ANALYSIS OF ROAD TRAFFIC ACCIDENTS WITH MEDICAL CONSEQUENCES ON THE FEDERAL HIGHWAY M-8 "KHOLMOGORY" IN THE ARKHANGELSK REGION A.V. Baranov
Northern State Medical University, Arkhangelsk, Russia
Cherepovets State University, Cherepovets, Russia
Having all signs of world pandemic, and taking one of the leading places in all-cause mortality, road traffic accident rate is the actual social and medical problem of the modern time [1-3]. Patients with severe polytrauma present the most complex category in road traffic injuries [4-8]. The main road of the North is the federal automobile road (FAR) M-8 "Kholmogory". It begins in Arctic in Severodvinsk, and passes from the North to the South through the whole Arkhangelsk region − the biggest region of the European part of the Russian Federation. This road has some features of all northern roads: long length, big distances between hospitals, low visibility due to climatic and geographic features of the North, resulting in high risk of road traffic accident (RTA) with medical consequences, with influence on quality and timeliness of medical care for victims [9-11].
Objective − to analyze road traffic accidents with medical consequences on the federal highway M-8 "Kholmogory" in the Arkhangelsk Region.
MATERIALS AND METHODS
906 medical records of patients injured in RTA and urgently treated in hospitals (form 003/u) of Arkhangelsk region in the period from January 1, 2012 to December 31, 2018 were selected.
Inclusion criteria:
1) male and female gender;
2) patients injured in RTA on FAR M-8 "Kholmogory" in Arkhangelsk region, treated in hospitals;
3) RTA injuries in 2012-2018.
Exclusion criteria:
1) patients at the age < 18;
2) no previous injuries in RTA.
Severity of injuries was estimated with ISS (S. Baker, 1974). This score supposes distribution of the body into six regions: 1) the head and neck; 2) the face; 3) the chest; 4) abdomen; 5) extremities and pelvis; 6) skin and soft tissues. An injury to each region was estimated with 5-point score. Scores of 3 maximally injured regions were squared and summed. The final result was the score.
Statistical preparation of the data was conducted with SPSS 22. It included testing of the hypothesis on concordance of empirical distribution to normal distribution law with use of Kolmogorov-Smirnov test. The pattern of distribution in all groups differed from the normal one. Therefore, the received quantitative data was presented as the median, and 25 % and 75 % quartiles. Mann-Whitney test was used for accept or reject of the null hypothesis. Kraskell-Wallis test was used for comparison of more than two groups. The identified intergroup differences were statistically significant at p < 0.05 with Bonferroni correction (for multiple comparisons).
The study was conducted in compliance with ethical standards of Helsinki Declare. The study protocol No. 08/11-17 from November 29, 2017, was approved by the expert biomedical ethics board of Northern State Medical University (Arkhangelsk, Russia).
RESULTS
The decrease in the rate of RTA with medical consequences and in number of victims and deceased from RTA was found in Arkhangelsk part of FAR M-8 "Kholmogory" (Fig. 1).
Figure 1
Time course of road traffic accidents with medical consequences, the number of victims and deceased on the federal road M-8 "Kholmogory" in Arkhangelsk region for 2012-2018, abs.
Note: :* – p < 0.001 (2012 vs. 2018),
** – p < 0.01, deceased (2014 vs. 2018).
Knowledge of causes and circumstances of injuries is important for realization of timely and qualitative diagnosis of RTA-related injuries to perform efficient medical care at all stages of transportation. The following categories of victims were separated for M-8 "Kholmogory": pedestrians injured in RTA − 269 (29.7 %) persons; drivers of motor vehicles − 274 (30.2 %); passengers − 249 (27.5 %); motorcyclists − 114 (12.6 %).
Male drivers were injured more often than women (p = 0.001). Pedestrians were older (p < 0.001), and motorcyclists were younger than other victims − 29 years [24; 37]. An increase in proportion of injured pedestrians by the moment of 2018 was noted in comparison of proportion of RTA victims on FAR M-8 "Kholmogory" in dependence on injury circumstances in 2012-2018 (p < 0.001) (Fig. 2).
Figure 2
The structure of victims of road traffic accidents on the federal road M-8 "Kholmogory" in dependence on their categories in 2012-2018, %
Note: * – for p < 0.001, comparison of percentage ratio of pedestrians for 2013-2018;
** – for p = 0.002, comparison of percentage ratio of passengers for 2015-2018.
Comparison of percentage ratio between years was conducted in pair manner with χ2 and Bonferroni correction.
P < 0.0024 was considered as statistically significant level in paired comparisons.
A decrease in proportion of passengers to minimal values (19.4 %) was observed in 2018 (p = 0.002). There were not any significant differences in time course of car drivers and motorcyclists for the studied period. However, the amount of motorcyclists achieved the minimal level (8.3 %) in 2018 for the whole studied period.
For systematization and analysis, all road traffic injuries were distributed into the following categories:
1) patients with single injuries;
2) patients with multiple injuries − several injuries in an anatomic region;
3) patients with associated injuries (polytrauma) in several anatomic regions.
Single injuries were identified in 207 (22.8 %) patients, multiple injuries − in 124 (13.7 %), concomitant injuries − in 575 (63.5 %). Such high percentage of severe concomitant injuries can be explained by the fact that all RTA were on the federal road with high velocity, i.e. it means the probability of high energy injuries to the whole body. There were more men in all studied groups (p < 0.001).
It was found that the highest proportion of severe concomitant and multiple injuries was in drivers (81 %). It is explained by the fact that the driver's seat was one of the most dangerous. The highest proportion of more mild and favorable prognosis of single injuries was in patients injured in accidents with motorcycles (27.2 %). It can be associated with relatively low speed of a motorcycle, and with lower proportion of accidents with motorcycles.
The mean value of ISS in patients with single injuries was 4 [4; 9] points, for multiple injuries − 9.5 [6; 16] points, for concomitant injuries (polytrauma) − 14 [8; 24] points (p < 0.001).
Comparison of severity of injuries on FAR M-8 "Kholmogory" showed higher severity of injuries in men (p = 0.035): ISS = 11 [6; 20]; ISS in women was 9 [4; 17].
The analysis of polytrauma severity on the basis of a category of patients showed the lowest ISS in car passengers − 9 [4; 5; 17]; the second place was taken by drivers − 10 [5; 21] and pedestrians − 10 [6; 20]; the highest score was in motorcyclists − 11 [5.75; 19.25].
The analysis of accident site showed that more severe RTA-related injuries (p < 0.001), with mean ISS of 12 [6; 21], happened on the part of FAR M-8 "Kholmogory" in Severodvinsk medical district. This fact can be explained by qualitative road coverage on the road between Severodvinsk and the regional center of Arkhangelsk, with high velocity of vehicles. The second place according to ISS was taken by the pat of the road in Velsk medical district − 11 [5; 19.75]. ISS showed the lowest level in the part of the road in Arkhangelsk medical district − 9 [4; 14] points.
The results of the analysis of the features of road traffic accident rate on FAR M-8 "Kholmogory" in Arkhangelsk region are:
− a trend to a decrease in amount of RTA with medical consequences (p < 0.001), in number of victims (p < 0.001) and deceased (p < 0.01) as result of road traffic injuries in the studied territory with the registered minimal values in 2018;
− the studied 7-year course of RTA showed an increase (p < 0.001) in proportion of pedestrians to 43.3 %, and a decrease in passengers of motor vehicles (p = 0.002) in 2018;
− severity of condition in patients with concomitant injury was higher (p = 0.001) than in patients with multiple or single injuries: ISS = 14 [8; 24] with predominance of men (p < 0.001) in all categories;
− the most severe injuries (p < 0.001) in RTA were on the part of FAR M-8 "Kholmogory" in Severodvinsk medical district, with average score of 12 [6; 21] points. ISS showed the lowest level in Arkhangelsk medical district − 9 [4; 14] points;
− the least severe injuries according to ISS were in car passengers − 9 [4.5; 17] points, the most severe injuries − in motorcyclists − 11 [5.75; 19.25] points;
− male car drivers and motorcyclists are injured more often (p = 0.001), pedestrians were older (p > 0.001), and motorcyclists were younger (p < 0.001) than other victims.
CONCLUSION
The described situation on FAR M-8 "Kholmogory" in Arkhangelsk region requires for improvement and optimization of medical care arrangement for RTA victims, as well as development of new models, especially for harsh conditions of Russian Arctic. The main aim of such complex approach to arrangement of medical care and treatment of RTA victims is a decrease in mortality, and maximal prevention of disability during management process. For realization of the above-mentioned aim, the Government of Arkhangelsk region passed some draft laws determining the directions for preservation of human potential of the Russian North:
− the Order of Government of Arkhangelsk region on June 18, 2019, No. 321-pp "About Confirmation of Strategy for Development of Sanitary Aviation in Arkhangelsk region till 2024", with the principles of distribution of Arkhangelsk region into medical districts with main regional medical facilities (level 1 and 2 trauma centers) responsible for specific parts of FAR and regional roads to increase the efficiency of patient transportation.
− the Regional Project of Government of Arkhangelsk region − "Development of System for Arrangement of Primary Medical Sanitary Aid till 2024".
− Connection of the Arkhangelsk regional clinical station of emergency aid and Territorial center of disaster medicine of Arkhangelsk region in 2019. It improved cooperation between mobile divisions of disaster medicine service and similar divisions of departmental healthcare and other urgent and operative services. It determined the conditions for creation and operative activation of special emergency medical teams to the accident site to arrange emergency care.
− the Concept for development of disaster medicine service of Arkhangelsk region is being created. It includes the following offers: improvement in professional skills of persons who deal with primary care for RTA victims; training of emergency medical teams and disaster medicine teams to arrange medical care for RTA victims, including patients with severe polytrauma; optimization of standards for arrangement of prehospital medical care, with consideration of conditions of Arctic; extension of practical training of employees of dispatcher services at the moment of receiving of information on RTA and other emergency situations, fast analytic estimation and development of optimal solution for correction of medical and sanitary consequences; realization of regular command complex trainings; update of transport park for aviation medical evacuation of RTA victims, and expansion of possibilities for arrangement of elements of specific medical care during transportation process that is very important for remote and extensive territories of the Russian Arctic.
According to our opinion, these offers are the most important ways for improvement in medical care arrangement system for RTA victims; their realization can decrease mortality and disability in Arkhangelsk region and increase the rapidness, efficiency and quality of arrangement of care.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.