 
 stopgap measure of cross - checking data with hospital 
 records themselves may be instituted . however , 
 devoting human resources to this task is also an 
 untenable drain on clinical work in the hospital . for future perspectives , the two most important areas 
 where further improvement of data collection needs to 
 take place are in scoring serious injury , and in recording 
 outcomes in the two - week follow - up . adequate 
 recording of this component is essential , as an accurate 
 calculation of the kts is dependent on it . the former 
 can be a challenge given the possibilities of rapid 
 clinical evolution in emergency settings . however , 
 refining the design of the survey in this regard may prove useful , requiring clinicians to list only the sites 
 where intervention was required . the data analysers can 
 then total up this elementary information to assign a 
 serious injury score themselves , ensuring that there is 
 no repetition of the same data in the collection . in this 
 way , the analysers can also do the work of calculating 
 the total kts , further relieving the burden from the data 
 collectors so they are required only to gather the most 
 elementary components of the data . furthermore , clear 
 definitions of what constitutes a serious injury need to 
 be refined further , taking into account that surgical 
 intervention alone can not be the most reliable marker of 
 gravity of trauma . it is conceivable that there is not 
 even a consensus amongst data collectors on what 
 constitutes a surgical intervention itself . sustaining the collection of outcome data is critical to 
 harness the entire potential of a trauma registry , in order 
 to monitor the effectiveness of treatment in each setting . 
 in this consideration , the lack of capacity to undertake a 
 two - week follow - up , even as minimally required by this 
 survey instrument , was limited with the resources 
 available to the hospital . even though most data 
 collected by the survey instrument was also 
 independently entered into the hospital records , there 
 was little time to cross - check this data with hospital 
 records , and certainly two - week follow - up was often 
 impossible by the emergency nurses even if the patient 
 remained in hospital . rather than research design , this 
 problem is a more structural issue in low - resource 
 settings of limited research capacity . clearly , addressing this difficulty can not be resolved 
 within one project alone . in the long - term , the registry 
 would ideally be integrated into routine care in the 
 emergency department across east africa , perhaps 
 incorporated into regular charting activities in order to 
 monitor the predicted outcomes and the course of 
 treatment of trauma patients . however , much needs to 
 be done to verify the validity of the tool until then . the establishment of research partnerships between highresource 
 settings and lower - resource contexts can be 
 helpful , only if there is a transfer of both financial and 
 human resources to local actors so that research 
 capacity within the society is enhanced . control of 
 research agendas and projects needs also to remain 
 within the developing world . the current process of data collection in tanzania 
 provides very interesting descriptive data on the nature 
 of injury in a particular setting , which provides 
 evidence upon which to build public health 
 interventions . however , to improve clinical outcomes , 
 further refinements in the data collection process need 
 to be instituted through modifications to the survey tool , 
 and particularly , further resource allocation to bolster 
 clinical research capacity in emergency rooms in the 
 country . once this capacity to monitor outcomes is 
 developed , further research into the correlation of 
 patient status and outcome , depending on interventions 
 used , needs to be undertaken in order to develop an 
 analysis of the clinical capacity to respond to trauma in 
 this context . the ultimate goal is , after all , to refine 
 practice to improve patient outcome . especially given 
 the increasingly high burden injuries are placing on 
 global health systems given the advent of motorised 
 traffic worldwide , this work is becoming imperative to 
 protect those most vulnerable to these accidents . however , the process requires a solid base of evidence 
 upon which to design both treatment and prevention 
 interventions . these challenges can not be overcome 
 unless there is serious investment in clinical research in 
 low- and middle - income countries .