Delays in hospital admissions for patients with fractures – Authors' reply

Pouramin, Panthea; Busse, Jason W.; Bhandari, Mohit

doi:10.1016/s2214-109x(20)30305-3

Cited by 13 publications

(25 citation statements)

References 4 publications

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“…This finding is common across most of sub-Saharan Africa where an estimated 91.3% of Africa’s population lacks access to emergency medical services 48. Use of various informal methods of transport is reported in other comparable settings where private vehicles and taxis are used more often for injured patient transport than ambulances,40 45 49 with foot and animal cart also commonly adopted 45…”

Section: Discussionmentioning

confidence: 93%

“…This highlights the importance of comprehensive health system assessments including the first delay, which has previously been relatively neglected in the existing literature 10. While some authors have found little delay in seeking care following injury, particularly for open long bone fractures,39 evidence for a real and important phase one delay following trauma in LMICs is growing 4 40 41…”

Section: Discussionmentioning

confidence: 99%

“…Injury severity perceptions may also vary among populations. A belief that there was no need for care following bone fracture was markedly observed in China,40 while few Rwandans thought it unnecessary 46. Knowing how best to respond has delayed injury care seeking in South Africa and Uganda,4 47 and represents another important dimension of health literacy.…”

Section: Discussionmentioning

confidence: 99%

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Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi

et al. 2023

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ObjectivesWe used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi.DesignFacilitated group process mapping workshops with summary process mapping synthesis.SettingProcess mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi.ParticipantsFifty-four healthcare workers from various cadres took part.ResultsAn overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were ‘cultural norms’, ‘healthcare literacy’, ‘traditional healers’ and ‘police processes’. For Delay 2 (reaching care) the barrier most frequently described was ‘transport’—a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of ‘physical resources’ (9 of 11 facilities).ConclusionsWe found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.

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Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi

et al. 2023

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“…Delays in seeking care occur when patients wait to seek treatment because of financial, geographic, cultural, or education reasons 10,15,16 . Delays in reaching care occur as a result of inadequate emergency care systems, transportation, patient poverty, or inaccessible hospital locations 10,16 . The third delay is in receiving care, which results from hospital resource constraints or the inability to provide adequate care 10 .…”

mentioning

confidence: 99%

Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania

Holler¹,

Cortez²,

Challa³

et al. 2022

Journal of Bone and Joint Surgery

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Background: Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes.While open tibial shaft fractures are common injuries in low-and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. Methods:We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ‡2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ‡12 hours after admission among patients with diaphyseal open tibial fractures.Results: Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ‡2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ‡12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ‡8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ‡12 hours after admission.Conclusions: Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs.Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. Musculoskeletal injuries are a leading cause of disability across the world and disproportionally affect people in low-and middle-income countries (LMICs) 1-5 . Among these injuries, tibial shaft fractures are the most common longbone and open fractures 6 . Despite surgical advances, open tibial fractures are associated with high complications rates and poor long-term quality of life for people in LMICs 7,8 . Globally, the surgical treatment of open fractures is used as a benchmark bellwether procedure for what first-level hospitals should be able to perform on a 24/7 basis to ensure appropriate delivery of care to their population 9,10 . However, patients in LMICs continue to face issues with delays to access...

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“…Previous work has highlighted the burden of trauma in developing nations and the lack of research 7 . The challenges of injury management in low-income countries are confounded by limited resources and delays in patient presentation 8,9 .…”

mentioning

confidence: 99%

Patient-Reported Outcome Measures for Acetabular Fractures Treated Operatively without a C-Arm in Ethiopia

Hailu¹,

Leulseged²,

Lemma³

2022

Journal of Bone and Joint Surgery

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Background:There is little evidence describing the open treatment of displaced acetabular fractures in low-resource environments. We endeavored to determine the results of the operative management of acetabular fractures without intraoperative C-arm use in a developing nation, through the assessment of patient-reported outcome measures.Methods:This was a prospective, single-surgeon, consecutive case series conducted in a tertiary referral hospital in Ethiopia, a high-population, low-income country. The primary author performed fixation without the use of a C-arm in 108 patients from among a total of 202 patients presenting with acetabular fracture. The modified Harris hip score (mHHS) and Short-Form Health Survey (SF)-36 at a minimum of 2 years postoperatively were used to assess the outcome.Results:Of the 108 patients potentially available for analysis, 92 (85%) were available for 2-year follow-up (mean age of 35 years; range, 15 to 70 years). The mean duration from injury to surgery was 16 days (range, 1 to 204 days). Seventy-three (78.5%; n = 93) of the patients had associated fracture patterns. The most common fractures were associated both-column type (22%) and transverse-plus-posterior-wall type (22%). The mean mHHS was 91; 88% of the patients had a score of ≥80, and 12% had a score of ≤79. SF-36 scores were in alignment with the mHHS. The majority (approximately 90%) of our cohort returned to work. We did not find a significant difference in the mean mHHS between patients with or without anatomic reduction (p = 0.31). However, 2-year radiographic outcomes were strongly associated with the mean mHHS (p < 0.001). Predictors of a lower mHHS included older age, cartilage damage, and lack of secondary congruence.Conclusions:Good functional outcomes were achieved at 2 years among patients with acetabular fractures surgically treated without the use of a C-arm in a limited-resource setting. Surgical congruence of the femoral head under the acetabular roof, rather than the absolute residual gap, seems essential in determining clinical outcomes. This information can help in planning increased access to care for individuals who experience traumatic injuries in low- and middle-income countries.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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Delays in hospital admissions for patients with fractures – Authors' reply

Cited by 13 publications

References 4 publications

Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi

Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi

Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania

Patient-Reported Outcome Measures for Acetabular Fractures Treated Operatively without a C-Arm in Ethiopia

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