Accelerated urbanization and industrialization have led to a disturbing increase in the rate of accidental injuries, crime, and subsequent violence in India. An unprecedented increase in the number of vehicles has outrun the development of adequate roads and highways.1 Road-traffic accidents (RTA) are increasing at an annual rate of 3% with a vehicular accident being reported every 2 minutes and a death every 8 minutes on Indian roads. A trauma-related death occurs in India every 1.9 minutes. Mortality in serious [Injury Severity Score (ISS) > 16] injuries is worse in a developing country such as India compared to a developed country. 90% of all Road Traffic Deaths occur in middle and low income countries like India. In addition to excess mortality, RTA cause tremendous burden of disability in developing nations. India loses approx 2-2.5% of its GDP to only Road Traffic Injuries.2 Injuries caused 9% of the total mortality. Among the total disability-adjusted life-years (DALYs), 13% were due to injuries. Among both, children aged 5–14 years and young people aged 15–29 years, road traffic injuries are the second-leading cause of death worldwide.3 Trauma is the third overall cause of death and the first before 40 years of age and is responsible for handicaps and high costs.4, 5 In developed countries, data is available from vital statistics registers and health care records. However, such records are limited in developing countries and hence the need for descriptive studies time and (time) again. This retrospective observational study aims to scrutinize the demographics and the mortality trends of trauma patients admitted to the intensive care unit at a Level 1 Trauma centre and Superspeciality hospital in North India which caters to a large part of eastern and central Indian population.

The present retrospective study was conducted at Trauma centre and Superspeciality Hospital, Institute of Medical Sciences, B.H.U., Varanasi, U.P., North India. We retrieved, tabulated and analysed the particulars of 1571 patients admitted to the intensive care unit at the Trauma Centre in the time frame between 1st January 2018 and 31st December 2019. The data collected from 2020 was omitted due to the covid-19 pandemic as it would lead to a selection bias. The demographic details of the patients with their diagnoses, course in the intensive care unit, daily census and eventual outcomes were recorded and analysed. Indices calculated were – ● Mortality (distributed over the time-frame, according to age-groups & injuries) ● Average length of stay ● Bed turnover rate ● Bed occupancy rate ● Admission rate ● Gross death rate ● Institutional death rate Statistical Analysis – Descriptive statistics has been used for this study purpose. SPSS version 20.0 for Windows (10) was used for the analysis. Mean and Median were analysed, frequency and percentages were calculated.

On analysing the 1571 in-patients at the Intensive care unit of a Level 1 Trauma centre and Superspeciality hospital in the time frame between 1st January 2018 and 31st December 2019, 1166 (74.22%) were found to be males and 405 (25.78%) females. The overall mortality was found to be 38.45% (604 deaths) Fig. 1- Number of Trauma ICU patients who died in the study period The overall mortality in 2019 (436 ~ 72.19%) was greater than in 2018 (168 ~ 27.82%), for every month. Fig. 2 – Number of patients who died in 2018 (month-wise) Fig. 3 – Number of patients who died in 2019 (month-wise) Fig. 4- Mortality rate in 2018 (month-wise) Fig. 5- Mortality rate in 2019 (month-wise) Out of the total 1571 admitted patients, 892 patients (56.78%) recovered and got shifted out of ICU to their respective wards while 75 patients (4.77%) took discharge against medical advice. When we grouped the patients into different age-groups, maximum number of admissions, deaths, discharges (with or against medical advice) happened in children and adults of the age groups 11-60 years. AGE GROUP ADMISSION DIED DISCHARGED/SHIFTED LAMA/DAMA NO. OF PATIENTS PERCENTAGE NO. OF PATIENTS PERCENTAGE NO. OF PATIENTS PERCENTAGE NO. OF PATIENTS PERCENTAGE 0-10 125 7.956715 44 2.800764 75 4.774029 6 0.381922 11-20 208 13.23997 70 4.455761 131 8.338638 7 0.445576 21-30 338 21.51496 108 6.874602 213 13.55824 17 1.082113 31-40 265 16.86824 89 5.665181 163 10.37556 13 0.827498 41-50 242 15.4042 97 6.174411 136 8.656906 9 0.572884 51-60 197 12.53978 93 5.919796 94 5.98345 10 0.636537 61-70 133 8.465945 67 4.264799 56 3.564609 10 0.636537 71-80 46 2.928071 29 1.845958 16 1.01846 1 0.063654 81-90 16 1.01846 7 0.445576 7 0.445576 2 0.127307 >91 1 0.063654 0 0 1 0.063654 0 0 Total 1571 604 38.44 892 56.77912 75 4.774029 Table 1- Age-group wise number of admissions, deaths, discharges (with or against medical advice) While observing the different categories of primary trauma, maximum number of admissions, deaths and discharges were in patients with traumatic brain injury (TBI) (admission- 806 patients ~ 51.31%, death- 306 patients ~ 19.48%, discharge- 464 patients ~ 29.54% and DAMA- 36 patients ~ 2.29%). Fig. 6- Number of admissions, deaths and discharges based on the type of injury With respect to the types of central nervous system injuries, maximum number of patients had cerebral contusion (272 patients ~ 17.31%) followed by subdural haemorrhage (179 patients ~ 11.39%) , extradural haemorrhage (133 patients ~ 8.47%), intracerebral haemorrhage (117 patients ~ 7.45%), diffuse axonal injury (96 patients ~ 6.11%), cervical spine injury (55 patients ~ 3.50%), subarachnoid haemorrhage (54 patients ~ 3.44%), intraventricular haemorrhage (35 patients ~ 2.23%) and hydrocephalus (28 patients ~ 1.78%). The rest of the patients had more than one type of CNS insult. On analysing the mortality in different age-groups, highest mortality was noted in the young adults of 21-30yrs of age (108~17.88%). Patients aged 21-60 yrs had higher mortality as compared to other age-groups. Fig. 7- Mortality in various age-groups On analysing the region of the body affected primarily on admission, maximum mortality was seen with patients admitted for traumatic brain injury (306~50.66%). Fig. 8- Mortality based on the type of primary injury On further analysing the patients with central nervous system injuries (with or without other injuries), patients with only cerebral contusion as the diagnosis had the maximum mortality (123~20.36%) followed by Subdural haemorrhage (66~10.93%), intracranial haemorrhage (57~9.44%), diffuse axonal injury (36~5.96%), extradural haemorrhage (34~5.63%) and cervical spine injury (20~3.31%). Fig. 9- Mortality based on the type of Central Nervous System injury When we grouped the patients into different age-groups to compare the durations of intensive care unit stay, the mean and median values between groups were found to be similar, ignoring the outliers contributing to the vast differences in standard deviations for the mean values. AGE GROUPS (years) LENGTH OF ICU STAY (days) MEAN ± SD MEDIAN 0-10 9.96±11.871 6 11-20 10.85±17.092 7 21-30 12.079±9.554 8 31-40 11.664±10.771 7 41-50 11.13±7.226 7 51-60 11.306±21.881 7 61-70 10.203±11.619 7 71-80 10.543±12.523 8 81-90 9.0±7.992 7 >91 8.0±0 8 Total 11.19±22.71 7 Table 2- Age-group wise average lengths of ICU stay On calculating the average lengths of stay depending on the primary region of the body traumatised, FMI+ABI (21±4.88) and all spinal injuries (21.34±18.65) had the maximum durations of stay in the ICU followed by TBI+SI (18.8±19.76), TBI+CI (18.08±17.45), TBI+ABI (16.89±3.50) and TBI+LI (14.24±18.67). Others had relatively lesser lengths of ICU care. The median length of stay, though, was the highest for TBI+SI (21) while others standing much lower. Fig. 10 and 11- Mean and Median average lengths of ICU stay depending on the primary region of the body traumatised On calculating certain hospital utilisation statistics, since the total beds avaialble for a year were 9855, average length of stay of the patients in 2018 was found to be 146.84 days and 160.32 days for 2019. The Bed occupancy rate for 2018 was found to b 1.489 while for 2019 it was 1.627. The bed turnover rate for 2018 was 3.679 while it was 3.688 for 2019. Fig. 12- Average lengths of ICU stay of patients, monthwise for each year The general trend in 2018 shows an increase in the average length of stay from January to July, followed by a decrease towards the end of the year. In 2019, there is a fluctuating pattern, with some months showing an increase and others a decrease in the average length of stay compared to the previous year. There are variations in the average length of stay for the same month between 2018 and 2019. December shows a significant increase in 2019 compared to 2018 (11.29 to 17.63). Similarly, January, February and August 2019 also show a substantial increase compared to 2018. August 2018 appears to have a relatively lower average length of stay compared to the surrounding months in both years. December 2019 stands out as having a notably higher average length of stay compared to the other months in 2019. There seems to be variability in the average length of stay across different months within each year. In both years, the summer months (June, July) generally have longer average stays compared to the winter months (January, December). Fig. 13- Average daily census for 2018 and 2019 On analysing, the differences in the average daily census between 2018 and 2019 are relatively small. While there are fluctuations from month to month, the overall differences might not be considered significant in a broader context. This suggests a degree of stability or consistency in the average daily census over the two years, with no drastic changes. Monthly values fluctuate, indicating changing patterns in the number of individuals present on an average, each day.

The burden of injuries and the deaths resulting thereof, is being recognized as a public health problem accounting for 12% of all deaths in India. Road traffic accidents are the 8th leading cause of death globally and the leading cause of death for youngsters aged 15– 29 years. Globally, the number of road traffic deaths each year remains unacceptably high at almost 1.24 million per year. Eighty per cent of road traffic deaths occur in middle-income countries like India, which account for 72% of the world’s population. The middle-income countries bear a disproportionately high burden of road traffic deaths compared to their level of motorization. Current trends suggest that by 2030, road traffic deaths shall become the 5th leading cause of death unless urgent action is taken.5,6,7 Mortality after trauma generally shows a trimodal pattern, consisting of immediate deaths (within the first hour), early deaths (during the first 24 hours) and late deaths(after the first day).8 Severe traumatic injuries are life-threatening and require crucial admission to the Intensive Care Unit (ICU). In-hospital mortality of trauma patients admitted to the ICU is related to severe brain injury and multi-organ failure. Information National Crime Records Bureau reveals that nearly 5,00,000 deaths occur yearly due to injuries and one-third of them are due to RTA. But, the official numbers are under-reported. In a nationally representative mortality survey of 1.1 million homes, it was estimated that nearly 1 million injury deaths occur every year and 60% of them had TBI. 9-13 In our retrospective study, similar to various other studies including registry data from western countries14,15, majority of patients were males (74.22%). As per analysis, sex distribution did not have any particular impact on outcome of RTA/TBI patients but it is worthy to note that majority of RTA/TBI affected population was male. This maybe correlated to the Indian scenario where males work outdoors more as compared to the women. According to the recent analysis by Dindi K. et al (2019)7 on the epidemiology of RTIs in India, mortality was highest among the most productive age group, viz. 25–65 years (53.4%) and 15–24 years (32.5%). Deaths among male road accident victims (85.2%) were higher than females (14.8%). Similar trends15 were noted in many other studies, viz., Verma et al, Shekhar et al.and Singh et al16,17,18 Certain western registry data showed maximum admissions (and mortality) of the older age group.14 In our study, maximum mortality was in the age group of 11-60 years (29.09%) of age, especially, 21-30 years age group (6.88%) out of the total mortality of 38.44% which is comparable with the data from other developing countires19 but the western data from developed countries shows lesser mortality.14 This might be majorly due to the differences in the pre-hospital care among the regions. India is leading the world in fatalities due to road traffic accidents. TBI is associated with noteworthy socioeconomic losses in developing countries including India especially due to rapid surge in urbanization, motorization and economical development.20 Outcome in trauma, including TBI, depends on patient factors like age, comorbidities, baseline physiology; injury factors (severity, mechanism, polytrauma, hypotension, hypoxia), TBI-specific factors (GCS, pupils, CT findings, intracranial pressure, secondary insults), pre-hospital care including transport quality, hospital care and rehabilitation measures. In the current study, maximum number of admissions, deaths and discharges were in patients with traumatic brain injury as the primary trauma with a mortality of 50.66%. With respect to the central nervous system injury, maximum patients had cerebral contusions (17.31%) followed by subdural haemorrhage (11.39%) and extradural haemorrhage (8.47%); the mortality in CNS injuries was maximum with cerebral contusion (20.36%) followed by Subdural haemorrhage (10.93%) and intracranial haemorrhage (9.44%). Chico-Fernández M et al14 in their prospective, multicenter registry reported that 64.9% patients of severe trauma disease admitted to ICU had Head injury/TBI, overall ICU length of stay of about 5 days and an overall ICU mortality of 12.3%. Ong AW et al21 in their 7-year retrospective study of Trauma ICU admissions, reported that patients with ICU length of stay > 30 days were mostly elderly (>65 years and associated with higher mortality) and severely injured (Injury severity score 28.4 ± 13.1 (Median = 26.0). In the present study, depending on the primary region of the body traumatised, facio-maxillary injuries with abdominal injuries (21±4.88) and all spinal injuries (21.34±18.65) had the maximum durations of stay in the ICU. We observed a mean ICU length of stay of 11.19±22.71 (median- 7) days with a maximum in the age group 51-60 years of 11.306±21.881 days. The findings did not correlate significantly with a particular age-group. Toptas M et al22 and Böhmer AB23 also in their study found organ dysfunctions and metabolic derangements as major determinants of prolonged ICU stay with age correlation being non-significant. Hence, treatment regimens, as well as secondary effects and complications of trauma and intensive care treatment are the major determinants of ICU length of stay. Shekhar C et al17 in their study, noticed male and younger age-group preponderance with duration of hospital stay of 4-7 days. On CT scan, they noted, brain contusion and subdural hematoma (SDH) in 26% cases, contusion and SDH in 15% cases, Skull fracture in 13% cases, brain contusion in 10% and pneumocephalus in 3% cases of TBI. Chalya PL et al19 in their study, again noted a male and younger age preponderance, overall ICU length of stay (LOS) for all trauma patients from 1 to 59 days (median = 8 days), median ICU length of hospital stay (LOS) for survivors and non-survivors as 8 and 5 days respectively (P = 0.002) and a mortality rate of 32.7%. The Head/neck injuries were the maximum (95.5%) followed by musculoskeletal (extremities) injuries (34.6%), chest injuries (26.3%), abdomen injuries (19.9%), pelvis injuries (4.5%), spine injuries (2.6%) and genitalia injuries (1.3%). Their results were similar to what we got in our study. In the current study, with respect to the Bed occupancy rate, the general trend in 2018 showed an increase in the average length of stay from January to July, followed by a decrease towards the end of the year. In 2019, there was a fluctuating pattern, with some months showing an increase and others a decrease in the average length of stay compared to the previous year. There was variability in the average length of stay across different months within each year. In both years, the summer months (June, July) generally had longer average stays compared to the winter months (January, December).The average daily census between 2018 and 2019 are relatively small. While there are fluctuations from month to month, the overall differences might not be considered significant in a broader context. The difference in the mortality rates between 2018 and 2019 can be explained by the Covid-19 pandemic causing increased severity of illnesses and mortality. We did not include the positivity status for Covid-19 in our study or the severity scores at presentation of the patient to the emergency department, due to lack of data. This limits our ability to corroborate and explain the difference in the mortality rates between the two years. Recommendations: 1. Considering that high proportion of RTI victims were young drivers, School road safety awareness programme should be frequently conducted alongwith enforcement of use of seat belts and helmets and penalties for drunken driving and mobile use while driving. 3. Strengthening pre hospital care and ambulance services. Strengths Severe trauma disease is a leading cause of mortality, morbidity, disability and socioeconomic losses in the Indian subcontinent. There is a lack of dependable data alongwith Registries. We attempted to build up a basic data set at our tertiary centre and stimulate detailed archiving with formation of Registries which will also enable secondary correlation analyses. The results from the study can be used for institutional audit and quality control purposes. Limitations We had several limitations. This was a single-center study and we cannot generalize our findings for other trauma centres and all other settings of our country. The patient information archiving (pre-ICU admission, status at admission and ICU course) should be detailed for better analyses.

Road traffic accidents related morbidity and mortality are a significant public health problem worldwide and require appropriate attention from researchers and policy-makers through the development of surveillance programs and the implementation of effective evidence-based interventions. By improving our system and better monitoring of the reality of healthcare with better reporting and documentation of cases, i.e., Trauma registry, we shall be able to plan timely appropriate multimodality approaches to achieve better outcome of cases within our limited resources. Trauma registries can fully monitor the severe trauma disease care pro-cess and will also help to monitor the epidemiological trends, promote public health and induce designing of individualized intervention plans with optimization of resources.

1. Joshipura MK. Trauma care in India: current scenario. World journal of surgery. 2008 Aug;32(8):1613-7. 2. Indian society of trauma and acute care 3. Peden M, Sminkey L. World Health Organization dedicates World Health Day to road safety.Inj Prev 2004; 10:67. 4. Murray CJ, Lopez AD: Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 1997; 349:1269–76 5. Dandona R, Kumar GA, Gururaj G, James S, Chakma JK, Thakur JS, Srivastava A, Kumaresh G, Glenn SD, Gupta G, Krishnankutty RP. Mortality due to road injuries in the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Public Health. 2020 Feb 1;5(2):e86-98. 6. World Health Organization, Global Status Report on Road Safety, Supporting a Decade of Action, 2013. 7. Dindi K, Bachani D, Singhal M, Singh AR. Road traffic injuries: epidemiology, challenges and initiatives in India. The National medical journal of India. 2019 Mar 1;32(2):113. 8. Pfeifer R, Tarkin IS, Rocos B, et al. Patterns of mortality andcauses of death in polytrauma patients ---- has anything changed?Injury. 2009;40:907---11. 9. European Association for Injury Prevention andSafety Promotion (EuroSafe). Injuries in the Euro-pean Union, Summary of injury statistics for theyears 2010---2012; 2014. Amsterdam, The Netherlands.Available at: http://www.eurosafe.eu.com/uploads/inline-files/IDB Report 2014 final%202010-2012.pdf. 10. Ulvik A, Wentzel-Larsen T, Flaatten H. Trauma patients in theintensive care unit: short- and long-term survival and predictorsof 30-day mortality. Acta Anaesthesiol Scand. 2007;51:171---7. 11. Brattstrom O, Granath F, Rossi P, et al. Early predictors of mor-bidity and mortality in trauma patients treated in the intensivecare unit. Acta Anaesthesiol Scand. 2010;54:1007---17. 12. Frutiger A, Ryf C, Bilat C, et al. Five years’ follow-up of severelyinjured ICU patients. J Trauma. 1991;31:1216---25, discussion25---26. 13. AMERICAN ASSOCIATION OF PHYSICIANS OF INDIAN ORIGIN – Traumatic Brain Injury – 3rd Edititon – pg. no. 13 14. Chico-Fernández M, Llompart-Pou JA, Guerrero-López F, Sánchez-Casado M, García-Sáez I, Mayor-García MD, Egea-Guerrero J, Fernández-Ortega JF, Bueno-González A, González-Robledo J, Servià-Goixart L. Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase. Medicina Intensiva (English Edition). 2016 Aug 1;40(6):327-47. 15. Abhilash KP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. Journal of family medicine and primary care. 2016 Jul 1;5(3):558-63. 16. Verma PK, Tewari KN. Epidemiology of Road Traffic Injuries in Delhi: Result of a survey: Regional health forum. WHO South-East Asia Region. 2004;8:1–10.epidemiology, challenges and initiatives in India. The National medical journal of India. 2019 Mar 1;32(2):113. 17. Shekhar C, Gupta LN, Premsagar IC, Sinha M, Kishore J. An epidemiological study of traumatic brain injury cases in a trauma centre of New Delhi (India). Journal of emergencies, trauma, and shock. 2015 Jul;8(3):131. 18. Singh A, Jena R, Pal R, Munivenkatappa A, Reddy V, Hegde K, Kumar S, Agrawal A. Morbidity audit of 704 traumatic brain injury cases in a dedicated South Indian trauma center. Asian Journal of Neurosurgery. 2018 Sep;13(03):714-20. 19. Chalya PL, Gilyoma JM, Dass RM, Mchembe MD, Matasha M, Mabula JB, Mbelenge N, Mahalu W. Trauma admissions to the intensive care unit at a reference hospital in Northwestern Tanzania. Scandinavian journal of trauma, resuscitation and emergency medicine. 2011 Oct 24;19(1):61. 20. Puvanachandra P, Hyder AA. The burden of traumatic brain injury in Asia: A call for Research. Pak J Neurol Sci. 2009;4:27–32. 21. Ong AW, Omert LA, Vido D, Goodman BM, Protetch J, Rodriguez A, Jeremitsky E. Characteristics and outcomes of trauma patients with ICU lengths of stay 30 days and greater: a seven-year retrospective study. Critical care. 2009 Sep 24;13(5):R154. 22. Toptas M, Sengul Samanci N, Akkoc İ, Yucetas E, Cebeci E, Sen O, Can MM, Ozturk S. Factors affecting the length of stay in the intensive care unit: our clinical experience. BioMed research international. 2018;2018(1):9438046. 23. Böhmer AB, Just KS, Lefering R, Paffrath T, Bouillon B, Joppich R, Wappler F, Gerbershagen MU. Factors influencing lengths of stay in the intensive care unit for surviving trauma patients: a retrospective analysis of 30,157 cases. Critical Care