Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

Abstract

BackgroundAbout 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.Materials and methodsThis systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.ResultsOf the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.ConclusionsThe findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.PROSPERO registration numberCRD42017064600.

Constructing a Trauma Scoring System from Databases of Road Crash Patients in Philippine Hospitals (2009–2019)

“…35,44 it underestimates the injury severity. It was not a good predictor for patients with blunt or penetrating traumas 12,44 because RTS does not account for body parts injured. This may be due to the large GCS constant in the RTS which can affect the values.…”

“…37,41,42 Head injuries and hemorrhage were also the leading cause of death in adult trauma patients in a study by Oyeniyi, et al (2017). 43 The determination of head injuries through GCS scoring is the strength of RTS; however, the latter has a tendency of under-triaging the severity of body injuries (Feldhaus, et al, 2020) 12 as the formula did not include that specific variable.…”

“…A systematic review also showed that KTS was better in predicting injury severity than RTS. 12 However, one study showed that in terms of sensitivity, KTS was higher than RTS, but the latter was higher in terms of specificity, diagnostic odds ratio, negative likelihood ratio, and positive likelihood ratio; thus, making RTS slightly better in predicting mortality in the LMIC setting. 11 On the other hand, several studies showed that TRISS is a better outcome predictor than RTS, KTS, and ISS in the LMIC setting.…”

Epidemiology of injured patients in rural Uganda: A prospective trauma registry’s first 1000 days

“…Due to concerns about the feasibility of collecting anatomical injury information, the Kampala Trauma Score (KTS) was chosen to categorize severity of injury (KTS 14–16 signifying a mild injury, 11–13 a moderate injury, 10 or below a severe injury). This physiologic-based scoring system has been validated as a useful tool for predicting mortality especially in LMIC settings [ 10 ]. The form also included items of particular interest in rural Uganda, pertaining to helmet use in road traffic injury or involvement of mob justice.…”

Predicting mortality in trauma patients - A retrospective comparison of the performance of six scoring systems applied to polytrauma patients from the emergency centre of a South African central hospital

“….However, these systems cannot always be replicated in resource-limited settings due to different patient characteristics, and also absent predictor variables. Hence, there is no literature consensus regarding interpretation and feasibility of such scores in developing countries [12] .…”