title: Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa.
abstract: BACKGROUND
  Traumatic injuries account for the greatest portion of global surgical burden particularly in low- and middle-income countries (LMICs). To assess effectiveness of a developing trauma system, we hypothesize that there are survival differences between direct and indirect transfer of trauma patients to a tertiary hospital in sub Saharan Africa.
  
  
  METHODS
  Retrospective analysis of 51,361 trauma patients within the Kamuzu Central Hospital (KCH) trauma registry from 2008 to 2012 was performed. Analysis of patient characteristics and logistic regression modelling for in-hospital mortality was performed. The primary study outcome is in hospital mortality in the direct and indirect transfer groups.
  
  
  RESULTS
  There were 50,059 trauma patients were included in this study. 6578 patients transferred from referring facilities and 43,481 patients transported from the scene. The indirect and direct transfer cohorts were similar in age and sex. The mechanism of injury for transferred patients was 78.1% blunt, 14.5% penetrating, and 7.4% other, whereas for the scene group it was 70.7% blunt, 24.0% penetrating, and 5.2% other. Median times to presentation were 13 (4-30) and 3 (1-14)h for transferred and scene patients, respectively. Mortality rate was 4.2% and 1.6% for indirect and direct transfer cohorts, respectively. A total of 8816 patients were admitted of which 3636 and 5963 were in the transfer and scene cohort, respectively. After logistic regression analysis, the adjusted in-hospital mortality odds ratio was 2.09 (1.24-3.54); P=0.006 for indirect transfer versus direct transfer cohort, after controlling for significant covariates.
  
  
  CONCLUSIONS
  Direct transfer of trauma patients from the scene to the tertiary care centre is associated with a survival benefit. Our findings suggest that trauma education and efforts directed at regionalization of trauma care, strengthening pre-hospital care and timely transfer from district hospitals could mitigate trauma-related mortality in a resource-poor setting.
authors.affiliation: Department of Surgery, University of North Carolina at Chapel Hill, United States.
authors.forename: Laura P
authors.initials: LP
authors.lastname: Boschini
authors.affiliation: School of Medicine, University of North Carolina at Chapel Hill, United States.
authors.forename: Yemeng
authors.initials: Y
authors.lastname: Lu-Myers
authors.affiliation: Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.
authors.forename: Nelson
authors.initials: N
authors.lastname: Msiska
authors.affiliation: Department of Surgery, University of North Carolina at Chapel Hill, United States.
authors.forename: Bruce
authors.initials: B
authors.lastname: Cairns
authors.affiliation: Department of Surgery, University of North Carolina at Chapel Hill, United States; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi. Electronic address: anthchar@med.unc.edu.
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Charles
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006302:Health Services Research; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010360:Patient Transfer / Q000592:standards / Q000706:statistics & numerical data*; D012042:Registries; D012189:Retrospective Studies; D061665:Time-to-Treatment; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000401:mortality* / Q000628:therapy; D055815:Young Adult
keywords: Developing countries; Injuries; Malawi; Transfer status; Trauma; Trauma systems
references.citation: Ann Surg. 2005 Jun;241(6):961-6; discussion 966-8
references.pmid: 15912045
references.citation: Injury. 2005 Jun;36(6):725-32
references.pmid: 15910824
references.citation: Prehosp Disaster Med. 2010 Mar-Apr;25(2):145-51
references.pmid: 20467994
references.citation: World J Surg. 2011 Mar;35(3):493-9
references.pmid: 21191583
references.citation: J Trauma. 2011 Dec;71(6):1885-900; discussion 1901
references.pmid: 22182900
references.citation: JAMA. 2012 Feb 15;307(7):667-8
references.pmid: 22337675
references.citation: J Trauma. 2001 Mar;50(3):409-13; discussion 414
references.pmid: 11265019
references.citation: Scand J Surg. 2002;91(1):7-10
references.pmid: 12075840
references.citation: Asian J Surg. 2004 Jan;27(1):58-64
references.pmid: 14719518
references.citation: J Trauma. 1989 May;29(5):623-9
references.pmid: 2657085
references.citation: Trop Geogr Med. 1991 Jan-Apr;43(1-2):80-4
references.pmid: 1750135
references.citation: J Trauma. 1993 Jun;34(6):890-8; discussion 898-9
references.pmid: 8315686
references.citation: Am Surg. 1998 Jan;64(1):88-91; discussion 91-2
references.pmid: 9457044
references.citation: Lancet. 2012 Dec 15;380(9859):2095-128
references.pmid: 23245604
references.citation: Surgery. 2013 Feb;153(2):272-81
references.pmid: 23063312
references.citation: N Engl J Med. 2013 May 2;368(18):1723-30
references.pmid: 23635052
references.citation: Prehosp Emerg Care. 2013 Oct-Dec;17(4):442-57
references.pmid: 23845080
references.citation: Int J Surg. 2014;12(5):509-15
references.pmid: 24560846
references.citation: Crit Care. 2013;17(4):R172
references.pmid: 23938104
references.citation: Lancet. 2015 Jan 10;385(9963):117-71
references.pmid: 25530442
references.citation: Lancet Glob Health. 2015 Apr 27;3 Suppl 2:S1-2
references.pmid: 25926313