An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.

Armand Zimmerman,Joao Ricardo Nickenig Vissoci,Francis Sakita,Samara Fox,Mark Mvungi,Charles J Gerardo,Randi Griffin,Catherine A Staton,Erika Bárbara Abreu Fonseca Thomaz,Taylor Nelp,Blandina T Mmbaga,Hans-Peter Simmen

doi:10.1371/journal.pone.0240528

Abstract

Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.

Highlights

An estimated 69 million people worldwide experience a traumatic brain injury (TBI) each year [1]
Data Availability Statement: All data underlying the results presented in this study were collected from Kilimanjaro Christian Medical Centre (KCMC)
Among low- and middle-income countries (LMICs) the greatest burden of TBI exists in the World Health Organization (WHO) Africa Region, which accounts for 15.9% and 11.5% of LMIC and global TBIs respectively [1]

Summary

Introduction

An estimated 69 million people worldwide experience a traumatic brain injury (TBI) each year [1] The distribution of this burden is biased towards low- and middle-income countries (LMICs) which endure 90% of global injury related deaths and three times more TBI cases than high-income countries [1,2,3]. In addition to enduring a high TBI incidence, patients who sustain a TBI in subSaharan Africa have disproportionately worse outcomes in comparison to patients in high income countries [8,9,10,11,12] The cause of this disparity may result largely from differences in the quality of prehospital and in-hospital care [8, 13, 14].

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Conclusion