Performance of Prognostication Scores for Mortality in Injured Patients in Rwanda.

Oliver Tang,Catalina González Marqués,Menelas Nkeshimana,Sonya Naganathan,Zachary Lipsman,Adam Levine,Andrew Stephen,Adam Aluisio,Doris Uwamahoro,Vincent Ndebwanimana,Naz Karim,Chantal Uwamahoro

doi:10.5811/westjem.2020.10.48434

Abstract

IntroductionWhile trauma prognostication and triage scores have been designed for use in lower-resourced healthcare settings specifically, the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. This study evaluated the Kampala Trauma Score (KTS), Revised Trauma Score (RTS), and Triage Early Warning Score (TEWS) for accuracy in predicting mortality among injured patients seeking emergency department (ED) care at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda.MethodsA retrospective, randomly sampled cohort of ED patients presenting with injury was accrued from August 2015–July 2016. Primary outcome was 14-day mortality and secondary outcome was overall facility-based mortality. We evaluated summary statistics of the cohort. Bootstrap regression models were used to compare areas under receiver operating curves (AUC) with associated 95% confidence intervals (CI).ResultsAmong 617 cases, the median age was 32 years and 73.5% were male. The most frequent mechanism of injury was road traffic incident (56.2%). Predominant anatomical regions of injury were craniofacial (39.3%) and lower extremities (38.7%), and the most common injury types were fracture (46.0%) and contusion (12.0%). Fourteen-day mortality was 2.6% and overall facility-based mortality was 3.4%. For 14-day mortality, TEWS had the highest accuracy (AUC = 0.88, 95% CI, 0.76–1.00), followed by RTS (AUC = 0.73, 95% CI, 0.55–0.92), and then KTS (AUC = 0.65, 95% CI, 0.47–0.84). Similarly, for facility-based mortality, TEWS (AUC = 0.89, 95% CI, 0.79–0.98) had greater accuracy than RTS (AUC = 0.76, 95% CI, 0.61–0.91) and KTS (AUC = 0.68, 95% CI, 0.53–0.83). On pairwise comparisons, RTS had greater prognostic accuracy than KTS for 14-day mortality (P = 0.011) and TEWS had greater accuracy than KTS for overall (P = 0.007) mortality. However, TEWS and RTS accuracy were not significantly different for 14-day mortality (P = 0.864) or facility-based mortality (P = 0.101).ConclusionIn this cohort of emergently injured patients in Rwanda, the TEWS demonstrated the greatest accuracy for predicting mortality outcomes, with no significant discriminatory benefit found in the use of the trauma-specific RTS or KTS instruments, suggesting that the TEWS is the most clinically useful approach in the setting studied and likely in other similar ED environments.

Highlights

While trauma prognostication and triage scores have been designed for use in lowerresourced healthcare settings the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood
For 14-day mortality, Triage Early Warning Score (TEWS) had the highest accuracy (AUC = 0.88, 95% confidence intervals (CI), 0.76–1.00), followed by Revised Trauma Score (RTS) (AUC = 0.73, 95% CI, 0.55–0.92), and Kampala Trauma Score (KTS) (AUC = 0.65, 95% CI, 0.47–0.84)
TEWS and RTS accuracy were not significantly different for 14-day mortality (P = 0.864) or facility-based mortality (P = 0.101). In this cohort of emergently injured patients in Rwanda, the TEWS demonstrated the greatest accuracy for predicting mortality outcomes, with no significant discriminatory benefit found in the use of the trauma-specific RTS or KTS instruments, suggesting that the TEWS is the most clinically useful approach in the setting studied and likely in other similar emergency department (ED) environments. [West J Emerg Med. 2021;22(2)435-444.]

Summary

Introduction

While trauma prognostication and triage scores have been designed for use in lowerresourced healthcare settings the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. Triage systems are an important method to assist in addressing health barriers as they can facilitate the prompt identification of patients with the most urgent needs and highest risks.[6,7] Prior research has demonstrated that triage systems used in acute care settings in LMICs are associated with reduced time to treatment and mortality.[8,9] Trauma prognostication scores, which are designed to stratify patient severity and predict mortality, have the potential to enhance triage for injured patients.[10] the Revised Trauma Score (RTS) has been used in high-income countries (HIC),[11] this metric and other scores initially developed in HICs may have limited application in LMICs.[5,10] the Kampala Trauma Score (KTS) was developed in Uganda in 1996 for use in trauma prognostication in sub-Saharan Africa and has since been validated.[3,5,10,12] Several studies comparing the RTS and KTS have shown that both scores have clinical utility in risk-stratifying injury cases and predicting mortality in sub-Saharan Africa,[2,3,5,10] but their accuracy has not been directly compared to established triage tools that are more broadly applicable to both injured and noninjured patients

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