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. 2017 Oct 31;12(10):e0182285.
doi: 10.1371/journal.pone.0182285. eCollection 2017.

A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda

Benjamin J Kuo  1   2   3 , Silvia D Vaca  4   5 , Joao Ricardo Nickenig Vissoci  1   2   6 , Catherine A Staton  1   2   6 , Linda Xu  5   7 , Michael Muhumuza  8 , Hussein Ssenyonjo  8 , John Mukasa  8 , Joel Kiryabwire  8 , Lydia Nanjula  8 , Christine Muhumuza  9 , Henry E Rice  2   10 , Gerald A Grant  5   7 , Michael M Haglund  1   2   11
Affiliations

A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda

Benjamin J Kuo et al. PLoS One. .

Abstract

Background: Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda.

Methods: We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.

Results: 563 TBI patients were enrolled from 1 June- 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.

Conclusions: The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Mulago National Referral Hospital (MNRH) traumatic brain injury (TBI) prospective rapid electronic data capture (REDCap) registry workflow.
Fig 2
Fig 2. Mortality of traumatic brain injury (TBI) patients presenting to Mulago National Referral Hospital (MNRH) by traumatic brain injury (TBI) severity and management pathway.
Fig 3
Fig 3. Multivariate model of predictors of traumatic brain injury mortality by adjusted odds ratios (OR).
This parsimonious multivariate model was generated through logistic regression using the stepwise backward elimination approach at the p<0.05 level. The model was adjusted for the following confounders: age, polytrauma, and CT diagnosis.
See this image and copyright information in PMC

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