Prehospital Factors Associated with Discharge Outcomes: Baseline Data from the Andhra Pradesh Traumatic Brain Injury Project

Kodanda Ram; Kadali VaraPrasad; Murali K Krishna; Nithya Kannan; Venkataraman Sundar; Mathew Joseph; Virendar D Sinha; Dhaval Shukla; Gopalakrishnan Gururaj; Raj K Narayan; Jogi V Pattisapu; Monica S Vavilala

doi:10.1016/j.wnsx.2019.100020

Prehospital Factors Associated with Discharge Outcomes: Baseline Data from the Andhra Pradesh Traumatic Brain Injury Project

World Neurosurg X. 2019 Feb 13:2:100020. doi: 10.1016/j.wnsx.2019.100020. eCollection 2019 Apr.

Authors

Affiliations

¹ Department of Neurosurgery, King George Hospital, Andhra Medical College Visakhapatnam, KGH, Opp KGH OP Gate, Maharani Peta, Visakhapatnam, Andhra Pradesh, India.
² Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA.
³ Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.
⁴ Department of Neurosurgery, Madras Medical College and Dr. Rai Memorial Medical Centre, Madras Medical College, Park Town, Chennai, Tamil Nadu, India.
⁵ Division of Neurocritical Care & Trauma, Department of Neurological Science, Christian Medical College, Vellore, Tamil Nadu, India.
⁶ Department of Neurosurgery, S.M.S Medical College Jaipur, Jawahar Lal Nehru Marg, Gangawal Park, Adarsh Nagar, Jaipur, Rajasthan, India.
⁷ Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India.
⁸ Department of Epidemiology and Centre for Public Health, National Institute of Mental Health and Neuro Sciences, Bangalore, India.
⁹ Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, Hempstead, New York, USA.
¹⁰ Department of Pediatric Neurosurgery, University of Central Florida College of Medicine, Orlando, Florida, USA.

Abstract

Objective: Strategies to improve traumatic brain injury (TBI) outcomes in India are ill defined. The objective of this study was to examine baseline prehospital (PH) factors associated with outcomes from the Andhra Pradesh Traumatic Brain Injury Project.

Methods: We conducted a prospective observational cohort study of adult patients with TBI admitted to the primary referral hospital. Modes of injury, prehospital care and transport, and factors associated with increased in-hospital mortality were evaluated. Poisson regression with robust error variance and adjusted attributable risk percent estimates determined factors associated with outcomes.

Results: A total of 447 adults (38% with mild TBI, 30% with moderate TBI, and 32% with severe TBI; 81% men) with isolated TBI (89%) from road traffic accidents (48.1%) or falls (46.5%) were enrolled. Of the patients, 45.7% were transported by ambulance, 61% had scalp/facial bleeding, 11% had respiratory distress, and 7% had cervical spine stabilization. Of these, 25.3% died and 34% had unfavorable outcomes. Among 335 direct admits, 45% traveled more than 50 km and nearly 20% traveled more than 100 km. Bleeding was associated with higher mortality (adjusted relative risk [aRR], 1.56; 95% confidence interval [CI], 1.05-2.31) and unfavorable outcome (aRR, 1.60; 95% CI, 1.18-2.17). Of the patients, 45 (31%) with severe TBI received PH airway management prior to definitive treatment, and respiratory distress was associated with unfavorable discharge outcomes (aRR, 1.23; 95% CI, 1.00-1.51).

Conclusions: Patients with TBI often received treatment far away from injury, bypassing closer hospitals. Scalp/facial bleeding was common and associated with unfavorable outcomes. Ambulance use was infrequent, and few patients received PH airway management, hemorrhage control, or cervical spine stabilization when needed.

Keywords: AR%, Adjusted attributable risk percent; CI, Confidence interval; CT, Computed tomography; ED, Emergency department; GCS, Glasgow Coma Scale; ICU, Intensive care unit; IQR, Interquartile range; KGH, King George Hospital; LOS, Length of stay; OR, Operating room; Outcomes; PH, Prehospital; Risk factors; TBI, Traumatic brain injury; Trauma; Trauma system; Traumatic brain injury; Triage; aRR, Adjusted relative risk.