Prevalence of a definitive airway in patients with severe traumatic brain injury received at four urban public university hospitals in India: a cohort study.

AIM: To estimate the proportion of patients arriving with a Glasgow Coma Scale (GCS) less than 9 who had a definitive airway placed prior to arrival. METHODS: We conducted a retrospective analysis of the data from a multicentre, prospective observational research project entitled Towards Improved Trauma Care Outcomes in India. Adults aged ≥18 years with an isolated traumatic brain injury (TBI) who were transferred from another hospital to the emergency department of the participating hospital with a GCS less than 9 were included. Our outcome was a definitive airway, defined as either intubation or surgical airway, placed prior to arrival at a participating centre. RESULTS: The total number of patients eligible for this study was 1499. The median age was 40 years and 84% were male. Road traffic injuries and falls comprised 88% of the causes of isolated TBI. The number of patients with GCS<9 who had a definitive airway placed before reaching the participating centres was 229. Thus, the proportion was 0.15 (95% CI 0.13 to 0.17). The proportions of patients with a definitive airway who arrived after 24 hours (19%) were approximately double the proportion of patients who arrived within 6 hours (10%) after injury to the definitive care centre. CONCLUSION: The rates of definitive airway placement are poor in adults with an isolated TBI who have been transferred from another health facility to tertiary care centres in India.

A multicenter observational cohort study of 24 h and 30 day in-hospital mortality of pediatric and adult trauma patients - An Indian urban tertiary care perspective.

BACKGROUND/PURPOSE: India with its evolving trauma system needs multicenter studies on trauma outcomes to help determine the need for planning and structuring care better and to bridge the gap between the burden of disease and research. Therefore here we studied 24 h and 30 day mortality in adult and pediatric trauma population presenting to urban tertiary care hospitals. METHODOLOGY: Data from multicenter observational cohort study conducted from July 2013 to December 2015, Towards improved trauma care outcomes in India (TITCO) were used. MAIN FINDINGS: 3381 pediatric and 12,666 adult trauma patients. Unadjusted analyses of mortality were significantly less in pediatric compared to adult group within 24 h (OR 0.513, 99% CI 0.4-0.658, p < 0.001) and 30 days (OR 0.442, 99% CI 0.383-0.511, p < 0.001). In adjusted analyses pediatric group did not have significantly lower odds of 24-h mortality (OR 0.778, 99% CI 0.106-5.717, P = 0.746). At 30 days, pediatric group had 89% lower odds of death compared to adults (OR 0.11, 99% CI 0.017-0.0714, p = 0.002). CONCLUSION: Children had mechanisms of injury different from adults leading to less severe injuries than adults. Children are more likely than adults to survive until 30 days after admission for trauma in urban India. LEVEL OF EVIDENCE: Level II.

Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths.

BACKGROUND: A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery. METHODS: All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI). RESULTS: During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging. CONCLUSION: Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.