1
|
Shakir M, Irshad HA, Ibrahim NUH, Alidina Z, Ahmed M, Pirzada S, Hussain N, Park KB, Enam SA. Temporal Delays in the Management of Traumatic Brain Injury: A Comparative Meta-Analysis of Global Literature. World Neurosurg 2024:S1878-8750(24)00827-1. [PMID: 38762022 DOI: 10.1016/j.wneu.2024.05.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE A meta-analysis was conducted to compare: 1) time from traumatic brain injury (TBI) to the hospital, and 2) time within the hospital to intervention or surgery, by country-level income, World Health Organization region, and healthcare payment system. METHODS A comprehensive literature search was conducted and followed by a meta-analysis comparing duration of delays (prehospital and intrahospital) in TBI management. Means and standard deviations were pooled using a random effects model and subgroup analysis was performed using R software. RESULTS Our analysis comprised 95,554 TBI patients from 45 countries. BY COUNTRY-LEVEL INCOME From 23 low- and middle-income countries, a longer mean time from injury to surgery (862.53 minutes, confidence interval [CI]: 107.42-1617.63), prehospital (217.46 minutes, CI: -27.34-462.25), and intrahospital (166.36 minutes, 95% CI: 96.12-236.60) durations were found compared to 22 high-income countries. BY WHO REGION African Region had the greatest total (1062.3 minutes, CI: -1072.23-3196.62), prehospital (256.57 minutes [CI: -202.36-715.51]), and intrahospital durations (593.22 minutes, CI: -3546.45-4732.89). BY HEALTHCARE PAYMENT SYSTEM Multiple-Payer Health Systems had a greater prehospital duration (132.62 minutes, CI: 54.55-210.68) but greater intrahospital delays were found in Single-Payer Health Systems (309.37 minutes, CI: -21.95-640.69). CONCLUSION Our study concludes that TBI patients in low- and middle-income countries within African Region countries face prolonged delays in both prehospital and intrahospital management compared to high-income countries. Additionally, patients within Single-Payer Health System experienced prolonged intrahospital delays. An urgent need to address global disparities in neurotrauma care has been highlighted.
Collapse
Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | | | | | - Zayan Alidina
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Muneeb Ahmed
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Sonia Pirzada
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Nowal Hussain
- Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Kee B Park
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
2
|
Shakir M, Altaf A, Irshad HA, Hussain N, Pirzada S, Tariq M, Trillo-Ordonez Y, Enam SA. Factors Delaying the Continuum of Care for the Management of Traumatic Brain Injury in Low- and Middle-Income Countries: A Systematic Review. World Neurosurg 2023; 180:169-193.e3. [PMID: 37689356 DOI: 10.1016/j.wneu.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Considering the disproportionate burden of delayed traumatic brain injury (TBI) management in low- and middle-income countries (LMICs), there is pressing demand for investigations. Therefore, our study aims to evaluate factors delaying the continuum of care for the management of TBIs in LMICs. METHODS A systematic review was conducted with PubMed, Scopus, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Observational studies with TBI patients in LMIC were included. The factors affecting management of TBI were extracted and analyzed descriptively. RESULTS A total of 55 articles were included consisting of 60,603 TBI cases from 18 LMICs. Road traffic accidents (58.7%) were the most common cause of injury. Among included studies, factors contributing to prehospital delays included a poor referral system and lack of an organized system of referral (14%), long travel distances (11%), inadequacy of emergency medical services (16.6%), and self-treatment practices (2.38%). For in-hospital delays, factors such as lack of trained physicians (10%), improper triage systems (20%), and absence of imaging protocols (10%), lack of in-house computed tomography scanners (35%), malfunctioning computed tomography scanners (10%), and a lack of invasive monitoring of intracranial pressure (5%), limited theater space (28%), lack of in-house neurosurgical facilities (28%), absence of in-house neurosurgeons (28%), and financial constraints (14%) were identified. CONCLUSIONS Several factors, both before and during hospitalization contribute to delays in the management of TBIs in LMICs. Strategically addressing these factors can help overcome delays and improve TBI management in LMICs.
Collapse
Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | - Ahmed Altaf
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Nowal Hussain
- Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sonia Pirzada
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Mahnoor Tariq
- Department of Community Health Sciences, Aga Khan University Hospital, Karachi, Pakistan
| | - Yesel Trillo-Ordonez
- Duke University Division of Global Neurosurgery and Neurology, Durham, North Carolina, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
3
|
Krishnamoorthy V, Temkin N, Barber J, Foreman B, Komisarow J, Korley FK, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Bartz R, Raghunathan K, Goldstein BA, Markowitz AJ, Vavilala MS. Association of Early Multiple Organ Dysfunction With Clinical and Functional Outcomes Over the Year Following Traumatic Brain Injury: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. Crit Care Med 2021; 49:1769-1778. [PMID: 33935162 PMCID: PMC8448900 DOI: 10.1097/ccm.0000000000005055] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Traumatic brain injury is a leading cause of death and disability in the United States. While the impact of early multiple organ dysfunction syndrome has been studied in many critical care paradigms, the clinical impact of early multiple organ dysfunction syndrome in traumatic brain injury is poorly understood. We examined the incidence and impact of early multiple organ dysfunction syndrome on clinical, functional, and disability outcomes over the year following traumatic brain injury. DESIGN Retrospective cohort study. SETTING Patients enrolled in the Transforming Clinical Research and Knowledge in Traumatic Brain Injury study, an 18-center prospective cohort study of traumatic brain injury patients evaluated in participating level 1 trauma centers. SUBJECTS Adult (age > 17 yr) patients with moderate-severe traumatic brain injury (Glasgow Coma Scale < 13). We excluded patients with major extracranial injury (Abbreviated Injury Scale score ≥ 3). INTERVENTIONS Development of early multiple organ dysfunction syndrome, defined as a maximum modified Sequential Organ Failure Assessment score greater than 7 during the initial 72 hours following admission. MEASUREMENTS AND MAIN RESULTS The main outcomes were: hospital mortality, length of stay, 6-month functional and disability domains (Glasgow Outcome Scale-Extended and Disability Rating Scale), and 1-year mortality. Secondary outcomes included: ICU length of stay, 3-month Glasgow Outcome Scale-Extended, 3-month Disability Rating Scale, 1-year Glasgow Outcome Scale-Extended, and 1-year Disability Rating Scale. We examined 373 subjects with moderate-severe traumatic brain injury. The mean (sd) Glasgow Coma Scale in the emergency department was 5.8 (3.2), with 280 subjects (75%) classified as severe traumatic brain injury (Glasgow Coma Scale 3-8). Among subjects with moderate-severe traumatic brain injury, 252 (68%) developed early multiple organ dysfunction syndrome. Subjects that developed early multiple organ dysfunction syndrome had a 75% decreased odds of a favorable outcome (Glasgow Outcome Scale-Extended 5-8) at 6 months (adjusted odds ratio, 0.25; 95% CI, 0.12-0.51) and increased disability (higher Disability Rating Scale score) at 6 months (adjusted mean difference, 2.04; 95% CI, 0.92-3.17). Subjects that developed early multiple organ dysfunction syndrome experienced an increased hospital length of stay (adjusted mean difference, 11.4 d; 95% CI, 7.1-15.8), with a nonsignificantly decreased survival to hospital discharge (odds ratio, 0.47; 95% CI, 0.18-1.2). CONCLUSIONS Early multiple organ dysfunction following moderate-severe traumatic brain injury is common and independently impacts multiple domains (mortality, function, and disability) over the year following injury. Further research is necessary to understand underlying mechanisms, improve early recognition, and optimize management strategies.
Collapse
Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Nancy Temkin
- Department of Neurosurgery, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Fred K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC
- Department of Neurosurgery, Duke University, Durham, NC
- Department of Neurology, Duke University, Durham, NC
| | | | | | - John Sampson
- Department of Neurosurgery, Duke University, Durham, NC
| | - Michael L. James
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University, Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Raquel Bartz
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | | | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | | |
Collapse
|