Saksham Gupta1, Monty Khajanchi2, Vineet Kumar3, Nakul P Raykar4,5, Blake C Alkire6, Nobhojit Roy7,8, Kee B Park5. 1. 1Harvard Medical School, Boston, Massachusetts. 2. 2Department of Surgery, Seth G.S. Medical College and King Edward Memorial Hospital, Mumbai. 3. 3Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, India. 4. 4Department of Surgery, Beth Israel Deaconess Medical Center, Boston. 5. 5Program for Global Surgery and Social Change, Harvard Medical School, Boston. 6. 6Department of Otolaryngology, Massachusetts Eye and Ear Institute, Boston, Massachusetts. 7. 7National Health Systems Resource Centre (NHSRC), Ministry of Health & Family Welfare, Government of India, New Delhi; and. 8. 8WHO Collaborating Centre for Research on Surgical Care Delivery in LMICs, BARC Hospital, Mumbai, India.
Abstract
OBJECTIVE: Traumatic brain injury (TBI) is a global epidemic with an increasing incidence in low- and middle-income countries (LMICs). The time from arrival at the hospital to receiving appropriate treatment ("third delay") can vary widely in LMICs, although its association with mortality in TBI remains unknown. METHODS: A retrospective cohort analysis with multivariable logistic regression was conducted using the Toward Improved Trauma Care Outcomes in India database, which contains data from 4 urban trauma centers in India from 2013-2015. RESULTS: There were 6278 TBIs included in the cohort. The patients' median age was 39 years (interquartile range 27-52 years) and 80% of patients were male. The most frequent mechanisms of injury were road traffic accidents (52%) and falls (34%). A majority of cases were transfers from other facilities (79%). In-hospital 30-day mortality was 27%; of patients who died, 21% died within 24 hours of arrival. The median third delay was 10 minutes (interquartile range 0-60 minutes); 34% of cases had moderate third delay (10-60 minutes) and 22% had extended third delay (≥ 61 minutes). Overall 30-day mortality was associated with moderate third delay (OR 1.3, p = 0.001) and extended third delay (OR 1.3, p = 0.001) after adjustment by pertinent covariates. This effect was pronounced for 24-hour mortality: moderate and extended third delays were independently associated with ORs of 3.4 and 3.8, respectively, for 24-hour mortality (both p < 0.001). CONCLUSIONS: Third delay is associated with early mortality in patients with TBI, and represents a target for process improvement in urban trauma centers.
OBJECTIVE:Traumatic brain injury (TBI) is a global epidemic with an increasing incidence in low- and middle-income countries (LMICs). The time from arrival at the hospital to receiving appropriate treatment ("third delay") can vary widely in LMICs, although its association with mortality in TBI remains unknown. METHODS: A retrospective cohort analysis with multivariable logistic regression was conducted using the Toward Improved Trauma Care Outcomes in India database, which contains data from 4 urban trauma centers in India from 2013-2015. RESULTS: There were 6278 TBIs included in the cohort. The patients' median age was 39 years (interquartile range 27-52 years) and 80% of patients were male. The most frequent mechanisms of injury were road traffic accidents (52%) and falls (34%). A majority of cases were transfers from other facilities (79%). In-hospital 30-day mortality was 27%; of patients who died, 21% died within 24 hours of arrival. The median third delay was 10 minutes (interquartile range 0-60 minutes); 34% of cases had moderate third delay (10-60 minutes) and 22% had extended third delay (≥ 61 minutes). Overall 30-day mortality was associated with moderate third delay (OR 1.3, p = 0.001) and extended third delay (OR 1.3, p = 0.001) after adjustment by pertinent covariates. This effect was pronounced for 24-hour mortality: moderate and extended third delays were independently associated with ORs of 3.4 and 3.8, respectively, for 24-hour mortality (both p < 0.001). CONCLUSIONS: Third delay is associated with early mortality in patients with TBI, and represents a target for process improvement in urban trauma centers.
Entities:
Keywords:
GCS = Glasgow Coma Scale; HICs = high-income countries; IQR = interquartile range; ISS = Injury Severity Score; LMICs; LMICs = low- and middle-income countries; RTA = road traffic accident; TBI = traumatic brain injury; TITCO = Toward Improved Trauma Care Outcomes; developing countries; low- and middle-income countries; surgical access; third delay; trauma process metrics; traumatic brain injury
Authors: Tom Bashford; Alexis Joannides; Kamal Phuyal; Santosh Bhatta; Julie Mytton; Robert Harrison; Peter Hutchinson Journal: BMJ Glob Health Date: 2019-08-30