165 Assessing Accuracy and Inter-rater Reliability of the Emergency Severity Index in Triage in the Al-Rahba Emergency Department: A Cross-Sectional Observational Study (original) (raw)

2016, Annals of Emergency Medicine

The study goal was to prospectively characterize the demographics, mechanisms of injury, diagnoses, and outcomes among trauma patients presenting to Mbarara Regional Referral Hospital (MRRH) prior to planned trauma training interventions. Methods: All patients presenting to the Accidents & Emergency (A&E) area at MRRH over a ten-week period who met the World Health Organization definition of major trauma were prospectively enrolled. Patient demographics, mechanism of injury, arrival mode, referral site, initial vital signs, and diagnoses were collected by direct observation and chart review. Disposition from A&E, vital status and therapeutic actions were determined by daily chart review for the first 14 days of hospitalization. Outpatients or their caregivers were contacted by phone at 2 weeks and 30 days to determine vital status. Ethical/research approval was obtained from the Mbarara University of Science and Technology (Mbarara, Uganda) and Partners Healthcare (Boston, USA). Results: 497 patients with traumatic injuries presented during the 10-week study period. We included the 415 who met WHO criteria for major trauma. Mean age was 26.5 years (range 1-76, SD 14.6), and 77.8% were male. Patients most frequently arrived by car (61.7%), followed by boda/motorbike (21.2%), and ambulance (13.5%). 122 patients arrived in transfer (29.4%). Mechanisms of injury included motor vehicle accidents (60.2%), pedestrians struck (18.3%), assaults (11.1%) and penetrating trauma (4.8%). Only 30.4% of patients had any single vital sign recorded during their trauma evaluation, with only 2.6% having a documented heart rate, blood pressure, respiratory rate and oxygen saturation. Invasive interventions were rare and limited to Foley catheters (6.3%), nasogastric tubes (2.4%), and chest tubes (1.7%). There were no interosseous, central or arterial lines placed and no intubations in A&E. Patients remained in A&E for variable periods but were then discharged to: home (45.5%), surgery ward (33.7%), operating theatre (8.2%), or morgue (5.3%). Only 1.7% (7) patients went to the ICU. Head injury was the most common discharge diagnosis (44.6%) in the 186 hospitalized patients with follow-up, followed by fracture/dislocation (29% closed, 13.4% open). Abdominal trauma was a rare diagnosis (5.9% blunt, 1.6% penetrating), as was chest trauma (2.7% blunt, 1.1% penetrating). There were 35 in-hospital deaths (8.4%, 95% CI ¼ 5.9%-11.5%); 48.6% were within 24 hours of presentation. Head injury was among the major diagnoses in 84% of deaths. While the lost-to-follow-up rate at 2 weeks was high (40%), 3 additional deaths were identified bringing the overall mortality estimate to 9.2% (95% CI ¼ 6.6%-12.4%). There were no known additional deaths at 30-day follow-up. Conclusions: The trauma burden and mortality at this referral hospital are high. The site manages critically ill patients but has limited resuscitation capacity in A&E including no functioning CT scanner, limited critical care if patients cannot pay for ICU care, and inconsistent diagnostic, medical, operative and ICU supplies. Training in the algorithmic management of trauma patients and emergency medicine is currently limited but planned.