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Secondary Overtriage of Trauma Patients to a Central Hospital in Malawi

  • Surgery in Low and Middle Income Countries
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Introduction

Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital.

Methods

A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information.

Results

Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6–31 versus median 26, IQR: 11–38, p < 0.001). Patients with primary extremity injury (5308, 59.9%) were overtriaged more than those with head injury (1991, 51.8%) or torso trauma (1349, 50.8%), p < 0.001. The OT rate was lower at night (18.9% v 28.7%, p < 0.001) and similar on weekends (20.4% v 21.8%, p = 0.03). OT was highest for penetrating wounds, bites, and falls; burns were the lowest. In multivariable modeling, risk of OT was greatest for burns and soft tissue injuries.

Conclusions

The majority of trauma patients who transfer to KCH are overtriaged. Implementation of transfer criteria, trauma protocols, and interhospital communication can mitigate the strain of OT in resource-limited settings.

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References

  1. Mock C, Joshipura M, Arreola-Risa C et al (2012) An estimate of the number of lives that could be saved through improvements in trauma care globally. World J Surg 36:959–963. https://doi.org/10.1007/s00268-012-1459-6

    Article  Google Scholar 

  2. Reynolds TA, Stewart B, Drewett I et al (2017) The impact of trauma care systems in low- and middle-income countries. Annu Rev Public Health 38:507–532

    Article  Google Scholar 

  3. Aaronson E, Mort E, Soghoian S (2017) Mapping the process of emergency care at a teaching hospital in Ghana. Healthc (Amst) 5:214–220

    Article  Google Scholar 

  4. Kubwimana O (2018) Elaborated plan for incoming surgical emergency management in Sub-Saharan Africa. Open Access Emerg Med 10:67–70

    Article  Google Scholar 

  5. Harmsen AM, Giannakopoulos GF, Moerbeek PR et al (2015) The influence of prehospital time on trauma patients outcome: a systematic review. Injury 46:602–609

    Article  CAS  Google Scholar 

  6. Tang A, Hashmi A, Pandit V et al (2014) A critical analysis of secondary overtriage to a Level I trauma center. J Trauma Acute Care Surg 77:969–973

    Article  Google Scholar 

  7. Ciesla DJ, Sava JA, Street JH 3rd et al (2008) Secondary overtriage: a consequence of an immature trauma system. J Am Coll Surg 206:131–137

    Article  Google Scholar 

  8. Con J, Long D, Sasala E et al (2015) Secondary overtriage in a statewide rural trauma system. J Surg Res 198:462–467

    Article  Google Scholar 

  9. Sorensen MJ, von Recklinghausen FM, Fulton G et al (2013) Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg 148:763–768

    Article  Google Scholar 

  10. Abebe Y, Dida T, Yisma E et al (2018) Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia. BMC Emerg Med 18:7

    Article  Google Scholar 

  11. Cannon CM, Braxton CC, Kling-Smith M et al (2009) Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma 67:1426–1430

    Article  Google Scholar 

  12. Gallaher J, Jefferson M, Varela C et al (2019) The Malawi trauma score: a model for predicting trauma-associated mortality in a resource-poor setting. Injury 50:1552–1557

    Article  Google Scholar 

  13. Eastwood K, Smith K, Morgans A et al (2017) Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study. BMJ Open 7:e016845

    Article  Google Scholar 

  14. Famoye F, Rothe DE (2003) Variable selection for Poisson regression model. J Mod Appl Stat Methods 2:11

    Article  Google Scholar 

  15. Knol MJ, Le Cessie S, Algra A et al (2012) Overestimation of risk ratios by odds ratios in trials and cohort studies: alternatives to logistic regression. CMAJ 184:895–899

    Article  Google Scholar 

  16. Mbengue MAS, Chasela C, Onoya D et al (2019) Clinical predictor score to identify patients at risk of poor viral load suppression at six months on antiretroviral therapy: results from a prospective cohort study in Johannesburg, South Africa. Clin Epidemiol 11:359–373

    Article  Google Scholar 

  17. Zou G (2004) A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 159:702–706

    Article  Google Scholar 

  18. Laytin AD, Kumar V, Juillard CJ et al (2015) Choice of injury scoring system in low- and middle-income countries: lessons from Mumbai. Injury 46:2491–2497

    Article  Google Scholar 

  19. Kawooya MG (2012) Training for rural radiology and imaging in sub-saharan Africa: addressing the mismatch between services and population. J Clin Imaging Sci 2:37

    Article  Google Scholar 

  20. Littman-Quinn R, Mibenge C, Antwi C et al (2013) Implementation of m-health applications in Botswana: telemedicine and education on mobile devices in a low resource setting. J Telemed Telecare 19:120–125

    Article  Google Scholar 

  21. Bracale M, Pepino A (1994) Medical technologies in developing countries: a feasibility study on the maintenance of medical equipment in Ethiopia. Med Biol Eng Comput 32:131–137

    Article  CAS  Google Scholar 

  22. Gajewski J, Bijlmakers L, Mwapasa G et al (2018) ‘I think we are going to leave these cases’. Obstacles to surgery in rural Malawi: a qualitative study of provider perspectives. Trop Med Int Health 23:1141–1147

    Article  CAS  Google Scholar 

  23. Gajewski J, Pittalis C, Lavy C, et al (2019) Anesthesia capacity of district-level hospitals in Malawi, Tanzania, and Zambia: a mixed-methods study. Anesth Analg. https://doi.org/10.1213/ANE.0000000000004363

    Article  Google Scholar 

  24. van Amelsfoort JJ, van Leeuwen PA, Jiskoot P et al (2010) Surgery in Malawi—the training of clinical officers. Trop Dr 40:74–76

    Article  Google Scholar 

  25. Bastawrous A, Armstrong MJ (2013) Mobile health use in low-and high-income countries: an overview of the peer-reviewed literature. J R Soc Med 106:130–142

    Article  Google Scholar 

  26. Kim J, Barreix M, Babcock C et al (2017) Acute care referral systems in Liberia: transfer and referral capabilities in a low-income country. Prehosp Disaster Med 32:642–650

    Article  Google Scholar 

  27. Augestad KM, Bellika JG, Budrionis A et al (2013) Surgical telementoring in knowledge translation—clinical outcomes and educational benefits: a comprehensive review. Surg Innov 20:273–281

    Article  Google Scholar 

  28. Augestad KM, Han H, Paige J et al (2017) Educational implications for surgical telementoring: a current review with recommendations for future practice, policy, and research. Surg Endosc 31:3836–3846

    Article  CAS  Google Scholar 

  29. Erridge S, Yeung DKT, Patel HRH et al (2018) Telementoring of surgeons: a systematic review. Surg Innov 26:95–111

    Article  Google Scholar 

  30. Pittalis C, Brugha R, Crispino G et al (2019) Evaluation of a surgical supervision model in three African countries—protocol for a prospective mixed-methods controlled pilot trial. Pilot Feasibility Stud 5:25

    Article  Google Scholar 

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Funding

This research did not receive external Grant funding.

Author information

Authors and Affiliations

  1. Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, NC, 27599, USA

    Rebecca G. Maine, Laura Purcell, Jared R. Gallaher, Trista D. Reid & Anthony G. Charles

  2. Department of Surgery, Kamuzu Central Hospital, Box 149, Lilongwe, Malawi

    Chifundo Kajombo & Gift Mulima

  3. Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA

    Jennifer Kincaid

  4. Department of Surgery, University of Washington Harborview Medical Center, 325 Ninth Ave, Box 359796, Seattle, WA, USA

    Rebecca G. Maine

Authors
  1. Rebecca G. Maine
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  2. Chifundo Kajombo
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  3. Gift Mulima
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  4. Jennifer Kincaid
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  5. Laura Purcell
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  6. Jared R. Gallaher
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  7. Trista D. Reid
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  8. Anthony G. Charles
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Corresponding author

Correspondence to Rebecca G. Maine.

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Conflict of interest

None of the authors have any conflict to declare.

Ethical approval

This study was approved by both University of North Carolina IRB and the Malawian National Health Science Research Council, who waved the need for individual consent given the nature of the study design.

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Maine, R.G., Kajombo, C., Mulima, G. et al. Secondary Overtriage of Trauma Patients to a Central Hospital in Malawi. World J Surg 44, 1727–1735 (2020). https://doi.org/10.1007/s00268-020-05426-0

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  • DOI: https://doi.org/10.1007/s00268-020-05426-0

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