Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa

Abstract

Introduction Traumatic injuries account for the greatest portion of global surgical burden particularly in low-and middle-income countries (LMICs). To assess effectiveness of a developing trauma system, we hypothesize that there are survival differences between direct and indirect transfer of trauma patients to a tertiary hospital in sub Saharan Africa. Methods Retrospective analysis of 51,361 trauma patients within the Kamuzu Central Hospital (KCH) trauma registry from 2008 to 2012 was performed. Analysis of patient characteristics and logistic regression modeling for in-hospital mortality was performed. The primary study outcome is in hospital mortality in the direct and indirect transfer groups. RESULTS There were 50,059 trauma patients were included in this study. 6,578 patients transferred from referring facilities and 43,481 patients transported from the scene. The indirect and direct transfer cohorts were similar in age and sex. The mechanism of injury for transferred patients was 78.1% blunt, 14.5% penetrating, and 7.4% other, whereas for the scene group it was 70.7% blunt, 24.0% penetrating, and 5.2% other. Median times to presentation were 13(4–30) and 3(1–14) hours for transferred and scene patients, respectively. Mortality rate was 4.2% and 1.6% for indirect and direct transfer cohorts, respectively. A total of 8816 patients were admitted of which 3636 and 5963 were in the transfer and scene cohort, respectively. After logistic regression analysis, the adjusted in-hospital mortality odds ratio was 2.09 (1.24–3.54);p=0.006 for indirect transfer versus direct transfer cohort, after controlling for significant covariates. Conclusions Direct transfer of trauma patients from the scene to the tertiary care center is associated with a survival benefit. Our findings suggest that trauma education and efforts directed at regionalization of trauma care, strengthening pre-hospital care and timely transfer from district hospitals could mitigate trauma-related mortality in a resource-poor setting.

Health system factors associated with post-trauma mortality at the prehospital care level in Africa: a scoping review

“…Direct referral from the scene to a trauma care facility was the most common referral type compared with indirect referral at the prehospital care level. 1 22 24 In Malawi, Boschini et al 22 examined the relationship between referral pathways and post-trauma mortality and found direct referral from injury scene to a specialized trauma care facility to be significantly associated with post-trauma mortality (p=0.006). Indirect transfer was found to be a mortality risk for severe trauma cases due to cases of delays and limited capacity to provide quality critical care in lower level facilities.…”

“…24 In Malawi, transport by non-ambulance means such as private vehicles was also found to confer significant survival benefits as a result of prompt evacuation to a treatment facility and reduction of delays to life-saving interventions. 22 None of the studies examined possible differences in post-trauma mortality based on ambulance ownership, public and private ambulance transport.…”

“…At the injury scene in low-resource countries, trauma patients are less likely to receive any basic life support (BLS) care such as first aid and are thus transferred to the nearest hospital by untrained lay responders. 12 22 23 According to Boschini et al , 22 direct transfer of trauma patients from the scene to the trauma center may confer a survival advantage by reducing time spent in referrals from peripheral hospitals. While this indirectly supports the value of the golden hour and ambulance transport in trauma distress responses, other studies refute this finding due to lack of strong evidence.…”

Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia

“…Inappropriate inter-facility ambulance use for patients deemed low-acuity after clinician evaluation offers few benefits over lay transportation, while limiting ambulance availability in higher-acuity settings elsewhere. When ambulances are free to respond in a timely fashion to high-acuity patients, a greater proportion of these patients may be brought directly from the scene to trauma centers like AaBET Hospital, bypassing outside institutions with little or no trauma expertise and improving mortality [ 33 ]. In our study, 103 low-acuity patients received ambulance transport from another facility (40% of all referred patients transported by ambulance), while one third (40) of high- and moderate-acuity patients arrived from the scene by other means (Additional file 1 : Table S1 and Additional file 2 : Table S2).…”

Medical demographics in sub-Saharan Africa: Does the proportion of elderly patients in accident and emergency units mirror life expectancy trends?

“…Regionalization of trauma systems will likely be necessary to provide injured patients with optimal care, especially for those presenting with severe injuries in the setting of preexisting medical conditions. [ 51 ] This process will require the development of sustainable, cost-effective multidisciplinary approaches that incorporate high-quality geriatric and critical care capabilities, as well as reliable access to emergency medical and surgical services. [ 52 53 ] Emergency and trauma providers accustomed to treating younger patients will need to make an important transition in both acute awareness and knowledge application regarding both general and specialty geriatric care including specifically targeted postgraduate, graduate, and medical education efforts.…”