For citation purposes: Verma V, Gupta K, Singh GK, Kumar S, Shantanu K, Kumar A. Effect of referral on mortality in trauma victims admitted in trauma centre of Chattrapati Shahuji Maharaj Medical University: A one year follow up study. Hard Tissue 2014 Jan 25;3(1):2.

Research study

 
Trauma & Orthopaedics

Effect of referral on mortality in trauma victims admitted in trauma centre of Chattrapati Shahuji Maharaj Medical University: A one year follow up study.

V Verma 1*, K Gupta 1, G Singh 1, S Kumar 1, K Shantanu1, A Kumar2
 

Authors affiliations

(1) Department of Orthopaedics, C S M Medical university, Lucknow

(2) Department of General Surgery, AIIMS, Patna

(4)

* Corresponding author Email: surgeonvikas@yahoo.co.in

Abstract

Introduction

The objectives of this study were to outline the effect of referral from peripheral hospitals on mortality in patients admitted to the trauma centre of Chattrapati Shahuji Maharaj Medical University and to describe inter-hospital transfer.

Methods

Patients admitted on all Mondays of a year and eight randomly selected Mondays and Wednesdays were enrolled and compared. Demographic and clinical profiles of patients presenting directly to the Trauma Centre of CSMMU and those referred from peripheral hospitals were compared. Transfer vehicle was evaluated and accompanying personnel were interviewed to ascertain the clinical status of the patients during transfer, details of the transfer process, training of the transfer personnel, adequacy of the transfer vehicle and its outfitted monitoring equipment.

Results

Five hundred seventy two patients were enrolled in the study including 327 referred and 245 directly admitted patients. There was 27 % mortality in the referred group and 22% mortality in the directly admitted group (p value 0.20). Despite similar ISS patients referred from peripheral hospitals had lower GCS ( p value 0.029), and higher TRISS (p value 0.01) Referred group had greater delay in presentation (p value 0.0001) to the trauma centre and longer duration of hospital stay (p value 0.013). The date and time of injury, GCS score, pupil size and reaction was not documented in transfer record in any of the 327 referred patients. Referral time, pulse rate and blood pressure were recorded in transfer records in 13.71%, 34.38% and 34.25% cases respectively. On arrival 71 patients had a GCS score of less than 8. Of these, none had been intubated in the referral hospital or on way. Ambulances were used for transfer in 15.12% cases. Equipment to measure blood pressure, intravenous access and fluids, and suctioning were present in 95.91%, 61.22%, and 44.89% of ambulances respectively.

Conclusion

Referral from a peripheral hospital results in significant delay in presentation to the trauma centre but does not affect mortality adversely. There is a need to devise a national referral policy.

Introduction

The trauma centre of Chattrapati Shahuji Maharaj Medical University (CSMMU) is the only trauma centre in Uttar Pradesh and serves the needs of rural areas of Uttar Pradesh up to a radius of 100 miles. Many trauma victims are first admitted to inadequately equipped primary or secondary care hospitals due to geographical and economic considerations. India has no trauma care referral algorithm, or an established system of pre-hospital care or transfer. This raises the possibility that the patients being referred from peripheral hospital may be adversely affected due to attendant delays with such transfers, lack of well-defined transfer protocols and poor treatment at peripheral hospitals. The objective of this study was to describe the process of inter-hospital transfer and the effect of referral on mortality.

Materials and methods

Patients that were simply picked up from the site of injury and transported by police, relatives or passerby to our institution without any medical treatment being administered were considered as ‘direct admissions’. Patients which stopped and received treatment at peripheral hospitals prior to referral to our institution were considered as ‘referred patients’. Similar treatment protocols were followed in both the groups after arrival at the emergency room of the trauma centre.

Approval for the study was obtained from the Institutional Review Board. A questionnaire was prepared in which item analysis was done for inter-observer and intra-observer variability. The inclusion criteria for the study were all patients admitted on all Mondays of a year (1[st] March 2010 to 28th February 2011) consecutively recruited subject to written informed consent. For critically ill patients consent was obtained from a relative. Additionally data was collected on patients admitted on Wednesdays and Saturdays of 8 randomly selected weeks (using opaque chits to ensure simple random sampling). Patients admitted on Wednesday and Saturdays were compared among themselves and with those admitted on Mondays to determine whether day of admission made any difference on patient characteristics. Patients admitted on Wednesdays and Saturdays were to be included in final analysis if they were found to be similar to patients admitted on Mondays. Data was collected by an Orthopaedic surgeon in the emergency room of the trauma centre as soon as the patient arrived. All injuries were recorded using Abbreviated Injury scale to calculate the Injury Severity Score.

Information about demographic and clinical details was collected. These included age, sex, preexisting chronic comorbidities (i.e. Coronary artery disease, Chronic obstructive pulmonary disease, Hypertension, Renal disease, Diabetes mellitus, Malignancies), Glasgow Coma Score (GCS)[1], Injury Severity Score (ISS)[2], Revised trauma score[3] Trauma Injury Severity Score (TRISS)[4], blood pressure at admission, respiratory rate at admission, time to first blood transfusion, number of blood units transfused, number of surgeries performed on the patient, time elapsed since injury to admission to trauma centre. Information on economic status of the patient was recorded using the “Below poverty line card” status of the patient. The investigator also evaluated the transfer vehicle and interviewed accompanying transfer personnel to record information on the clinical status of the patients during transfer, details of the transfer process, training of the transfer personnel, adequacy of the transfer vehicle and its outfitted monitoring equipment. Data communicated to the trauma centre from the referring hospitals were also collected from the transfer records. Since the peripheral hospitals do not have access to internet and no data is transferred electronically by them, no attempt was made to collect it.

Patients were classified into mutually exclusive injury subsets namely head injury alone, head injury with any other injury, single segment of an extremity (for e.g.: thigh, arm, leg, foot), >1 segment of an extremity (arm and forearm) or > 1 extremity (thigh of left extremity and leg of right extremity), abdominal injury alone, chest injury alone, face injury alone, cervical spine injury alone, thoracic spine injury alone, lumbar spine injury alone and other poly-trauma (All other combinations of injuries which do not fit in other categories). This was done to identify injury subsets having a higher proportion in the referred group and address the possibility that patients of a particular injury subset (trauma pattern) may benefit from early treatment being provided at a peripheral hospital.

Statistical methods

Descriptive statistics were described as mean±Standard Deviation/median and frequency/percentage. Level of significance between the difference was estimated by using Pearson’s c[2] test and making adjustment for low cell frequencies (expected frequency<5) or Fisher’s Exact test as applicable. The quantitative variables were compared by using two-sample t-test for normally distributed data or otherwise Mann-Whitney U-test.

Results

Five hundred ninety two patients met the inclusion criteria for the study. However twenty patients did not consent to be included in study and hence they were not included in the study. Thus, five hundred seventy two patients were included in the study. These included three hundred seventy eight patients admitted on 33 Mondays, ninety nine patients admitted on 8 Wednesdays and ninety five patients admitted on 8 Saturdays. Patients were predominantly male (83.5%) with median age of 38 years, median ISS of 9, and mean GCS of 12.20±4.1 (median 15). Mean time to admission to the trauma centre was 54.22±185.2 hours. Median time to admission to the referring hospital was 4 hrs. Out of total 572 patients, 327 (57%) patients were referred patients and 245(43%) were directly admitted patients.

The clinical and demographic profiles as well as mortality outcome of patients admitted on different days of the same week were compared and found to be similar on the parameters age, sex, and mortality, status at discharge, ISS and admission gap (Table 1).

Patients referred from peripheral hospitals had significantly lower GCS (p value 0.0296), higher TRISS (p value 0.01), higher time to admission to trauma centre (p value < 0.0001) and longer duration of hospital stay (p value 0.013). The ISS was not significantly different in the two groups (p value 0.06). Out of the 327 referred patients 73 i.e. 22.32% had a below poverty line card while 36/245 (14.69%) in the directly admitted group had a below poverty line card ((p value 0.0215). (Table 2) Patients referred from peripheral hospitals had a trend towards higher operative rates (0.544 operations per patient vs. 0.461operations per patient), lower blood pressure at admission, a greater proportion of head injuries and higher proportion of female patients but the differences were not statistically significant. Hypotension at admission defined as a systolic BP <109 mm of Hg was present in 61/317 (19.24%) referred patients without neurogenic shock. 148/327 (45.25%) of the referred patients required operative intervention while 102/245 (41.63%) of the directly admitted patients required operative intervention. An important finding of our study was that ISS (p value 0.06) of head injury patients was not significantly different in both the groups but TRISS was significantly worse in the referred group (p value 0.0170).

139/327 (42.50%) of the referred patients had ISS more than 15. 79/245 (32.24%) of the directly admitted patients had ISS > 15. 90/327 (27.52%) of the referred patients had GCS < 9 while 42/245 (17.14%) of the directly admitted patients had a GCS < 9. One year mortality since the time of injury was 27% in the referred group and 22% in the directly admitted group. Three patients that died due to causes (as per results of verbal autopsy) other than trauma were excluded from analysis. One year mortality among patients with ISS >15 was 55.39% (77/139 died) in the referred group and 50.63% (40/79 died) in the directly admitted group. One year mortality among patients with GCS < 9 was 68.88% (62/90 died) in the referred group and 64.42% (27/42 died) in the directly admitted group.

The level of documentation in transfer records from the referral hospital accompanying the patient was generally sub-optimal. The date and time of injury, GCS score, pupil size and reaction was not documented in transfer records in any of the 327 referred admitted patients. Referral time was recorded in 44/327 (13.71%) cases by the referring hospitals. Only 110/327 (34.38%) patients had pulse rate and 112/327 (34.25%) had blood pressure recorded on the transfer documents. (Table 3.) On arrival 71 patients had a GCS score of less than 8. Of these, none had been intubated in the referral hospital or on way.

Table 1

Clinical and demographic profiles and mortality in patients admitted on different days of the week

Table 2

Comparison of baseline characteristics of referred admitted and direct admitted patients.

Table 3

Describing the details of inter-hospital transfer

The request for transfer was made in only 3 (0.93%) cases. All the cases were transferred using roads. Ambulances were used for transfer in 49 (15.12%) cases while the rest were transferred using a non-ambulance vehicles. Equipment to measure blood pressure was present in 47/49 (95.91%) ambulances. Automated monitoring devices to measure blood pressure, heart rate and pulse oximetry were present in two privately operated ambulances. Functional equipment for suctioning were present in 22 (44.89%) of the ambulances. (Table 3). Equipment for intravenous access and intravenous fluids were present in 30/49(61.22%) ambulances.

Intravenous access and infusions in progress were present in 192/327 (58.71%) transferred patients. The majority received physiological solutions i.e. Ringer Lactate or Normal Saline but non physiological solutions like 5% Dextrose in water was given to 22 (5.94%) patient. Urethral catheters were present in 49 (15.17%) patients. Only 9/327 (2.79%) transferred patients had hard cervical immobilization. Table 3. All of these were cervical spine injury patients. However 5 of the 14 cervical spine injury patients who were referred did not have any kind of cervical immobilization. None of the patients with GCS < 8 had cervical immobilization.

Twelve cases (3.66%) were accompanied by a paramedic or a nurse. A doctor did not accompany the referred patient in any of the cases. Two hundred and four (62.39%) of the 327 referred cases were referred by a government run hospital while 123 (37.61%) had been referred by a private hospital or a private practitioner. All the patients who were accompanied by a nurse or paramedic had been referred by private hospitals.

Discussion

An important finding of our study is significantly higher time to admission to the trauma centre in the referred group as compared to the directly admitted group. A significantly higher time to admission to the trauma centre in the referred group as reported by us has also been reported by other studies[5,6]. Treating the life-threatening effects of injury before arrival at trauma centre--either pre-hospital or at the first hospital, is reported to be more relevant to decreasing mortality than simply shortening the time to admission to trauma centre[7]. It is said that any delay in transfer to a specialized trauma centre should cause concern and any intervention prior to transfer should be justified by its impact on survival[7]. Though the mortality in the referred group was higher but the difference was not statistically significant. The reason for this could be very low numbers of patients in subgroups (major trauma, severe head injury, SDH and EDH) where early treatment at trauma centre is known to be beneficial.

Another important finding of our study was presence of hypotension at admission in 19.24% referred cases. A systolic blood pressure of <109 mm Hg at presentation is known to be associated with mortality in trauma patients[8]. This raises the possibility of under-resuscitation prior to transfer which may lead to a higher mortality.

Our results are consistent with other studies that report a higher injury severity[7] and higher proportion of head injuries[5] in the referred group. A higher proportion of head injury patients in the referral group may be due to the requirement of airway intervention (a facility which is lacking in many peripheral hospitals) in these patients. This was subsequently corroborated by significantly higher tracheostomy (for airway maintenance) rates in the referral group.

An important finding in our study was a significantly higher proportion of major trauma patients and severe head injury patients in the referred group. We also found a trend towards lower mortality in head injury patients with GCS < 9 directly admitted to a trauma centre though the result was statistically insignificant. However the benefit of direct admission to trauma centre in cases of head injury is reported at GCS < 9 in an organized state trauma system with facilities of pre-hospital care[10]. Another trend though statistically insignificant seen in our study was lower mortality in directly admitted subdural haematoma and extradural cases. Direct admission of all head injured patients to a neurosurgical unit is reported to lead to a significant reduction in mortality and morbidity in patients with an extradural haematoma [11]. Another important finding of our study was a higher proportion of major trauma victims (ISS > 15) in the referred group. Sampalis et al [12] have reported that direct transport to a tertiary care center lowers mortality among major trauma victims but this could be done after introducing a system of effective prehospital care, an organized system of triage, referral and transport. A future study focussing on some categories of patients such as those demonstrating Sub-Dural haematoma, GCS less than 9 or ISS more than 15 may yield interesting data to support the designing of local inter-hospital transport protocols.

An important finding of our study was significantly worse TRISS scores in the referred group despite similar ISS in the two groups. This could be because of the inadequacies of the inter-hospital transfer like lack of airway intubation in head injury patients with GCS < 9 or use of non-physiological intravenous solutions. Airway intubation in head injury patients is a well-accepted international practice and is known to decrease neurological deterioration[13,14,15].

Another alarming findings of our study was that referral from a peripheral hospital was positively associated with below poverty line status of the patient. This may be on account of poorer going to the nearby hospital instead of rushing to the trauma centre due to lack of knowledge or money to hire a vehicle. An ambulance was sometimes available at the referring hospital. Another reason for the positive association between below poverty line status and referral could be selective referral of such patients to the trauma center. On the basis of available evidence from our study, it is not possible to conclude as to what was the reason for the positive association between referral from peripheral hospital and below poverty line status of the patient.

One particularly worrisome finding was that none of the 71 patients with GCS scores < 8 had airway protection in the form of endotracheal intubation, contrary to all current recommendations (13-15). Hypoxia and hypercarbia are substantial contributors to worsened neurologic outcomes from head trauma and other injuries. The lack of definitive airway establishment may reflect a lack of adequately trained personnel in the recognition of the need for airway protection and the lack of ability or supplies to do so. Additionally, minimal use of cervical immobilization prior to and during transfer is again contrary to international guidelines that state that cervical immobilization should be applied to all blunt trauma patients with GCS < 8 and certainly, all patients with a cervical spine injury. The lack of cervical spine immobilization may reflect the lack of suitably trained emergency department staff and/or lack of supplies at the referral hospitals. The choice of inadequate resuscitative intravenous fluids in 22 (5.94%) patients and the prevalence of untreated hypotension at arrival found in 106/317 (32.41%) referred patients without neurogenic shock signify delayed recognition of shock states and under resuscitation in patients.

Inter-hospital transfer of trauma patients is a potentially hazardous process due to a possibility of well documented complications like hypoxia, hypotension, hypercarbia, convulsions, intracranial haematoma and neurological deterioration[16,17,18]. The timeliness, duration and quality of transfer process itself may govern morbidity and mortality outcomes. Most countries follow existing guidelines to govern the safe transportation of injured patients [13,14,15] but no such guidelines or referral systems exist in India. These existing guidelines generally demand that a nominated consultant be available at the referring and receiving institutions; mutually agreed local policies between the institutions involved; thorough resuscitation and stabilization of all patients prior to transfer; intubation and ventilation prior to transfer for patients with significantly depressed levels of consciousness; and mobile communication must exist between both units during transfer[13,14,15]. Monitoring of the patient during transfer should be similar to that in an intensive care unit[13,14,15]. In addition, the entire process should be the subject of education and audit and funding should be available at appropriate levels[13,14,15].

Conclusion

Patients referred to CSMMU trauma center have similar mortality as patients directly admitted despite being more seriously injured (higher TRISS and lower GCS), stay hospitalized in the trauma centre for a longer duration and have a higher proportion of major trauma and severe head injury. Referral from a peripheral hospital results in significant delay to admission to trauma centre. However treatment at peripheral hospital does not appear to affect mortality, either positively or negatively.

Despite the efforts being made, the condition as of now is unacceptable and needs a rational referral policy contributed to and agreed by all service providers which must be strongly enforced without delay. On the basis of evidence generated by this paper and similar papers published elsewhere our recommendations are that:

All hospitals share a unified electronic medical record which can capture provider documentation, patient data, photos and videos.

All interfacility transfer ambulances must also have the ability to access, retrieve and update the electronic medical record of the patient regarding the patient’s clinical status enroute to a higher level of care.

All transfer of substantially injured patients should be accompanied by trained health care providers.

All vehicles involved with the transfer of injured patients should contain agreed upon basic equipment including pulse oxymetry, suction, oxygen and automated patient monitoring equipment.

Standardized communication with the receiving trauma facility should be mandated before patient transfer

Policy makers should recognize the need for integrated trauma care to maximize survivability of an increasing public health threat.

Conflict of interests

None declared.

Competing interests

None declared

References

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2.Baker SP, O'Neill B, Haddon W Jr, Long WB. “The Injury Severity Score: A method for describing patients with multiple injuries and evaluating trauma care. Journal of Trauma 14; 187-196:1974

3.Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. “A Revision of the Trauma Score”. J Trauma. 1989;29:623-629

4.Boyd CR, Tolson MA, Copes WS: “Evaluating Trauma Care: The TRISS Method”. Journal of Trauma 1987; 27:370-8.

5.Fatovich DM, Phillips M., Jacobs IG. A comparison of major trauma patients transported to trauma centers vs. non-trauma centers in metropolitan Perth. Resuscitation. 2011 May;82(5):560-3. Epub 2011 Feb 22.

6.Helling TS., Davit F., Edward K. First echelon hospital care before trauma center transfer in a rural trauma system: does it affect outcome? J Trauma. 2010 Dec; 69(6):1362-6.

7.Gomes E, Araujo R, Carneiro A, Dias C, Costa-Pereira A, Lecky FE. The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma. Resuscitation. 2010; 81:440–5.

8.Edelman DA, White MT, Tyburski JG, et al. Post-traumatic hypotension: should systolic blood pressure of 90–109 mm Hg be included? Shock 2007;27(2):134–8

9.Rogers FB, Osler TM, Shackford SR, Cohen M, Camp L, Lesage M. Study of the Outcome of Patients Transferred to a Level I Hospital after Stabilization at an

Outlying Hospital in a Rural Setting. J Trauma. 1999 Feb;46(2):328-33.

10.Hartl R., Gerber L M., Iacono L., Ni Q., Lyons K., Ghajar J. Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury. J Trauma. 2006 Jun;60(6):1250-6; discussion 1256.

11.Poon W S., Li K. Comparison of management outcome of primary and secondary referred patients with traumatic extradural haematoma in a neurosurgical unit. Injury. 1991 Jul;22(4):323-5.

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13.Working Party of the Neuroanaesthesia Society and Association of Anaesthetists. Recommendations for the transfer of patients with acute head injuries to neurosurgical units. London: Neuroanaesthesia Society of Great Britain and Ireland and the Association of Anaesthetists of Great Britain and Ireland; 1996.

14.Scottish Intercollegiate Guidelines Network. Early management of patients with head injury. Royal College of Physicians of Edinburgh;2000

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    Licensee to OAPL (UK) 2014. Creative Commons Attribution License (CC-BY)

    Clinical and demographic profiles and mortality in patients admitted on different days of the week

    Quantitative variables

    Parameter

    Monday

    Wednesday

    Saturday

    P value

     

    N

    Mean

    N

    Mean

    N

    Mean

    Age

    378

    41.03±16.6

    99

    41.12±15.5

    90

    40.06±16.1

    0.8282

    ISS

    376

    12.88±7.6

    99

    11.16±6.2

    95

    12.68±7.4         

    0.2218

    TRISS

    349

    7.01±13.3         

    97

    6.18±13.5

    86

    4.71±9.1

    0.440

    Qualitative variables

     

    N

    %

    N

    %

    N

    %

     

    Expiry

    378                 

    25.93     

    99

    21.21     

    90

    24.44

    0.624

    Female sex

    70               

    18.52     

    13

    13.13     

    11

    12.22

    0.211

    Pre-existing comorbidities

    Coronary artery disease

    11               

    2.91            

    3

    3.03

    3

    3.33

    0.978

    COPD

    19                

    5.03      

    4

    4.04      

    4

    4.44

    0.908

    Hypertension

    15         

    3.97     

    5

    5.05

    6

    6.67

    0.530

    Renal disease

    2

    0.53      

    0

    0.00      

    2

    2.22

    0.148

    Diabetes Mellitus

    11

    2.91             

    2

    2.02     

    2

    2.22

    0.854

    Deranged Respiratory rate

    <=10

    7

    1.85             

    0

    0.00

    1

    1.11

    0.401

    11-26

    302        

    79.89     

    85

    85.86     

    77

    85.56

    >26

    69

    18.25     

    14

    14.14     

    12

    13.33

    Referral

    217

    57.41     

    49

    49.49     

    59

    65.56

    0.083

    Systolic BP <100

    51

    13.49     

    12

    12.12     

    20

    22.22

    0.080

     

     

    Comparison of baseline characteristics of referred admitted and direct admitted patients.

     

    Quantitative variable

    Rreferred admitted

    Direct admitted

     

    P

    N

    Mean±SD/Median

    N

    Mean±SD/Median

    Age

    327

    41.11±16.4/40

    245

    40.40±16.1/37

    0.5994

    ISS

    327

    13.08±7.4/9

    243

    11.87±7.2/9

    0.0536

    RR

    327

    22.02±5.5/20

    245

    21.38±6.2/20

    0.1248

    Time to first blood transfusion (hrs)

    101

    58.51±73.1/24

    46

    39.28±47.2/24

    0.2089

    Number of blood unit transfused

    101

    2.46±1.7/2

    46

    2.09±1.3/2

    0.5490

    GCS

    311

    11.87±4.2/15

    226

    12.66±3.9/15

    0.0296

    TRISS

    311

    7.00±12.5/1.5

    225

    5.67±13.0/1

    0.0101

    Time to admission to referral centre (hrs)

    327

    12.65±36.5/4

     

     

     

    Time to admission in trauma centre (hrs)

    327

    78.02±235.0/14.92

    245

    22.44±68.8/5

    <0.0001

    Hospital stay (Days)

    327

    10.89±12.3/7

    245

    9.25±13.3/6

    0.013

     

    Qualitative variables

    N

    %

    N

    %

    P

    Female sex

    327

    18.96

    245

    13.06

    0.0596

    Previous associated morbidities

     

     

     

     

     

    CAD

    327

    2.45

    245

    3.67

    0.3925

    COPD

    327

    4.89

    245

    4.49

    0.8223

    Hypertension

    327

    4.89

    245

    4.08

    0.6448

    Renal disease

    327

    0.61

    245

    0.82

    0.7713

    Diabetes mellitus

    327

    4.28

    245

    0.41

    0.003

    Tracheostomy at CSMMU

    327

    6.73

    245

    2.04

    0.0089

    BPL Card 

    327

    22.32

    245

    14.69

    0.0215

    Respiratory rate

     

     

     

     

     

    ≤10

    327

    0.92

    245

    2.04

    83.27

    14.69

    0.3176

    11-26

    327

    81.04

    245

    >26

    327

    18.04

    245

    Systolic Blood Pressure 100

    327

    16.82

    245

    11.43

    0.07

    Diastolic Blood Pressure 60

    327

    13.46

    245

    8.98

    0.0973

    ISS > 15

    327

    42.50

    245

    32.24

    0.015

    GCS < 9

    311

    28.94

    226

    18.58

    0.006

    Mortality in Extra Dural Haematoma

    19

    42.11

    9

    33.33

    »1.0000

    Mortality in Sub Dural Haematoma

    10

    70.00

    9

    33.33

    0.1790

    Mortality in major trauma ISS > 15

    139

    55.39

    79

    50.63

    0.750

    Mortality in severe head injury patients (GCS < 9)

    90

    68.88

    42

    64.42

    0.599

    Trauma pattern

     

     

     

     

     

       Head injury

    327

    35.17

    245

    27.76

    0.06

       Head injury combined with any other injury 

    327

    10.09

    245

    11.84

    0.506

       Single segment of an extremity

    327

    29.05

    245

    33.06

    0.304

       >1 segment of an extremity or > 1 extremity

    327

    6.42

    245

    8.98

    0.251

       Other poly trauma

    327

    7.34

    245

    6.53

    0.707

       Cervical spine

    327

    4.28

    245

    5.31

    0.567

       Thoracic Spine

    327

    1.53

    245

    1.22

    0.759

        Lumbar spine

    327

    0.92

    245

    1.22

    0.721

       Chest

    327

    2.75

    245

    2.86

    0.94

       Abdominal trauma

    327

    2.14

    245

    0.82

    0.208

       Face

    327

    0.31

    245

    0.41

    0.837

     

     

    Describing the details of inter-hospital transfer

    Documentation on referral slips (N=327)

    Pulse rate

    110 (33.63%)

    Blood Pressure

    112(34.25%)

    Referral Time

    44(13.45%)

    Pupillary size and reaction

    0(0%)

    GCS

    0(0%)

    Equipment in ambulance (N=49)

    Oxygen

    48 (97.95%)

    Blood Pressure cuff manometer

    47 (95.91%)

    Equipment for iv access and iv fluids

    30(61.22%)

    Suction

    22 (44.89%)

    Pulse Oxymeter

    1(0.02%)

    Intravenous infusions present on arrival (N=327)

    Ringer Lactate or Normal Saline

    170 (51.98%)

    None

    135 (41.28%)

    5% Dextrose

       22 (6.72%)

    Protective patient devices in situ on arrival (N=51)

    Cervical Collar

    9 (2.79%)

    Endotracheal Intubation prior to arrival

    0(0%)

    Urethral Catheterisation

    49(15.17%)

    Nasogastric intubation

    20(6.11%)

     

     

    Keywords