Patient and process factors associated with opportunities for improvement in trauma care: a registry-based study.

BACKGROUND: Trauma is one of the leading causes of morbidity and mortality worldwide. Morbidity and mortality review of selected patient cases is used to improve the quality of trauma care by identifying opportunities for improvement (OFI). The aim of this study was to assess how patient and process factors are associated with OFI in trauma care. METHODS: We conducted a registry-based study using all patients between 2017 and 2021 from the Karolinska University Hospital who had been reviewed regarding the presence of OFI as defined by a morbidity and mortality conference. We used bi- and multivariable logistic regression to assess the associations between the following patient and process factors and OFI: age, sex, respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), survival at 30 days, highest hospital care level, arrival on working hours, arrival on weekends, intubation status and time to first computed tomography (CT). RESULTS: OFI was identified in 300 (5.8%) out of 5182 patients. Age, missing Glasgow Coma Scale, time to first CT, highest hospital care level and ISS were statistically significantly associated with OFI. CONCLUSION: Several patient and process factors were found to be associated with OFI, indicating that patients with moderate to severe trauma and those with delays to first CT are at the highest odds of OFI.

Profile and triage validity of trauma patients triaged green: a prospective cohort study from a secondary care hospital in India.

OBJECTIVES: To evaluate the profile of non-urgent patients triaged 'green', as part of a triage trial in the emergency department (ED) of a secondary care hospital in India. The secondary aim was to validate the triage trial with the South African Triage Score (SATS). DESIGN: Prospective cohort study. SETTING: A secondary care hospital in Mumbai, India. PARTICIPANTS: Patients aged 18 years and above with a history of trauma defined as having any of the external causes of morbidity and mortality listed in block V01-Y36, chapter XX of the International Classification of Disease version 10 codebook, triaged green between July 2016 and November 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures were mortality within 24 hours, 30 days and mistriage. RESULTS: We included 4135 trauma patients triaged green. The mean age of patients was 32.8 (±13.1) years, and 77% were males. The median (IQR) length of stay of admitted patients was 3 (13) days. Half the patients had a mild Injury Severity Score (3-8), with the majority of injuries being blunt (98%). Of the patients triaged green by clinicians, three-quarters (74%) were undertriaged on validating with SATS. On telephonic follow-up, two patients were reported dead whereas one died while admitted in hospital. CONCLUSIONS: Our study highlights the need for implementation and evaluation of training in trauma triage systems that use physiological parameters, including pulse, systolic blood pressure and Glasgow Coma Scale, for the in-hospital first responders in the EDs.

Glasgow coma scale compared to other trauma scores in discriminating in-hospital mortality of traumatic brain injury patients admitted to urban Indian hospitals: A multicentre prospective cohort study.

BACKGROUND: Glasgow Coma Scale (GCS) is one of the most commonly used trauma scores and is a good predictor of outcome in traumatic brain injury (TBI) patients. There are other more complex scores with additional physiological parameters. Whether they discriminate better than GCS in predicting mortality in TBI patients is debatable. The aim of this study was to compare the discrimination of GCS with that of MGAP, GAP, RTS and KTS for 24-hour and 30-day in-hospital mortality in adult TBI patients, in a resource limited LMIC setting. METHOD: We analysed data from the multicentre, observational trauma cohort Towards Improved Trauma Care Outcome (TITCO) in India. We included all patients 18 years or older, admitted from the emergency department with TBI. The Area Under the Receiver Operating Characteristic (AUROC) curve was used to quantify and compare the discrimination of all scores: GCS; Revised Trauma Score (RTS); mechanism, GCS, age, systolic blood pressure (MGAP); GCS, age, systolic blood pressure (GAP) and Kampala Trauma Score (KTS) in the prediction of 24-hour and 30-day in-hospital mortality. RESULTS: A total of 3306 TBI patients were included in this study. The majority were within the GCS range 3-8. The commonest mechanism of injury was road traffic injuries [1907(58.0%)]. In-hospital mortality was 27.2% (899). There was no significant difference in discrimination in 24-hour in-hospital mortality when comparing GCS with MGAP and GAP. While GCS performed better than KTS, RTS performed better than GCS. For 30-day in-hospital mortality, GCS discriminated significantly better compared with KTS, but there was no significant difference when compared to MGAP and RTS. GAP discriminated significantly better when compared with GCS. CONCLUSION: This study shows that the discrimination of GCS is comparable to that of more complex trauma scores in predicting 24-hour and 30-day in-hospital mortality in adult TBI patients in a resource limited LMIC setting.

Mortality from fall: A descriptive analysis of a multicenter Indian trauma registry.

INTRODUCTION: Fall is the second most common mechanism of trauma worldwide after road traffic injuries. Data on fall predominantly comes from the high-income countries (HICs) and mostly includes injuries in children and elderly. There are very few studies from low- and middle-income countries(LMICs) that describe fall related injuries other than fragility fractures in elderly. This study describes the profile of poly-trauma patients admitted with a history of 'fall' and assesses the variables associated with mortality. METHOD: We analyzed data from the 'Towards Improved Trauma Care Outcome' (TITCO) database which prospectively collected data of poly-trauma patients admitted to four major tertiary care hospitals of India between 2013 to 2015. Patients across all age groups admitted to hospital with the history of 'fall'; were included in our study. Single bone fractures were excluded.  The Kaplan Meier survival analysis was used to estimate the survival probability in different age groups. RESULTS: A total of 3686 patients were included in our study. The median age of the patients was 28 years (IQR: 9, 47) with the majority being males (73.6%). Almost one-third of the patients were within the age group of 0-14 (30.4%). Most of the patients (79.9%) had a diagnosis of traumatic brain injury (TBI). The overall in-hospital mortality was 18% (664), but higher at 39.0% among patients over 65 years of age. Probability of survival decreased with increase of age. CONCLUSION: Falling from height is a common injury mechanism in India, occurring more in young males and usually associated with TBI. Isolated TBI and TBI associated with other injuries are the main contributors of mortality in fall injuries. Mortality from these injuries increased with age and ISS.

Predicting mortality with the international classification of disease injury severity score using survival risk ratios derived from an Indian trauma population: A cohort study.

BACKGROUND: Trauma is predicted to become the third leading cause of death in India by 2020, which indicate the need for urgent action. Trauma scores such as the international classification of diseases injury severity score (ICISS) have been used with great success in trauma research and in quality programmes to improve trauma care. To this date no valid trauma score has been developed for the Indian population. STUDY DESIGN: This retrospective cohort study used a dataset of 16047 trauma-patients from four public university hospitals in urban India, which was divided into derivation and validation subsets. All injuries in the dataset were assigned an international classification of disease (ICD) code. Survival Risk Ratios (SRRs), for mortality within 24 hours and 30 days were then calculated for each ICD-code and used to calculate the corresponding ICISS. Score performance was measured using discrimination by calculating the area under the receiver operating characteristics curve (AUROCC) and calibration by calculating the calibration slope and intercept to plot a calibration curve. RESULTS: Predictions of 30-day mortality showed an AUROCC of 0.618, calibration slope of 0.269 and calibration intercept of 0.071. Estimates of 24-hour mortality consistently showed low AUROCCs and negative calibration slopes. CONCLUSIONS: We attempted to derive and validate a version of the ICISS using SRRs calculated from an Indian population. However, the developed ICISS-scores overestimate mortality and implementing these scores in clinical or policy contexts is not recommended. This study, as well as previous reports, suggest that other scoring systems might be better suited for India and other Low- and middle-income countries until more data are available.