L. N. Purcell1, T. N. Reid1, C. Mabedi2, A. N. Charles1, R. N. Maine1 1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA 2Kamuzu Central Hospital,Lilongwe, LILONGWE, Malawi
Introduction: Trauma is a leading cause of morbidity and mortality worldwide with the burden borne by low- and middle-income countries (LMICs). Important trauma principles are early triage, expedited care, and transfer of patients to appropriate higher levels of care. Inappropriate transfers (IT), or overtriage, tax overburdened hospitals in LMICs. Little data exists on efficacy of trauma transfers in LIMCs. We sought to determine the rate and characteristics of inappropriate trauma transfer patients in Malawi.
Methods: A retrospective analysis of prospectively collected data was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. IT were defined as patients discharged alive from the emergency department or patients admitted for less than one day without undergoing surgery. Variables included were demographics, injury severity and characteristics. Bivariate analysis, Kruskal-Wallis, t-Test, and logistic regression were utilized when appropriate.
Results: From February 2008 – July 2017, 120,573 trauma patients presented. Transferred patients constituted 17.0% (n=20,460), of these 57.3% (n=11,725) were IT. Inappropriately transferred patients were younger (mean 21.9±17.2 yrs, CI: 21.6 – 22.2) than appropriately transferred (mean 26.3±19.8 yrs, CI: 25.8 – 26.7), p<0.001. IT occurred more in women than men, 60.5% versus 56.0%, respectively (p<0.001). Primary extremity injury were more often IT (n=6,975, 61.7%) compared to primary torso (n=1,764, 48.5%) or head injuries (n=2,862, 54.0%), p<0.001. IT (median 1 hr, IQR 1-1 hr) arrived at KCH faster than appropriate transfers (median 1 hr, IQR 1-2), p=0.002. Fewer IT occurred at night (n=2554, 46.6%, p,0.001) vs day (n=9141, 61.4%) and on weekends (n=2653,55.8%, p=0.02) vs weekdays (n=2563, 55.8%). The injury mechanisms with the highest rate of IT were lacerations (n=320, 69.3%), animal bites (n=295, 70.7%), and falls (n=4199, 64.1%). IT rates were lowest in motor vehicle collisions (n=3098, 50.0%) and burns (n=429, 31.3%) injury mechanisms. In the logistic regression model, lacerations (OR 2.26, CI 1.63 – 3.13), animal bites (OR 1.97, CI 1.48 – 2.63), assault (OR 1.76, CI 1.54 – 2.00), falls (OR 1.25, CI 1.12 – 1.40), and female sex (OR 1.21, CI 1.10 – 1.32) had increased odds of IT, p<0.001. Night admits (OR 0.54, CI 0.49 – 0.59) and burn injuries (OR 0.44, CI 0.37–0.54) were protective for IT, p<0.001. Primary head (OR 1.34, CI 1.17 – 1.52) and extremity injuries (OR 1.86, CI 1.65 – 2.10) had increased odds of IT compared to torso injuries, p<0.001.
Conclusion: The majority of patients transferring to KCH for injury care are inappropriately transferred. The lack of clear transfer triage criteria and protocols contribute to this overtriage. Implementation of transfer criteria, trauma protocols, and inter-hospital clinician communication can mitigate the strain of IT in the resource limited setting.