Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda

Vaca, Silvia D; Kuo, Benjamin Jyhhan; Vissoci, João Ricardo Nickenig; Staton, Catherine A.; Xu, Linda; Muhumuza, Michael; Ssenyonjo, Hussein; Mukasa, John; Kiryabwire, Joel; Rice, Henry E.; Grant, Gerald A.; Haglund, Michael M.

doi:10.1093/neuros/nyy004

Cited by 58 publications

(50 citation statements)

References 28 publications

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“…Conversely, limited access to transport, shortages or malfunctions in key equipment, including sterilization and operative supplies, were not uncommon at KCH, although the extent of their contribution to delays was not evaluated. Several studies 7,8,13,20,26,27 have noted delays associated with obtaining diagnostic test results. Preoperative imaging was not associated with IHDs in this cohort, but the minority of patients who had preoperative laboratory assessments did experience more delay.…”

Section: Resultsmentioning

confidence: 99%

“…In sub‐Saharan Africa, limited data suggest that IHDs are also associated with worse outcomes for specific conditions. Patients with perforated peptic ulcer disease in the Ivory Coast had a hazard ratio for mortality of 15·6 if surgery was delayed more than 24 h from symptom onset, and in patients with traumatic brain injury in Uganda IHDs increased mortality.…”

Section: Discussionmentioning

confidence: 99%

“…Several studies have noted delays associated with obtaining diagnostic test results. Preoperative imaging was not associated with IHDs in this cohort, but the minority of patients who had preoperative laboratory assessments did experience more delay.…”

Section: Discussionmentioning

confidence: 99%

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Effect of in‐hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi

et al. 2019

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Background In sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD. Methods Utilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD. Results Of 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment. Conclusion IHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Effect of in‐hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi

et al. 2019

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“…2,12 Mortality and morbidity largely depend on the time required for patients to access care. 21,33 Minimizing this figurative "golden hour" has been a priority for various health systems. 24 Various factors can delay the evaluation and management of TBI.…”

Section: Introductionmentioning

confidence: 99%

“…These include uncertainty in determining where to seek care after an injury, inefficiency in transportation to the appropriate hospital and transfers between hospitals; workforce and equipment shortages; and inefficient hospital processes and protocols. 8,21,25,33 Patients' neurological conditions can deteriorate during these delays, contributing to the high rates of irreversible damage or death seen in this population. Borrowing from the maternal health literature, First and second delays represent time from injury to seeking care and time from the decision to seek care to arrival at a hospital with capacity to manage trauma, respectively.…”

Section: Introductionmentioning

confidence: 99%

Third delay in traumatic brain injury: time to management as a predictor of mortality

Gupta

Khajanchi

Kumar

et al. 2020

Journal of Neurosurgery

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OBJECTIVETraumatic brain injury (TBI) is a global epidemic with an increasing incidence in low- and middle-income countries (LMICs). The time from arrival at the hospital to receiving appropriate treatment (“third delay”) can vary widely in LMICs, although its association with mortality in TBI remains unknown.METHODSA retrospective cohort analysis with multivariable logistic regression was conducted using the Toward Improved Trauma Care Outcomes in India database, which contains data from 4 urban trauma centers in India from 2013–2015.RESULTSThere were 6278 TBIs included in the cohort. The patients’ median age was 39 years (interquartile range 27–52 years) and 80% of patients were male. The most frequent mechanisms of injury were road traffic accidents (52%) and falls (34%). A majority of cases were transfers from other facilities (79%). In-hospital 30-day mortality was 27%; of patients who died, 21% died within 24 hours of arrival. The median third delay was 10 minutes (interquartile range 0–60 minutes); 34% of cases had moderate third delay (10–60 minutes) and 22% had extended third delay (≥ 61 minutes). Overall 30-day mortality was associated with moderate third delay (OR 1.3, p = 0.001) and extended third delay (OR 1.3, p = 0.001) after adjustment by pertinent covariates. This effect was pronounced for 24-hour mortality: moderate and extended third delays were independently associated with ORs of 3.4 and 3.8, respectively, for 24-hour mortality (both p < 0.001).CONCLUSIONSThird delay is associated with early mortality in patients with TBI, and represents a target for process improvement in urban trauma centers.

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Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

Gamble

Luggya

Mabweijano

et al. 2020

African Journal of Emergency Medicine

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Introduction Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality. Methods A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded. Results Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6). Conclusion Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.

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Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda

Cited by 58 publications

References 28 publications

Effect of in‐hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi

Effect of in‐hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi

Third delay in traumatic brain injury: time to management as a predictor of mortality

Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

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