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. 2019 Jan 1;84(1):95-103.
doi: 10.1093/neuros/nyy004.

Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda

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

Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda

Silvia D Vaca et al. Neurosurgery. .

Abstract

Background: Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the "3 delays" model to evaluate TBI outcomes in low- and middle-income countries has not been performed.

Objective: To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda.

Methods: Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed.

Results: Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04).

Conclusion: Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.

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Figures

FIGURE 1.
FIGURE 1.
Study design workflow of the collection of neurosurgical care continuum variables using a modified “3 delays” modeled for traumatic brain injury.
FIGURE 2.
FIGURE 2.
Management pathway of all patients.
FIGURE 3.
FIGURE 3.
Relative contribution of mild and moderate TBI groups to mortality within management pathways. Compared to the surgery received group, the nonoperative group has a similar proportion of mild/moderate TBI cases but relatively higher mild/moderate TBI mortality. Likewise, compared to the surgery received group, the surgery-not-received group had a lower proportion of mild/moderate TBI cases, but equally high mild/moderate TBI mortality.
FIGURE 4.
FIGURE 4.
Time interval along the neurosurgical care continuum by TBI severity. *Interval 3 significantly differed by TBI severity (Kruskal-Wallis, P = .0193). *Interval 4 significantly differed by TBI severity (Kruskal-Wallis, P = .0435).
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