Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study

Abstract

Background The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. MethodsIn this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63•8%) were men, and 14 524 (46•5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71•9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27•5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88•7%] of 195 patients with open fractures; 426 [44•7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47•7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50•5%]), while Second Delays ...

Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting

“…Quality has been found to be comparable to most higher income countries and is perhaps related to ambulance one hour availability nearly 100% of the time in Colombia [10]. However, large studies suggest Latin American countries may have some of the highest interfacility transfers in the world with an unknown impact on definitive surgical time [25].…”

“…A number of studies have utilized time to arrival to the nearest hospital i.e., first hospital, as representative of "timely access" to surgical care in LMICs [26,27]. To date, in the largest study of interfacility transfer and surgical disease to exist, Latin America had the highest delay of fracture care and the highest proportion of interfacility transfers [25,28]. There were concerning delays in admission to a hospital for fractures in the region, with 88�7% of open fracture, and 44�7% of closed fracture admissions delayed], with a significant association between such delays and interfacility transfer [25].…”

“…To date, in the largest study of interfacility transfer and surgical disease to exist, Latin America had the highest delay of fracture care and the highest proportion of interfacility transfers [25,28]. There were concerning delays in admission to a hospital for fractures in the region, with 88�7% of open fracture, and 44�7% of closed fracture admissions delayed], with a significant association between such delays and interfacility transfer [25]. However, it is unknown whether interfacility transfers are a cause or outcome of second (reaching care) or a third (receiving care) delay.…”

Association of clinical characteristics with decision making in patients with severe lower extremity trauma

“…The only study evaluating the delays to treatment of orthopedic injuries was performed by Pouramin et al, on behalf of the INORMUS investigators. This multinational, multicenter study involves a large cohort of patients, and focuses on delays to hospital admission, caused mainly by geographic or socioeconomic factors [14]. Even in comprehensive studies such as the Lower Extremity Assessment Project (LEAP) [8] or the study by de Mestral et al [15], data on the process from admission to definitive treatment is missing.…”

Influence of administrative factors on the effectiveness of health care delivery to victims with acute spine and spinal cord injuries: regional retrospective study as a base for improving national clinical guidelines

“…Вопросы выбора оптимального места, тактики и способа лечения пострадавших с позвоночно-спинномозговой травмой (ПСМТ) на сегодняшний день достаточно далеки от окончательного разрешения [1][2][3]. Основной причиной этого является то, что возможности полноценного (широкого, стабильного и эффективного) применения современного спектра технологий консервативного и, что наиболее важно, хирургического лечения довольно часто оказываются ограниченными особенностями организации системы оказания медицинской помощи [4,5]. Именно вследствие этого в нашей стране при разработке национальных клинических рекомендаций законодательно утверждена необходимость четкого регламентирования организационных вопросов оказания медицинской помощи [6].…”