Nobhojit Roy1, Martin Gerdin2, Eric Schneider3, Deepa K Kizhakke Veetil4, Monty Khajanchi5, Vineet Kumar6, Makhal Lal Saha7, Satish Dharap8, Amit Gupta9, Göran Tomson10, Johan von Schreeb11. 1. Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden; BARC Hospital (Govt of India), HBNI University, Mumbai, India. Electronic address: nobsroy@gmail.com. 2. Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden. Electronic address: martin.gerdin@ki.se. 3. Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02120, USA. Electronic address: eschnei1@jhmi.edu. 4. Department of General Surgery, King Edward Memorial Hospital, Mumbai, India. Electronic address: deepu2315@yahoo.co.in. 5. BARC Hospital (Govt of India), HBNI University, Mumbai, India. Electronic address: monta32@gmail.com. 6. Department of General Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India. Electronic address: drvineetkumar@gmail.com. 7. Department of Surgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, India. Electronic address: drmlsaha@yahoo.com. 8. Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai,India. Electronic address: drdharap@hotmail.com. 9. Department of Surgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. Electronic address: amitguptaaiims@gmail.com. 10. Department of Learning, Informatics, Management & Ethics (LIME) and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. Electronic address: goran.tomson@ki.se. 11. Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden. Electronic address: Johan.Von.Schreeb@ki.se.
Abstract
INTRODUCTION: In the Lower-Middle Income Country setting, we validate trauma severity scoring systems, namely Injury Severity Score (ISS), New Injury Severity Scale (NISS) score, the Kampala Trauma Score (KTS), Revised Trauma Score (RTS) score and the TRauma Injury Severity Score (TRISS) using Indian trauma patients. PATIENTS AND METHODS: From 1 September 2013 to 28 February 2015, we conducted a prospective multi-centre observational cohort study of trauma patients in four Indian university hospitals, in three megacities, Kolkata, Mumbai and Delhi. All adult patients presenting to the casualty department with a history of injury and who were admitted to inpatient care were included. The primary outcome was in-hospital mortality within 30-days of admission. The sensitivity and specificity of each score to predict inpatient mortality within 30days was assessed by the areas under the receiver operating characteristic curve (AUC). Model fit for the performance of individual scoring systems was accomplished by using the Akaike Information criterion (AIC). RESULTS: In a registry of 8791 adult trauma patients, we had a cohort of 7197 patients eligible for the study. 4091 (56.8%)patients had all five scores available and was the sample for a complete case analysis. Over a 30-day period, the scores (AUC) was TRISS (0.82), RTS (0.81), KTS (0.74), NISS (0.65) and ISS (0.62). RTS was the most parsimonious model with the lowest AIC score. Considering overall mortality, both physiologic scores (RTS, KTS) had better discrimination and goodness-of-fit than ISS or NISS. The ability of all Injury scores to predict early mortality (24h) was better than late mortality (30day). CONCLUSION: On-admission physiological scores outperformed the more expensive anatomy-based ISS and NISS. The retrospective nature of ISS and TRISS score calculations and incomplete imaging in LMICs precludes its use in the casualty department of LMICs. They will remain useful for outcome comparison across trauma centres. Physiological scores like the RTS and KTS will be the practical score to use in casualty departments in the urban Indian setting, to predict early trauma mortality and improve triage.
INTRODUCTION: In the Lower-Middle Income Country setting, we validate trauma severity scoring systems, namely Injury Severity Score (ISS), New Injury Severity Scale (NISS) score, the Kampala Trauma Score (KTS), Revised Trauma Score (RTS) score and the TRauma Injury Severity Score (TRISS) using Indian traumapatients. PATIENTS AND METHODS: From 1 September 2013 to 28 February 2015, we conducted a prospective multi-centre observational cohort study of traumapatients in four Indian university hospitals, in three megacities, Kolkata, Mumbai and Delhi. All adult patients presenting to the casualty department with a history of injury and who were admitted to inpatient care were included. The primary outcome was in-hospital mortality within 30-days of admission. The sensitivity and specificity of each score to predict inpatient mortality within 30days was assessed by the areas under the receiver operating characteristic curve (AUC). Model fit for the performance of individual scoring systems was accomplished by using the Akaike Information criterion (AIC). RESULTS: In a registry of 8791 adult traumapatients, we had a cohort of 7197 patients eligible for the study. 4091 (56.8%)patients had all five scores available and was the sample for a complete case analysis. Over a 30-day period, the scores (AUC) was TRISS (0.82), RTS (0.81), KTS (0.74), NISS (0.65) and ISS (0.62). RTS was the most parsimonious model with the lowest AIC score. Considering overall mortality, both physiologic scores (RTS, KTS) had better discrimination and goodness-of-fit than ISS or NISS. The ability of all Injury scores to predict early mortality (24h) was better than late mortality (30day). CONCLUSION: On-admission physiological scores outperformed the more expensive anatomy-based ISS and NISS. The retrospective nature of ISS and TRISS score calculations and incomplete imaging in LMICs precludes its use in the casualty department of LMICs. They will remain useful for outcome comparison across trauma centres. Physiological scores like the RTS and KTS will be the practical score to use in casualty departments in the urban Indian setting, to predict early trauma mortality and improve triage.