title: A standardized trauma care protocol decreased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country.
abstract: BACKGROUND
  Standardized trauma protocols (STP) have reduced morbidity and in-hospital mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not implemented STPs, often because of financial and logistic limitations. We report the impact of an STP designed for the care of trauma patients in the emergency department (ED) at an LMIC hospital on patients with severe traumatic brain injury (STBI).
  
  
  METHODS
  We developed an STP based on generally accepted best practices and damage control resuscitation for a level I trauma centre in Colombia. Without a pre-existing trauma registry, we adapted an administrative electronic database to capture clinical information of adult patients with TBI, a head abbreviated injury score (AIS) ≥3, and who presented ≤12h from injury. Demographics, mechanisms of injury, and injury severity were compared. Primary outcome was in-hospital mortality. Secondary outcomes were Glasgow Coma Score (GCS), length of hospital and ICU stay, and prevalence of ED interventions recommended in the STP. Logistic regression was used to control for potential confounders.
  
  
  RESULTS
  The pre-STP group was hospitalized between August 2010 and August 2011, the post-STP group between September 2011 and June 2012. There were 108 patients meeting inclusion criteria, 68 pre-STP implementation and 40 post-STP. The pre- and post-STP groups were similar in age (mean 37.1 vs. 38.6, p=0.644), head AIS (median 4.5 vs. 4.0, p=0.857), Injury Severity Scale (median 25 vs. 25, p=0.757), and initial GCS (median 7 vs. 7, p=0.384). Post-STP in-hospital mortality decreased (38% vs. 18%, p=0.024), and discharge GCS increased (median 10 vs. 14, p=0.034). After controlling for potential confounders, odds of in-hospital mortality post-STP compared to pre-STP were 0.248 (95%CI: 0.074-0.838, p=0.025). Hospital and ICU stay did not significantly change. The use of many ED interventions increased post-STP, including bladder catheterization (49% vs. 73%, p=0.015), hypertonic saline (38% vs. 63%, p=0.014), arterial blood gas draws (25% vs. 43%, p=0.059), and blood transfusions (3% vs. 18%, p=0.008).
  
  
  CONCLUSIONS
  An STP in an LMIC decreased in-hospital mortality, increased discharge GCS, and increased use of vital ED interventions for patients with STBI. An STP in an LMIC can be implemented and measured without a pre-existing trauma registry.
authors.affiliation: University of Pittsburgh School of Medicine, United States. Electronic address: kesingermr2@upmc.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Kesinger
authors.affiliation: University of Pittsburgh School of Nursing, United States. Electronic address: lisarnagy7@gmail.com.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Nagy
authors.affiliation: University of Pittsburgh, United States. Electronic address: Des103@pitt.edu.
authors.forename: Denisse J
authors.initials: DJ
authors.lastname: Sequeira
authors.affiliation: Universidad Surcolombiana, Colombia. Electronic address: danielcharry06@hotmail.com.
authors.forename: Jose D
authors.initials: JD
authors.lastname: Charry
authors.affiliation: University of Pittsburgh School of Nursing, United States. Electronic address: puyajc@upmc.edu.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Puyana
authors.affiliation: Universidad Surcolombiana, Colombia. Electronic address: rubianoam@gmail.com.
authors.forename: Andres M
authors.initials: AM
authors.lastname: Rubiano
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000401:mortality* / Q000628:therapy; D002985:Clinical Protocols; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality / Q000639:trends*; D006784:Hospitals, Teaching / Q000458:organization & administration; D006801:Humans; D007902:Length of Stay / Q000639:trends*; D008297:Male; D008875:Middle Aged; D009936:Organizational Innovation; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D058996:Quality Improvement / Q000458:organization & administration*; D012015:Reference Standards; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014481:United States / Q000453:epidemiology
keywords: Outcomes; Quality improvement in LMIC; Severe TBI; Trauma