Importance Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity.

Objective To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools.

Design, Setting, and Participants This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013.

Main Outcomes and Measures The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital.

Results The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11 612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n = 11 612) had statistically significant higher completion rates compared with paper records (n = 9236) (for all comparisons, P < .001). The eTHR successfully captured quality indicators recommended for trauma system evaluation which were previously challenging to collect in a timely and accurate manner. Of the 11 612 patient admissions over the study period, injury location was captured 11 075 times (95.4%), injury mechanism 11 135 times (95.9%), systolic blood pressure 11 106 times (95.6%), and Glasgow Coma Scale 11 140 times (95.9%). These fields were successfully captured with statistically higher rates than previous paper documentation. Epidemiologic analysis confirmed a heavy burden of violence-related injury (51.8% of all injuries) and motor vehicle crash injuries (14.3% of all injuries). Mapping analysis demonstrated clusters of injuries originating mainly from vulnerable and low-income neighborhoods and their respective referring trauma facilities, Mitchell’s Plain Hospital (734 [10.1%]), Guguletu Community Health Center (654 [9.0%]), and New Somerset Hospital (400 [5.5%]).

Conclusions and Relevance Accurate capture and simultaneous analysis of trauma data in low-resource trauma settings are feasible through the integration of surveillance into clinical workflow and the timely analysis of electronic data.

重要性 收集和分析最新，准确的伤害监测数据是创伤系统成熟的关键一步。由于创伤数量，成本和复杂性的负担，事实证明在中低收入国家很难建立创伤登记处。

目的 确定医生使用的电子创伤健康记录（eTHR）是否可以用作同时的临床文档和数据采集工具。

设计，设置和参加者 这项由两部分组成的质量改进研究包括：（1）eTHR的实施前和实施后，对41位外科医生的满意度，完成时间以及与纸质图表和电子海图进行比较收集的数据质量进行评估；（2）前瞻性生态学研究描述了在一级创伤中心发现的创伤负担，该研究使用了eTHR在12个月研究期内连续患者的实时数据。该研究于2010年10月1日至2011年9月30日在南非开普敦的Groote Schuur医院进行。数据分析时间为2011年10月15日至2013年1月15日。

主要成果和措施 第一部分的主要成果是通过电子或书面文件获得的有关创伤登记册项目的数据领域竞争率。第2部分的主要措施是确定开普敦创伤的危险因素以及Groote Schuur医院建议用于创伤系统评估的质量指标。

结果 研究中包括的41位医生发现电子病历更有效，更可取。准确记录并及时分析了总共11612个创伤表现。与纸质记录（n = 9236）相比，eTHR中与伤害监测相关的字段（n = 11 612）在统计学上具有较高的完成率（对于所有比较，P <.001）。eTHR成功捕获了推荐用于创伤系统评估的质量指标，这些指标以前难以及时准确地收集。在研究期间的11612名患者中，受伤部位被记录了11 075次（95.4％），受伤机制11 135次（95.9％），收缩压11106次（95.6％）和格拉斯哥昏迷量表11 140次（95.9％）。这些字段以比以前的书面文档更高的统计率成功地被捕获。流行病学分析证实，暴力相关伤害（占所有伤害的51.8％）和机动车碰撞伤害（占所有伤害的14.3％）负担很重。测绘分析显示，伤害群主要来自脆弱和低收入社区以及他们各自提到的创伤设施，

结论和相关性 通过将监视集成到临床工作流程中并及时分析电子数据，在资源贫乏的创伤环境中准确捕获和同步分析创伤数据是可行的。