Improving trauma care in low- and middle-income countries by implementing a standardized trauma protocol.

BACKGROUND: Standardized trauma protocols (STPs) have reduced morbidity and mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not yet implemented such protocols, often due to financial and logistic limitations. We report preliminary findings from a trauma quality improvement (QI) initiative, using and evaluating the impact of a low-cost STP in an LMIC university hospital. METHODS: We developed an STP based on generally accepted best practices and damage control resuscitation. It was designed for the resources available at the test institution. The Neiva University Hospital (NUH) is a tertiary care hospital and level I trauma center in Neiva, Colombia. As in most LMIC hospitals, there was no trauma information data system at NUH. Therefore, we adapted an administrative electronic database to capture clinically relevant information of adult patients who were hospitalized or died in the emergency department (ED) between August 2010 and June 2012 with an International Classification of Diseases, 10th revision (ICD-10) diagnoses indicating trauma (S00-Y98). Interventions that were recommended in the STP were compared in these two groups. Length of hospital stay (LOS) and mortality were also examined. RESULTS: A total of 4,324 patients were included, of whom, 2,457 patients were in the pre-protocol period and 1,867 were in the post-protocol period. The use of several interventions increased: blood product transfusions in the ED (1.0 vs. 2.7%; p < 0.001), use of hypertonic fluids in hypotensive patients (3.2 vs. 8.9 %; p < 0.001), placement of Foley catheters (11.1 vs. 13.8%; p = 0.007), arterial blood gas draws (16.6 vs. 26.4%; p < 0.001), tetanus vaccinations (19.3 vs. 26.0%; p < 0.001), placement of multiple large bore peripheral catheters (29.5 vs. 34.7%; p < 0.001), prophylactic antibiotics (34.9 vs. 38.0%; p = 0.035), and the use of analgesics (64.5 vs. 68.0%; p = 0.016). Other interventions also trended upwards. Length of stay (LOS) decreased for both surgical and non-surgical patients (surgical 13.4 vs. 11.8 days; p = 0.017; non-surgical 4.4 vs. 3.8 days; p = 0.059). All-cause mortality of trauma patients decreased (3.9 vs. 2.9%; p = 0.088). CONCLUSIONS: The institution of an STP at a university hospital in an LMIC has increased the use of vital interventions while decreasing overall LOS for all-cause trauma patients.

Probabilistic Matching Approach to Link Deidentified Data from a Trauma Registry and a Traumatic Brain Injury Model System Center.

OBJECTIVE: There is no civilian traumatic brain injury database that captures patients in all settings of the care continuum. The linkage of such databases would yield valuable insight into possible care interventions. Thus, the objective of this article is to describe the creation of an algorithm used to link the Traumatic Brain Injury Model System (TBIMS) to trauma data in state and national trauma databases. DESIGN: The TBIMS data from a single center was randomly divided into two sets. One subset was used to generate a probabilistic linking algorithm to link the TBIMS data to the center's trauma registry. The other subset was used to validate the algorithm. Medical record numbers were obtained and used as unique identifiers to measure the quality of the linkage. Novel methods were used to maximize the positive predictive value. RESULTS: The algorithm generation subset had 121 patients. It had a sensitivity of 88% and a positive predictive value of 99%. The validation subset consisted of 120 patients and had a sensitivity of 83% and a positive predictive value of 99%. CONCLUSIONS: The probabilistic linkage algorithm can accurately link TBIMS data across systems of trauma care. Future studies can use this database to answer meaningful research questions regarding the long-term impact of the acute trauma complex on health care utilization and recovery across the care continuum in traumatic brain injury populations.

Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge.

BACKGROUND: Long-term outcomes following traumatic brain injury (TBI) correlate with initial head injury severity and other acute factors. Hospital-acquired pneumonia (HAP) is a common complication in TBI. Limited information exists regarding the significance of infectious complications on long-term outcomes after TBI. We sought to characterize risks associated with HAP on outcomes 5 years after TBI. METHODS: This study involved data from the merger of an institutional trauma registry and the Traumatic Brain Injury Model Systems outcome data. Individuals with severe head injuries (Abbreviated Injury Scale [AIS] score ≥ 4) who survived to rehabilitation were analyzed. Primary outcome was Glasgow Outcome Scale-Extended (GOSE) at 1, 2, and 5 years. GOSE was dichotomized into low (GOSE score < 6) and high (GOSE score ≥ 6). Logistic regression was used to determine adjusted odds of low GOSE score associated with HAP after controlling for age, sex, head and overall injury severity, cranial surgery, Glasgow Coma Scale (GCS) score, ventilation days, and other important confounders. A general estimating equation model was used to analyze all outcome observations simultaneously while controlling for within-patient correlation. RESULTS: A total of 141 individuals met inclusion criteria, with a 30% incidence of HAP. Individuals with and without HAP had similar demographic profiles, presenting vitals, head injury severity, and prevalence of cranial surgery. Individuals with HAP had lower presenting GCS score. Logistic regression demonstrated that HAP was independently associated with low GOSE scores at follow-up (1 year: odds ratio [OR], 6.39; 95% confidence interval [CI], 1.76-23.14; p = 0.005) (2 years: OR, 7.30; 95% CI, 1.87-27.89; p = 0.004) (5-years: OR, 6.89; 95% CI, 1.42-33.39; p = 0.017). Stratifying by GCS score of 8 or lower and early intubation, HAP remained a significant independent predictor of low GOSE score in all strata. In the general estimating equation model, HAP continued to be an independent predictor of low GOSE score (OR, 4.59; 95% CI, 1.82-11.60; p = 0.001). CONCLUSION: HAP is independently associated with poor outcomes in severe TBI extending 5 years after injury. This suggests that precautions should be taken to reduce the risk of HAP in individuals with severe TBI. LEVEL OF EVIDENCE: Prognostic study, level III.