J. Kincaid1,3, G. Mulima3, N. Rodriguez-Ormaza2, A. Charles2, R. Maine2 1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 3Kamuzu Central Hospital,Surgery,Lilongwe, Malawi
Introduction: Mass-casualty incidents (MCI) suddenly strain a healthcare system with an influx of trauma patients. Little is known about how MCIs in low resource settings impact mortality. We aimed to determine if the resource strain from MCIs at a tertiary hospital in Malawi increased mortality for MCI patients and patients who arrived on the same day as an MCI compared to patients who presented days without MCIs.
Methods: This is a retrospective analysis of a prospective trauma registry, from January 1, 2012 through December 31, 2016, at a tertiary hospital in Malawi. MCIs were defined as ≥ 4 trauma patients who present simultaneously to the casualty department. We conducted bivariate analysis comparing patient, mechanism of injury, and outcome characteristics by whether or not the event was an MCI. Next, we determined whether non-MCI patients presented on the same day as an MCI or on a non-MCI day and compared the same variables. Categorical variables were compared with Pearson chi-squared test or the Fisher’s exact test; continuous variables were compared using Student t-test, Wilcoxon rank sum test or the Kruskal-Wallis test by ranks, as appropriate. Multivariable analysis using a Modified Poisson regression was utilized to estimate risk ratios (RR) and 95% confidence intervals (CI). We adjusted for sex, age, primary body area injured, transfer status, nighttime presentation, vehicle-related trauma and admission year. P-values <0.05 were statistically significant.
Results: The registry included 75,350 trauma patients; 3% (2,227) were part of an MCI and 11,365 (15%) presented on the same day as an MCI. Overall more patients who presented as part of an MCI died, 90 (4%) vs. 2,124 (2.9%), p <0.001). This difference was driven by a higher proportion of MCI patients who were dead on arrival (2.9% vs. 1.1%, p<0.001), as in-hospital mortality rates for MCI or non-MCI traumas did not differ statistically (4.1% vs. 3.7%, p=0.671). However, trauma patients who were not a part of an MCI but presented to the ED the same day as an MCI had higher in-hospital mortality than patients who presented on days without an MCI (7.0% vs. 5.4% vs. 5.6%, p=0.015). When compared to non-MCI trauma patients presenting on a non-MCI day, being part of an MCI increased the risk of in-hospital mortality by 19% (RR=1.19, 95%CI: 0.98-1.44, p=0.0821).
Conclusion: MCIs presented frequently to this Malawian tertiary hospital, which stressed the hospital’s limited capacity. The higher in-hospital mortality of trauma patients not involved in MCI but who presented the same day as an MCI points to the strain on the limited resources resulting in poorer patient outcomes when the hospital suffers the stress of an MCI. Both improved capacity for treating trauma patients at the central hospital and district hospitals coupled with improved triage protocols could decrease inappropriate transfers of trauma patients, which contributes to overwhelming the central hospital.