Neurotrauma Care Delivery in a Limited Resource Setting—Lessons Learned From Referral and Patient Flow in a Tertiary Care Center

Abstract

With the increasing population, motorization, and road traffic accidents, neurotrauma has been increasing in India. Inadequate triage and underusage of locally available resources at all healthcare levels has led to nonuniform neurotrauma care delivery. We present our experience at a tertiary care hospital. We evaluated the referral pattern of mild traumatic brain injury (mTBI) cases to enable adequate care to patients with moderate and severely injured TBI. All patients with head injury (n= 3891) referred to the emergency department of our institution during a 4-month period were evaluated. The demographic characteristics, ambulance usage, and time management during in-hospital patient flow were evaluated using the Lean Six Sigma approach. We have also provided solutions for optimal usage of available resources. Patients with mTBI comprised 77% of head injury referrals. Of all the patients referred from peripheral hospitals, 48% had normal head computed tomography (CT) scan findings. The CT waiting and lead (arrival-to-discharge) times were 35 ± 44 minutes and 114 minutes, respectively. No clinical to radiological correlation was found between the head CT scan findings and a decision to refer a patient to our institute. Only 10% of the patients with abnormal head CT scans (41%) required neurosurgical intervention. The mean duration from CT imaging to the initiation of surgery was 192.7 ± 172.1 minutes. Most of the patients with mTBI were referred to a tertiary care center, leading to secondary overtriage and overburdening of the existing resources at a specialized care hospital, possibly owing to ineffective triage at the primary and secondary healthcare centers. This would limit the adequate management of moderate to severe TBI cases in such a hospital.