Malawi Trauma Score is Predictive of Mortality at a District Hospital: A Validation Study.

BACKGROUND: Trauma scoring systems can identify patients who should be transferred to referral hospitals, but their utility in LMICs is often limited. The Malawi Trauma Score (MTS) reliably predicts mortality at referral hospitals but has not been studied at district hospitals. We sought to validate the MTS at a Malawi district hospital and evaluate whether MTS is predictive of transfer to a referral hospital. METHODS: We performed a retrospective study using trauma registry data from Salima District Hospital (SDH) from 2017 to 2021. We excluded patients brought in dead, discharged from the Casualty Department, or missing data needed to calculate MTS. We used logistic regression modeling to study the relationship between MTS and mortality at SDH and between MTS and transfer to a referral hospital. We used receiver operating characteristic analysis to validate the MTS as a predictor of mortality. RESULTS: We included 2196 patients (84.3% discharged, 12.7% transferred, 3.0% died). These groups had similar ages, sex, and admission vitals. Mean (SD) MTS was 7.9(3.0) among discharged patients, 8.4(3.9) among transferred patients, and 14.2(8.0) among patients who died (p < 0.001). Higher MTS was associated with increased odds of mortality at SDH (OR 1.21, 95% CI 1.14-1.29, p < 0.001) but was not related to transfer. ROC area for mortality was 0.73 (95% CI 0.65-0.80). CONCLUSIONS: MTS is predictive of district hospital mortality but not inter-facility transfer. We suggest that MTS be used to identify patients with severe trauma who are most likely to benefit from transfer to a referral hospital.

Underutilization of Operative Capacity at the District Hospital Level in a Resource-Limited Setting.

INTRODUCTION: Improving surgical care in a resource-limited setting requires the optimization of operative capacity, especially at the district hospital level. METHODS: We conducted an analysis of the acute care surgery registry at Salima District Hospital in Malawi from June 2018 to November 2019. We examined patient characteristics, interventions, and outcomes. Modified Poisson regression modeling was used to identify risk factors for transfer to a tertiary center and mortality of patients transferred to the tertiary center. RESULTS: Eight hundred eighty-eight patients were analyzed. The most common diagnosis was skin and soft tissue infection (SSTI) at 35.9%. 27.5% of patients were transferred to Salima District Hospital, primarily from health centers, with a third for a diagnosis of SSTI. Debridement of SSTI comprised 59% of performed procedures (n = 241). Of the patients that required exploratory laparotomy, only 11 laparotomies were performed, with 59 patients transferred to a tertiary hospital. The need for laparotomy conferred an adjusted risk ratio (RR) of 10.1 (95% confidence interval [CI] 7.1, 14.3) for transfer to the central hospital. At the central hospital, for patients who needed urgent abdominal exploration, surgery had a 0.16 RR of mortality (95% CI 0.05, 0.50) while time to evaluation greater than 48 h at the central hospital had a 2.81 RR of death (95% CI 1.19, 6.66). CONCLUSIONS: Despite available capacity, laparotomy was rarely performed at this district hospital, and delays in care led to a higher mortality. Optimization of the district and health center surgical ecosystems is imperative to improve surgical access in Malawi and improve patient outcomes.