Validation of international trauma scoring systems in urban trauma centres in India.
BACKGROUND
In the Lower-Middle Income Country setting, we validate trauma severity scoring systems, namely Injury Severity Score (ISS), New Injury Severity Scale (NISS) score, the Kampala Trauma Score (KTS), Revised Trauma Score (RTS) score and the TRauma Injury Severity Score (TRISS) using Indian trauma patients.


METHODS
From 1 September 2013 to 28 February 2015, we conducted a prospective multi-centre observational cohort study of trauma patients in four Indian university hospitals, in three megacities, Kolkata, Mumbai and Delhi. All adult patients presenting to the casualty department with a history of injury and who were admitted to inpatient care were included. The primary outcome was in-hospital mortality within 30-days of admission. The sensitivity and specificity of each score to predict inpatient mortality within 30days was assessed by the areas under the receiver operating characteristic curve (AUC). Model fit for the performance of individual scoring systems was accomplished by using the Akaike Information criterion (AIC).


RESULTS
In a registry of 8791 adult trauma patients, we had a cohort of 7197 patients eligible for the study. 4091 (56.8%)patients had all five scores available and was the sample for a complete case analysis. Over a 30-day period, the scores (AUC) was TRISS (0.82), RTS (0.81), KTS (0.74), NISS (0.65) and ISS (0.62). RTS was the most parsimonious model with the lowest AIC score. Considering overall mortality, both physiologic scores (RTS, KTS) had better discrimination and goodness-of-fit than ISS or NISS. The ability of all Injury scores to predict early mortality (24h) was better than late mortality (30day).


CONCLUSIONS
On-admission physiological scores outperformed the more expensive anatomy-based ISS and NISS. The retrospective nature of ISS and TRISS score calculations and incomplete imaging in LMICs precludes its use in the casualty department of LMICs. They will remain useful for outcome comparison across trauma centres. Physiological scores like the RTS and KTS will be the practical score to use in casualty departments in the urban Indian setting, to predict early trauma mortality and improve triage.
Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden; BARC Hospital (Govt of India), HBNI University, Mumbai, India. Electronic address: nobsroy@gmail.com.
Nobhojit
N
Roy
Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden. Electronic address: martin.gerdin@ki.se.
Martin
M
Gerdin
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02120, USA. Electronic address: eschnei1@jhmi.edu.
Eric
E
Schneider
Department of General Surgery, King Edward Memorial Hospital, Mumbai, India. Electronic address: deepu2315@yahoo.co.in.
Deepa K
DK
Kizhakke Veetil
BARC Hospital (Govt of India), HBNI University, Mumbai, India. Electronic address: monta32@gmail.com.
Monty
M
Khajanchi
Department of General Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India. Electronic address: drvineetkumar@gmail.com.
Vineet
V
Kumar
Department of Surgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, India. Electronic address: drmlsaha@yahoo.com.
Makhal Lal
ML
Saha
Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai,India. Electronic address: drdharap@hotmail.com.
Satish
S
Dharap
Department of Surgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. Electronic address: amitguptaaiims@gmail.com.
Amit
A
Gupta
Department of Learning, Informatics, Management & Ethics (LIME) and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. Electronic address: goran.tomson@ki.se.
Göran
G
Tomson
Department of Public Health Sciences, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden. Electronic address: Johan.Von.Schreeb@ki.se.
Johan
J
von Schreeb
D000328:Adult; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D009104:Multiple Trauma / Q000145:classification / Q000175:diagnosis* / Q000401:mortality; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012016:Reference Values; D012042:Registries; D015203:Reproducibility of Results; D014193:Trauma Centers; D015599:Trauma Severity Indices
ISS; India; Injury; Injury scoring system; KTS; NISS; RTS; TRISS; Trauma; Urban