Open access Original research Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2021-000674 on 26 August 2021. Downloaded from Delays in emergency department intervention for patients with traumatic brain injury in Uganda Amber Mehmood ,1,2 Armaan Ahmed Rowther,3 Olive Kobusingye ,4 Hussein Ssenyonjo,5 Nukhba Zia,2 Adnan A Hyder6 ► Additional supplemental ABSTRACT the global rate. Beyond acute injury, TBI can result material is published online Background In Sub-Sahar an African countries, the in severe long- term health sequelae, including life- only. To view, please visit the 3 4 journal online (http:// dx. doi. incidence of traumatic brain injury (TBI) is estimated long disability or death. With greater urbaniza- org/ 10. 1136/ tsaco- 2021- to be many folds higher than the global average and tion of SSA countries and increasing risk factors for 000674). outcome is hugely impacted by access to healthcare road traffic injuries, falls, and violent assaults, the services and quality of care. We conducted an analysis magnitude and severity of TBIs as a public health 1 College of Public Health, of the TBI registry data to determine the disparities and problem are increasing, making early and appro- University of South Florida, Tampa, Florida, USA delays in treatment for patients presenting at a tertiary priate management of suspected head injuries an 2International Health, Johns care hospital in Uganda and to identify factors predictive important health system priority for the region.5 Hopkins University Bloomberg of delayed treatment initiation. The cumulative incidence of TBI- related admis- School of Public Health, Methods The study was conducted at the Mulago sions at Mulago National Referral Hospital, Kampala Baltimore, Maryland, USA 3Department of International National Referral Hospital, Kampala. The study included has been estimated at 89 per 100 000 population Health, Johns Hopkins University all patients presenting to the emergency department per year, and mortality among the patients admitted Bloomberg School of Public (ED) with suspected or documented TBI. Early treatment with severe TBI was reported to be as high as 26%.6 Health, Baltimore, Maryland, was defined as first intervention within 4hours of ED The leading cause is motorcycle- related road traffic USA presentation—a cut-off determined using sensitivity 6 7 4Trauma, Injury, & Disability injuries. The outcome of TBI is hugely impacted Unit, Makerere University’s analysis to injury severity. Descriptive statistics were by availability and access to healthcare services, School of Public Health, generated and Pearson’s χ2 test was used to assess the timely implementation of TBI management guide- Kampala, Uganda sample distribution between treatment time categories. lines, and overall quality of care.8 9 Early diag- 5Neurosurgery, Mulago National Univariable and multivariable logistic regression models copyright. Referral Hospital, Kampala, nosis and treatment including appropriate surgical Uganda with <0.05 level of significance were used to derive the intervention can improve survival and may reduce 6Department of Global Health, associations between patient characteristics and early hospital length of stay.10 Suboptimal or delayed George Washington University intervention for TBI. management of brain injuries increases the risk of Milken Institute School of Public Results Of 3944 patients, only 4.6% (n=182) 11 Health, Washington, DC, USA death or permanent disability. This is of particular received an intervention for TBI management within concern in Uganda, where prehospital and in- hos- 1 hour of ED presentation, whereas 17.4% of patients Correspondence to pital delays and non- adherence to standardized care Dr Amber Mehmood; (n=708) received some treatment within 4 hours of contribute to hospital mortality as high as 45% to amehmood@ usf. edu presentation. 19% of those with one or more serious 75%.12–14 injuries and 18% of those with moderate to severe head The health system in Uganda is financed by Received 4 January 2021 injury received care within 4 hours of arrival. Factors several sources including national government, Accepted 20 July 2021 http://tsaco.bmj.com/ independently associated with early treatment included private sector, households, and health development young age, severe head injury, and no known pre- partners (external funding agencies). In the past existing conditions, whereas older or female patients had 5 years, the health sector budget as a proportion significantly less odds of receiving early treatment. of the national budget remained between 6% and Discussion With the increasing number of patients 8%, which is far from the target of 15%.15 Of the with TBI, ensuring early and appropriate management five East African countries, only Uganda is without must be a priority for Ugandan hospitals. Delay in national health insurance. Uganda abolished formal initiation of treatment may impact survival and functional user fees in 2001 in all public health facilities to on September 25, 2021 by guest. Protected outcome. Gender- related and age- related disparities in eliminate financial access barriers.16 As reported care should receive attention and targeted interventions. recently, the proportion of government contribu- Level of evidence Prognostic and epidemiological tion dropped to 57% in 2019 to 2020 from 64% in study; level II evidence. 2015 to 2016, and per capita allocation for health increased from US$13 in 2015 to 2016 to US$17 in 2019 to 2020, which is still below the WHO recom- © Author(s) (or their INTRODUCTION mendation of US$60 per capita.15 17 Nonetheless, employer(s)) 2021. Re- use Ugandans have continued to experience high levels permitted under CC BY-NC . No Traumatic brain injury (TBI) is a leading cause commercial re-use . See rights of neurological disorders and disability globally, of out- of- pocket expenditure owing to indirect fees and permissions. Published affecting as many as 69 million people annually (such as transportation costs), additional fees to pay by BMJ. and disproportionately burdening low-income for radiology, medicines, and supplies, and illegal 1 2 To cite: Mehmood A, and middle- income countries (LMICs). In Sub- fees demanded ostensibly by medical staff for free Rowther AA, Kobusingye O, Saharan Africa (SSA) the incidence of TBI has services.18 19 In this backdrop, there are potentially et al. Trauma Surg Acute Care recently been estimated to be as high as 801 per several factors influencing the healthcare service Open 2021;6:e000674. 100 000 person- years, several folds greater than delivery and quality of care in Uganda. Mehmood A, et al. Trauma Surg Acute Care Open 2021;6:e000674. doi:10.1136/tsaco-2021-000674 1 Open access Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2021-000674 on 26 August 2021. Downloaded from Improved understanding of the timeliness of care for patients severity.25 This consisted of testing the robustness of the observed with TBI and the factors predictive of treatment time in a association between GCS and treatment time across alternative resource- constrained setting such as Uganda can help inform thresholds for defining early treatment as an outcome ranging efforts to reduce delays, improve quality, and improve outcomes from 4±2 hours after patient assessment. To analyze the impact of TBI care. Recently, a dedicated TBI registry was implemented of age we used a linear spline mode where appropriate knots at the Mulago National Referral Hospital, Kampala to ensure were obtained using a smoothed Locally Weighted Scatterplot an evidence-based approach toward quality improvement (QI).20 Smoothing (LOWESS) plot for the relationship between early Using the TBI registry data, this study was conducted to (1) treatment as a dichotomous outcome variable and age of the investigate the time interval from emergency department (ED) patient. Three knots were identified, and these were used to presentation to TBI management interventions for patients construct linear splines that were included in subsequent logistic presenting with TBI and (2) identify patient characteristics regression analyses: 18 years, 40 years, and 60 years.26 27 GCS and injury factors predictive of early treatment initiation in a score reflecting injury severity was converted into ordinal cate- Ugandan context. gories of mild (13–15), moderate (9–12), and severe (<9). KTS was similarly analyzed as categories of mild (9–15), moderate 23 METHODS (7–8), and severe (4–6). The study was based on the Kampala internet- based Traumatic Brain Injury Registry (KiTBIR) data from the Mulago National Data analysis Referral Hospital in Kampala, Uganda. KiTBIR was based on the Descriptive statistics and tabulations were generated for patient core principles of hospital-based injury surveillance presented by clinical and demographic characteristics, prehospital care data, Mitchell et al,21 and customized specifically for Uganda through injury characteristics, and ED treatment times. Pearson’s χ2 test a collaboration between Mulago Hospital (MH), Makerere was used to assess the sample distribution between treatment University, and Johns Hopkins Bloomberg School of Public time categories.28 Univariable logistic regression models were Health. followed by multivariable logistic regression models with <0.05 level of significance to derive the associations between patient Study setting and participants and injury characteristics and early intervention for TBI, and MH is the largest tertiary care hospital