Dataset Information

An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.

ABSTRACT:

Background

Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting.

Methods

We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes.

Results

Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery.

Conclusions

Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.

SUBMITTER: Zimmerman A

PROVIDER: S-EPMC7549769 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.

Zimmerman Armand A Fox Samara S Griffin Randi R Nelp Taylor T Thomaz Erika Bárbara Abreu Fonseca EBAF Mvungi Mark M Mmbaga Blandina T BT Sakita Francis F Gerardo Charles J CJ Vissoci Joao Ricardo Nickenig JRN Staton Catherine A CA Staton Catherine A CA

PloS one 20201012 10

<h4>Background</h4>Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describ ...[more]

PMID: 33045030

Similar Datasets

Project description:BackgroundLife-threatening obstetric complications usually lead to the need for referral and constitute the commonest direct causes of maternal deaths. Urgent management of referrals can potentially lower the maternal mortality rate. We explored the experiences of women referred with obstetric emergencies to Mbarara Regional Referral Hospital (MRRH) in Uganda, in order to identify barriers and facilitating factors.MethodsThis was an exploratory qualitative study. In-depth interviews (IDIs) were conducted with 10 postnatal women and 2 attendants as key informants. We explored health system and client related factors to understand how these could have facilitated or hindered the referral process. Data was analyzed deductively employing the constructs of the Andersen Healthcare Utilization model.ResultsWomen experienced transport, care delays and inhumane treatment from health care providers (HCPs). The obstetric indications for referral were severe obstructed labor, ruptured uterus, and transverse lie in advanced labor, eclampsia and retained second twin with intrapartum hemorrhage. The secondary reasons for referral included; non-functional operating theatres due to power outages, unsterilized caesarian section instruments, no blood transfusion services, stock outs of emergency drugs, and absenteeism of HCPs to perform surgery. Four (4) themes emerged; enablers, barriers to referral, poor quality of care and poor health facility organization. Most referring health facilities were within a 30-50 km radius from MRRH. Delays to receive emergency obstetric care (EMOC) led to acquisition of in-hospital complications and eventual prolonged hospitalization. Enablers to referral were social support, financial preparation for birth and birth companion's knowledge of danger signs.ConclusionThe experience of obstetric referral for women was largely unpleasant due to delays and poor quality of care which contributed to perinatal mortality and maternal morbidities. Training HCPs in respectful maternity care (RMC) may improve quality of care and foster positive postnatal client experiences. Refresher sessions on obstetric referral procedures for HCPs are suggested. Interventions to improve the functionality of the obstetric referral pathway for rural south-western Uganda should be explored.

Project description:BackgroundThe novel coronavirus disease 2019 (COVID-19) pandemic has been at its peak for the past 8 months and has affected more than 215 countries around the world. India is now the second most-affected nation with more than 48,000,000 cases and 79,000 deaths. Despite this, and the fact that it is a lower-middle-income nation, the number of deaths is almost one third that of the United States and one half that of Brazil. However, there has been no experience published from non-COVID-19-designated hospitals, where the aim is to manage noninfected cases with neurosurgical ailments while keeping the number of infected cases to a minimum.MethodsWe analyzed the number of neurosurgical cases (nontrauma) done in the past 5 months (March-July 2020) in our institute, which is the largest neurosurgical center by volume in southern India, and compared the same to the concurrent 5 months in 2019 and 5 months preceding the pandemic. We also reviewed the total number of cases infected with COVID-19 managed during this time.ResultsWe operated a total of 630 cases (nontrauma) in these 5 months and had 9 COVID-19 infected cases operated during this time. There was a 57% (P = 0.002) reduction in the number of cases operated as compared with the same 5 months in the preceding year. We employed a dual strategy of rapid antigen testing and surgery for cases needing emergency intervention and reverse transcriptase-polymerase chain reaction test for elective cases. The hospital was divided into 3 zones (red, orange, and green) depending on infectivity level with minimal interaction. Separate teams were designated for each zone, and thus we were able to effectively manage even infected cases despite the absence of pulmonology/medical specialists.ConclusionsWe present a patient management protocol for non-COVID-19-designated hospitals in high-volume centers with the constraints of a lower-middle-income nation and demonstrate its effectiveness. Strict zoning targeted testing and effective triage can help in management during the pandemic.

Project description:BackgroundTraumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda.MethodsWe used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.Results563 TBI patients were enrolled from 1 June- 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.ConclusionsThe overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Project description:The emergency department (ED) of the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) handles many cases of poisoning. However, there is scant information on the factors, agents, and outcomes of poisoning at the hospital. The aim of this work was to determine the factors, agents, and outcomes of poisoning at JOOTRH. Records of patients who presented to JOOTRH with symptoms of poisoning between January 2011 and December 2016 were retrieved. Data on age, gender, offending agents, time, and season of exposure were collected. Information on the route of exposure, motive, and clinical symptoms of poisoning was also included. Other information included the laboratory evaluation, first aid measures, period of hospitalization, and outcome of poisoning. Mean, standard deviation, frequencies and bar graphs were used to describe the demographic factors of the study population. Multivariate logistic regression was used to determine the strength of association between risk factors and outcome of poisoning among patients. The level of significance for inferential analysis was set at 5%. There were 385 cases of poisoning: 57.9% (223/385) were male, 31.9% (123/385) were 13⁻24 years of age, and 83.9% (323/385) of exposures were in Kisumu County. The peak time of exposure was 6:00⁻00:00, and 23.6% (91/385) presented 1⁻4 h after exposure. About 62.9% (242/385) of the cases were due to accidental poisoning. Snakebites and organophosphates (OPPs) contributed to 33.0% (127/385) and 22.1% (85/385) of all cases, respectively. About 62.1% (239/385) of exposures were oral, and 63.9% (246/385) of all cases occurred in the rainy season. Additionally, 49.2% (60/122) of intentional poisoning was due to family disputes, and 16.1% (10/62) of pre-hospital first aid involved the use of tourniquets and herbal medicine. About 28.6% (110/385) of the victims were subjected to laboratory evaluation and 83.9% (323/385) were hospitalized for between 1⁻5 days. Other results indicated that 80.0% (308/385) responded well to therapy, while 7.3% (28/385) died, 68% (19/28) of whom were male. Furthermore, 39.3% (11/28) of the deaths were related to OPPs. Our findings suggest that the earlier the victims of poisoning get to the hospital, the more likely they are to survive after treatment is initiated. Similarly, victims of poisoning due to parental negligence are more likely to survive after treatment compared to other causes of poisoning, including family disputes, love affairs, snakebites, and psychiatric disorders. The management of JOOTRH should consider allocating resources to support the development of poison management and control.

Project description:Sex and gender are well-established determinants of health in adult and adolescent populations in low resource settings. There are limited data on sex as a determinant of host response to disease and clinical outcome in febrile children in sub-Saharan Africa, where the risk of infection-related mortality is greatest. We examined sex differences and gender biases in health-seeking behavior, clinical care, biological response to infection, or outcome in a prospective observational cohort of febrile children under 5 years of age presenting to a regional referral hospital in Jinja, Uganda. Main outcomes (stratified by sex) were disease severity at presentation measured by clinical and biological parameters, clinical management (e.g., time to see a physician, treatment by diagnosis), and disease outcome (e.g., mortality). Clinical measures of disease severity included Lambaréné Organ Dysfunction Score (LODS), Signs of Inflammation in Children that Kill (SICK), and the Pediatric Early Death Index for Africa (PEDIA). Biological measures of disease severity were assessed using circulating markers of immune and endothelial activation associated with severe and fatal infections. Differences in outcome by sex were analyzed using bivariate analyses with Bonferroni correction for multiple comparisons. In this cohort of febrile patients admitted to hospital (n = 2049), malaria infection was common (59.2%). 15.9% of children presented with severe disease (LODS score ≥ 2). 97 children (4.7%) died, and most deaths (n = 83) occurred within 48 hours of hospital admission. Clinical measures of disease severity at presentation, clinical management, and outcome (e.g., mortality) did not differ by sex in children under five years of age. Host response to infection, as determined by endothelial and inflammatory mediators (e.g., sTREM1, Ang-2) quantified at hospital presentation, did not differ by sex. In this cohort of children under the age of five, sex was not a principal determinant of disease severity at hospital presentation, clinical management, disease outcome, or biological response to infection (p-values not significant for all comparisons, after Bonferroni correction). The results suggest that health seeking behavior by caregivers and clinical care in the hospital setting did not reflect a gender bias in this cohort.

Project description:IntroductionHypoglycemia is a recognized feature of severe malaria but its diagnosis and management remain problematic in resource-limited settings. There is limited data on the burden and prognosis associated with glycemia dysregulation in non-neonate children in non-malaria areas. We prospectively assessed the abnormal blood glucose prevalence and the outcome and risk factors of deaths in critically ill children admitted to a national referral hospital in Laos.MethodsConsecutive children (1 month-15 years) admitted to the pediatric ward of Mahosot hospital, were categorized using the integrated management of childhood illness (IMCI). Blood glucose was assessed once on admission through a finger prick using a bedside glucometer. Glycemia levels: hypoglycemia: < 2.2 mmol/L (< 40 mg⁄ dl), low glycemia: 2.2-4.4 mmol/L (40-79 mg⁄ dl), euglycemia: 4.4-8.3 mmol/L (80-149 mg⁄ dl), and hyperglycemia: > 8.3 mmol/L (≥150 mg⁄ dl), were related to the IMCI algorithm and case fatality using univariate and multivariate analysis.ResultsOf 350 children, 62.2% (n = 218) were severely ill and 49.1% (n = 172) had at least one IMCI danger sign. A total of 15 (4.2%, 95%CI: 2.4-6.9) had hypoglycemia, 99 (28.2%, 95%CI: 23.6-33.3) low glycemia, 201 (57.4%, 95% CI: 52.0-62.6) euglycemia and 35 (10.0%, 95% CI: 7.0-13.6) hyperglycemia. Hypoglycemia was associated with longer fasting (p = 0.001) and limited treatment before admission (p = 0.09). Hypoglycemia and hyperglycemia were associated with hypoxemia (SaO2) (p = 0.001). A total of 21 (6.0%) of the children died: 66.6% with hypoglycemic, 6.0% with low glycemic, 5.7% with hyperglycemic and 1.4% with euglycemic groups. A total of 9 (2.5%) deaths occurred during the first 24 hours of admission and 5 (1.7%) within 3 days of hospital discharge. Compared to euglycemic children, hypoglycemic and low glycemic children had a higher rate of early death (20%, p<0.001 and 5%, p = 0.008; respectively). They also had a higher risk of death (OR: 132; 95%CI: 29.0-596.5; p = 0.001; and OR: 4.2; 95%CI: 1.1-15.6; p = 0.02; respectively). In multivariate analyses, hypoglycemia (OR: 197; 95%CI: 33-1173.9), hypoxemia (OR: 5.3; 95%CI: 1.4-20), presence of hepatomegaly (OR: 8.7; 95%CI: 2.0-37.6) and having an illiterate mother (OR: 25.9; 95%CI: 4.2-160.6) were associated with increased risk of death.ConclusionHypoglycemia is linked with a high risk of mortality for children in non malaria tropical settings. Blood sugar should be monitored and treatment provided for sick children, especially with danger signs and prolonged fasting. Further evaluations of intervention using thresholds including low glycemia is recommended in resource-limited settings. Research is also needed to determine the significance, prognosis and care of hyperglycemia.

Project description:BackgroundPregnancy complications can be unpredictable and many women in developing countries cannot access health facilities where life-saving care is available. This study assesses the effects of referral interventions that enable pregnant women to reach health facilities during an emergency, after the decision to seek care is made.Methods and findingsSelected bibliographic databases were searched with no date or language restrictions. Randomised controlled trials and quasi experimental study designs with a comparison group were included. Outcomes of interest included maternal and neonatal mortality and other intermediate measures such as service utilisation. Two reviewers independently selected, appraised, and extracted articles using predefined fields. Forest plots, tables, and qualitative summaries of study quality, size, and direction of effect were used for analysis. Nineteen studies were included. In South Asian settings, four studies of organisational interventions in communities that generated funds for transport reduced neonatal deaths, with the largest effect seen in India (odds ratio 0·48 95% CI 0·34-0·68). Three quasi experimental studies from sub-Saharan Africa reported reductions in stillbirths with maternity waiting home interventions, with one statistically significant result (OR 0.56 95% CI 0.32-0.96). Effects of interventions on maternal mortality were unclear. Referral interventions usually improved utilisation of health services but the opposite effect was also documented. The effects of multiple interventions in the studies could not be disentangled. Explanatory mechanisms through which the interventions worked could not be ascertained.ConclusionsCommunity mobilisation interventions may reduce neonatal mortality but the contribution of referral components cannot be ascertained. The reduction in stillbirth rates resulting from maternity waiting homes needs further study. Referral interventions can have unexpected adverse effects. To inform the implementation of effective referral interventions, improved monitoring and evaluation practices are necessary, along with studies that develop better understanding of how interventions work.

Dataset Information

An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.

Background

Methods

Results

Conclusions

Publications

An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets