This paper describes the three main steps for trauma registry implementation in a developing country; a- the process of development of the registry; b- affordability of its development and implementation and c- the challenges of the implementation of the software. The team of trauma experts and software developers took almost 2 years with a direct cost of USD: 9,600 to develop a functional trauma registry. The most critical test of the success of the effort was in the implementation of the registry in a real hospital based patient care scenario.
There is limited literature on TRs in developing countries [23–25]. Kampala Trauma Registry was developed to establish an injury surveillance system in Uganda . This was a paper based data collection system and attempted to demonstrate the feasibility of a trauma registry in limited resource setting. There was no electronic software and survival analysis was based on Kampala Trauma score (KTS). Similarly, a pilot test of trauma registry was undertaken in Haiti, utilizing a paper form for data collection and Epi Info® for data entry and analysis . The registry variables included mechanism of injury, Glasgow coma score, body region, treatment and investigations but did not anatomical injury scores. The Cape Town Trauma Registry was designed for middle-income setting with a spatial distribution of injury events using GIS mapping, for injury surveillance and control . The above examples are registries with serve as injury surveillance systems and focus on systematic data collection and analysis, with intent to defining issues in implementing a trauma registry in a low income setting. Other examples from LMIC attempted survival outcome comparison with the US Major Trauma Outcome Study  or creation of a database to record a particular type of injuries . A recent report from a high-income country in the Middle East described the process of converting a single centre registry into a multicenter database, which is hard to replicate in low-income settings .
Similar to other settings, we found four critical success factors for the implementation of trauma registry in our hospital. 1- The fundamental importance of good patient records, patient identification and documentation of all relevant information cannot be overstated. In settings with a paper-based health information system, there would be a need for creating a process of patient identification, data collection and follow-up. The most effective strategy to identify patients post-hoc in our settings was the ED triage where a system of identifying and separating trauma patients was likely to lead to most capture. 2- Training of personnel and availability of technical support to the staff [1, 3, 7]. 3- A third prerequisite is sustainable funding, which is by far the most common reason for the lack of a long-term implementation plan for a registry [1, 3, 7, 12]. 4- Finally, one of the most important factors which alone can impact these barriers is institutional buy-in from senior hospital management. This provides an impetus for enhancing the quality of trauma care, improves motivation and participation of the care providers, ensures confidentiality of data and protects from medico-legal aspects of providing care to the injured [12, 23–25, 29].
Data abstraction and case ascertainment from this pilot revealed some important factors which will impact the process of implementation at a larger scale. The coordinator based implementation model did not include direct contact with patients, attendants or health care providers. Potentially it may result in loss of information of some variables which are supposed to be a part of medical records, as in our experience. In those settings where electronic health records are not available, access to medical records can be difficult. The alternative method of provider based data collection may ensure a higher level of completeness but in high volume facilities this could be challenging and more expensive.
The study was done in a single tertiary-care academic institution with a electronic health information system, trauma team and round-the-clock availability of computed tomography (CT) and other diagnostic modalities. This setting may not reflect the reality of all private or public tertiary-care centres in Pakistan or in other developing countries. Wider, multi centre implementation studies would be needed to improve the data collection system and the implementation process.