Profile and triage validity of trauma patients triaged green: a prospective cohort study from a secondary care hospital in India.

OBJECTIVES: To evaluate the profile of non-urgent patients triaged 'green', as part of a triage trial in the emergency department (ED) of a secondary care hospital in India. The secondary aim was to validate the triage trial with the South African Triage Score (SATS). DESIGN: Prospective cohort study. SETTING: A secondary care hospital in Mumbai, India. PARTICIPANTS: Patients aged 18 years and above with a history of trauma defined as having any of the external causes of morbidity and mortality listed in block V01-Y36, chapter XX of the International Classification of Disease version 10 codebook, triaged green between July 2016 and November 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures were mortality within 24 hours, 30 days and mistriage. RESULTS: We included 4135 trauma patients triaged green. The mean age of patients was 32.8 (±13.1) years, and 77% were males. The median (IQR) length of stay of admitted patients was 3 (13) days. Half the patients had a mild Injury Severity Score (3-8), with the majority of injuries being blunt (98%). Of the patients triaged green by clinicians, three-quarters (74%) were undertriaged on validating with SATS. On telephonic follow-up, two patients were reported dead whereas one died while admitted in hospital. CONCLUSIONS: Our study highlights the need for implementation and evaluation of training in trauma triage systems that use physiological parameters, including pulse, systolic blood pressure and Glasgow Coma Scale, for the in-hospital first responders in the EDs.

Perceived usefulness of trauma audit filters in urban India: a mixed-methods multicentre Delphi study comparing filters from the WHO and low and middle-income countries.

OBJECTIVE: To compare experts' perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness. DESIGN: A mixed-methods approach using a multicentre online Delphi technique. SETTING: Two large tertiary hospitals in urban India. METHODS: Filters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments. RESULTS: 26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity. CONCLUSIONS: Audit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

A pilot multicentre cluster randomised trial to compare the effect of trauma life support training programmes on patient and provider outcomes.

INTRODUCTION: Trauma accounts for nearly 10% of the global burden of disease. Several trauma life support programmes aim to improve trauma outcomes. There is no evidence from controlled trials to show the effect of these programmes on patient outcomes. We describe the protocol of a pilot study that aims to assess the feasibility of conducting a cluster randomised controlled trial comparing advanced trauma life support (ATLS) and primary trauma care (PTC) with standard care. METHODS AND ANALYSIS: We will pilot a pragmatic three-armed parallel, cluster randomised controlled trial in India, where neither of these programmes are routinely taught. We will recruit tertiary hospitals and include trauma patients and residents managing these patients. Two hospitals will be randomised to ATLS, two to PTC and two to standard care. The primary outcome will be all-cause mortality at 30 days from the time of arrival to the emergency department. Our secondary outcomes will include patient, provider and process measures. All outcomes except time-to-event outcomes will be measured both as final values as well as change from baseline. We will compare outcomes in three combinations of trial arms: ATLS versus PTC, ATLS versus standard care and PTC versus standard care using absolute and relative differences along with associated CIs. We will conduct subgroup analyses across the clinical subgroups men, women, blunt multisystem trauma, penetrating trauma, shock, severe traumatic brain injury and elderly. In parallel to the pilot study, we will conduct community consultations to inform the planning of the full-scale trial. ETHICS AND DISSEMINATION: We will apply for ethics approvals to the local institutional review board in each hospital. The protocol will be published to Clinical Trials Registry-India and ClinicalTrials.gov. The results will be published and the anonymised data and code for analysis will be released publicly.

'Coming home does not mean that the injury has gone'-exploring the lived experience of socioeconomic and quality of life outcomes in post-discharge trauma patients in urban India.

Trauma results in long-term socioeconomic outcomes that affect quality of life (QOL) after discharge. However, there is limited research on the lived experience of these outcomes and QOL from low - and middle-income countries. The aim of this study was to explore the different socioeconomic and QOL outcomes that trauma patients have experienced during their recovery. We conducted semi-structured qualitative interviews of 21 adult trauma patients between three to eight months after discharge from two tertiary-care public hospitals in Mumbai, India. We performed thematic analysis to identify emerging themes within the range of different experiences of the participants across gender, age, and mechanism of injury. Three themes emerged in the analysis. Recovery is incomplete-even up to eight months post discharge, participants had needs unmet by the healthcare system. Recovery is expensive-participants struggled with a range of direct and indirect costs and had to adopt coping strategies. Recovery is intersocial-post-discharge socioeconomic and QOL outcomes of the participants were shaped by the nature of social support available and their sociodemographic characteristics. Provisioning affordable and accessible rehabilitation services, and linkages with support groups may improve these outcomes. Future research should look at the effect of age and gender on these outcomes.

Measuring socioeconomic outcomes in trauma patients up to one year post-discharge: A systematic review and meta-analysis.

INTRODUCTION: Trauma accounts for nearly one-tenth of the global disability-adjusted life-years, a large proportion of which is seen in low- and middle-income countries (LMICs). Trauma can affect employment opportunities, reduce social participation, be influenced by social support, and significantly reduce the quality of life (QOL) among survivors. Research typically focuses on specific trauma sub-groups. This dispersed knowledge results in limited understanding of these outcomes in trauma patients as a whole across different populations and settings. We aimed to assess and provide a systematic overview of current knowledge about return-to-work (RTW), participation, social support, and QOL in trauma patients up to one year after discharge. METHODS: We undertook a systematic review of the literature published since 2010 on RTW, participation, social support, and QOL in adult trauma populations, up to one year from discharge, utilizing the most commonly used measurement tools from three databases: MEDLINE, EMBASE, and the Cochrane Library. We performed a meta-analysis based on the type of outcome, tool for measurement, and the specific effect measure as well as assessed the methodological quality of the included studies. RESULTS: A total of 43 articles were included. More than one-third (36%) of patients had not returned to work even a year after discharge. Those who did return to work took more than 3 months to do so. Trauma patients reported receiving moderate social support. There were no studies reporting social participation among trauma patients using the inclusion criteria. The QOL scores of the trauma patients did not reach the population norms or pre-injury levels even a year after discharge. Older adults and females tended to have poorer outcomes. Elderly individuals and females were under-represented in the studies. More than three-quarters of the included studies were from high-income countries (HICs) and had higher methodological quality. CONCLUSION: RTW and QOL are affected by trauma even a year after discharge and the social support received was moderate, especially among elderly and female patients. Future studies should move towards building more high-quality evidence from LMICs on long-term socioeconomic outcomes including social support, participation and unpaid work.

Measuring post-discharge socioeconomic and quality of life outcomes in trauma patients: a scoping review.

PURPOSE: Trauma is a global public health challenge. Measuring post-discharge socioeconomic and quality-of-life outcomes can help better understand and reduce the consequences of trauma. METHODS: We performed a scoping review to map the existing research on post-discharge outcomes for trauma patients, irrespective of the country or setting in which the study was performed. The scoping review was conducted by searching six databases - MEDLINE, EMBASE, the Cochrane Library, Global Index Medicus, BASE, and Web of Science - to identify all articles that report post-discharge socioeconomic or quality of life outcomes in trauma patients from 2009 to 2018. RESULTS: Seven hundred fifty-eight articles were included in this study, extracting 958 outcomes. Most studies (82%) were from high-income countries (HICs). More studies from low- and middle-income countries (LMICs) were cross-sectional (71%) compared with HIC settings (46%). There was a wide variety of different definitions, interpretations, and measurements used by various articles for similar outcomes. Quality of life, return to work, social support, cost, and participation were the main outcomes studied in post-discharge trauma patients. CONCLUSIONS: The wide range of outcomes and outcome measures reported across different types of injuries and settings. This variability can be a barrier when comparing across different types of injuries and settings. Post-discharge trauma studies should move towards building evidence based on standardized measurement of outcomes.

Comparative analysis of gender differences in outcomes after trauma in India and the USA: case for standardised coding of injury mechanisms in trauma registries.

INTRODUCTION: While females generally have better outcomes than males after traumatic injury, higher mortality has been shown to occur in females after intentional trauma in lower-income countries. However, gender differences in trauma outcomes in different countries have not been previously compared. We conducted a two-country comparative analysis to characterise gender differences in mortality for different mechanisms of injury. METHODS: Two urban trauma databases were analysed from India and the USA for fall, motor vehicle collision (MVC) and assault patients between 2013 and 2015. Coarsened exact matching was used to match the two groups based on gender, age, injury severity score, Glasgow Coma Score and type of injury (blunt vs penetrating). The primary outcome of mortality was studied by using logistic regression to calculate the odds of death in the four country/gender subgroups. RESULTS: A total of 10 089 and 14 144 patients were included from the Indian and US databases, respectively. After matching on covariates, 7505 and 9448 patients were included in the logistic regression. Indian males had the highest odds of death compared with US males, US females and Indian females for falls, MVC and assaults. Indian females had over 7 times the odds of dying after falls, 5 times the odds of dying for MVC and 40 times the odds of dying after assaults when compared with US females. CONCLUSION: The high odds of death for Indian females compared with US females suggests that there are other injury and systemic factors that contribute to this discrepancy in mortality odds. This same mortality pattern and implication is seen for Indian males compared with all subgroups. Standardised coding of injury mechanism in trauma registries, in addition to intentionality of injury, can help further characterise discrepancies in outcomes by gender and country, to guide targeted injury prevention and care.

A question of ethics, not nationalism: author's response.

The aim of the comment "Use of pellet guns for crowd control in Kashmir: How lethal is 'non-lethal'?" was neither to disparage the armed forces, nor recommend counterinsurgency strategies, nor support any particular community or group. It sought to raise discussions around the question pointed out by the responder himself, namely, "the ethical point of view" on the use of pellet guns in controlling violent mobs. The author also feels that the question is not so much about "favouring" the protestors or the security forces, but whether an instrument that causes significant fatalities and morbidities among bystanders should continue to be used as a method of crowd control.

Use of pellet guns for crowd control in Kashmir: How lethal is "non-lethal"?

The use of pellet guns during the recent unrest in Kashmir as a method of crowd control has been questioned because of several deaths and numerous injuries. Across the world, these rubber pellets have been shown to inflict serious injuries, permanent disability, and death. The volatility of mob violence, inaccuracies in aim of the pellets, over-use of the pellet guns, and the perception of their harmlessness enhances the destructive potential of these so-called non-lethal weapons. There is also the larger ethical question whether any form of pain, however minimal, could be inflicted to control violent crowds.

Lessons from the frontline: using experiences from conflict zones to improve trauma care and outcomes.

Over the years healthcare services during conflict have informed healthcare practice especially in trauma care. Conflict zones have constraints not very different from low-resource settings specifically in dealing with urban violence. Yet, there is limited in-depth study on conflict medicine. This is being slowly recognised in health literature. Two recent papers in International Health have indicated that trauma care packages in conflict settings could be adapted in low-resource settings. There is a need to overview and audit healthcare services in conflict zones further to identify more areas of overlap and possible lessons it holds for improving trauma outcomes in other settings.

Ethics in occupational health and safety: case studies from Gujarat.

Rapid industrialisation in India is giving employment to millions of people in the formal sector, and many more in the unorganised sector. However, the absence of clear policies, poorly enforced regulations, lack of systematic reporting of occupational diseases, lamentable socioeconomic conditions of the workers and their limited access to healthcare make occupational health and safety (OHS) a critical area.

Public health perspectives from the biggest human mass gathering on earth: Kumbh Mela, India.

Mass gathering events pose critical health challenges, especially for the control of diseases. The rising population, better connectivity, and scope of travel have increased the frequency and magnitude of mass gatherings and underscore the need to shift the discourse from reacting to the public health issues they throw up to taking active steps in preventing them based on evidence through research. The Kumbh Mela is a religious event in India that constitutes the largest number of people gathered at a specific place and at a specific time. It is older than the Hajj by centuries, yet the public health aspects related to this event, which is held every 3 years, have not been fully studied. Understanding the Kumbh Mela can highlight the health challenges faced and provide crucial lessons for the management of mass gatherings. This investigation used the Kumbh Mela in the city of Allahabad as a case study to describe the health problems and the efforts taken to manage them. In-depth studies of the Kumbh Mela in the future are required to generate evidence for context-specific measures to address the complex health challenges of mass gatherings.

Vulnerabilities of Local Healthcare Providers in Complex Emergencies: Findings from the Manipur Micro-level Insurgency Database 2008-2009.

BACKGROUND: Research on healthcare delivery in zones of conflict requires sustained and systematic attention. In the context of the South Asian region, there has been an absence of research on the vulnerabilities of health care workers and institutions in areas affected by armed conflict. The paper presents a case study of the varied nature of security challenges faced by local healthcare providers in the state of Manipur in the North-eastern region of India, located in the Indo-Myanmar frontier region which has been experiencing armed violence and civil strife since the late 1960s. . The aim of this study was to assess longitudinal and spatial trends in incidents involving health care workers in Manipur during the period 2008 to 2009. METHODS: We conducted a retrospective database analysis of the Manipur Micro-level Insurgency Database 2008-2009, created by using local newspaper archives to measure the overall burden of violence experienced in the state over a two year period. Publicly available press releases of armed groups and local hospitals in the state were used to supplement the quantitative data. Simple linear regression was used to assess longitudinal trends. Data was visualized with GIS-software for spatial analysis. RESULTS: The mean proportion of incidents involving health care workers per month was 2.7% and ranged between 0 and 6.1% (table 2). There was a significant (P=0.037) month-to-month variation in the proportion of incidents involving health care workers, as well as a upward trend of about 0.11% per month. Spatial analysis revealed different patterns depending on whether absolute, population-adjusted, or incident-adjusted frequencies served as the basis of the analysis. CONCLUSIONS: The paper shows a small but steady rise in violence against health workers and health institutions impeding health services in Manipur's pervasive violence. More evidence-building backed by research along with institutional obligations and commitment is essential to protect the health-systems Keywords: India, Manipur, insurgency, healthcare, security, ethnic strife.