Elsevier

Injury

Volume 35, Issue 4, April 2004, Pages 386-390
Injury

Measuring trauma outcomes in India: An analysis based on TRISS methodology in a Mumbai university hospital

https://doi.org/10.1016/S0020-1383(03)00214-6Get rights and content

Abstract

Background: In this prospective study, the TRISS methodology is used to compare trauma care at a university hospital (Lokmanya Tilak Municipal General (LTMG) Hospital) in Mumbai, India, with the standards reported in the Major Trauma Outcome Study (MTOS). Methods: Between 1 August 2001 and 31 May 2002, 1074 severely injured patients were included in the study. Survival analysis was completed for 98.3% of the patients. Results: The majority of the patients were men (84%) and the average age was 31 years. 90.4% were blunt injuries, with road traffic crashes (39.2%) being the most common cause. The predicted mortality was 10.89% and the observed mortality was 21.26%. The mean Revised Trauma Score (RTS) was 6.61±1.65 and the mean Injury Severity Score (ISS) was 16.7±10.67. The average probability of survival (Ps) was 89.14. The M and Z statistics were 0.84 and −14.1593, respectively. Conclusion: The injured in India were found to be older, the injuries more severe and with poorer outcomes, than in the MTOS study.

Introduction

Injury in a developing country like India is a leader together with non-communicable diseases, when measured in terms of disability adjusted life years (DALYs) lost. The younger population is more prone to injury and the resulting mortality accounts for a higher number of life years lost. The severity and the resulting disability is higher than in any other disease.8 It is recognised that there is a lack of information on the quality of trauma care in India. One of the causes of injury not being acknowledged as a serious public health problem is due to its association with the word “accident” which offsets any attempt at planning and prevention. It has yet to be accepted in India that accidental deaths can be measured, predicted and thereafter prevented by setting up injury prevention systems. These would eventually replace the ad hoc treatment scenario of the present with comprehensive and cost-effective care thereby preventing the loss of lives of those who are in their most productive years. Trauma systems have been shown to decrease the number of preventable deaths caused by trauma.5

The Lokmanya Tilak Municipal General (LTMG) Hospital (1416-bed) is a Level I trauma centre, which caters to the megapolis of Mumbai (formerly, Bombay). Its location at the termination of two major arterial roadways (the Eastern and the Western Express Highways) makes it the recipient hospital of virtually all vehicular crash victims in Mumbai. Also, since it is located close to the two of the three rail mass transit networks (the Harbour line and the Central line), it caters for a large number of railway casualties. Another pool of trauma patients, mainly of assault and riot victims, is received from the communally sensitive areas around the hospital (Dharavi and Koliwada).

The aim of this study was to evaluate this developing country trauma centre in terms of treatment and outcome and compare it with centres around the world. An attempt at auditing the casualties received over a period of 10 months has been performed based on the injury scoring systems and the Major Trauma Outcome Study (MTOS) initiated in the US by Champion et al. in 1990.6 This study measured the overall severity of the injury, recorded management and outcome, provided a database for audit in the individual patient and now allows for comparison of performance over time and between hospitals. The TRISS methodology is often used for outcome analysis in the injured patient. The TRISS system combines both the physiologic (Revised Trauma Score (RTS) and anatomic Injury Severity Score (ISS))11 assessments of injury, with age and mechanism of injury (blunt versus penetrating), to quantify the probability of survival (Ps) for each individual patient.4 Also, the Z and M statistics were calculated to compare the number of survivors in this institution to the number expected on the basis of the MTOS norm.

Section snippets

Method

A total of 1074 patients were treated in the Trauma Ward of the Lokmanya Tilak General Hospital between August 2001 and May 2002. Registrars in surgery provide standardised care in the Trauma Ward, round the clock. Only trauma patients with multiple or severe injuries (Abbreviated Injury Score (AIS)>2) are admitted in the Trauma Ward and were included in the study. Only those patients with the complete set of parameters required to calculate the RTS were included in the study.

The parameters of

Limitations and exclusions

Firstly, 18 records were excluded due to incomplete data entry. Secondly, deaths due to railway accidents are not routinely subjected to post-mortems, as per a government order; therefore, the autopsy findings were excluded from all cases in this study. Railway accidents were not collisions, but injuries sustained by falling off overcrowded trains, sometimes in a state of inebriation or while crossing the tracks.

Results

Between 1 August 2001 and 31 May 2002, 1074 severely injured patients admitted to the Trauma Intensive Care Unit of the LTMG Hospital were studied. ‘Severely injured’ was defined as ISS>25 or an AIS>4 in one body region. Eighteen patients were eliminated because the data was incomplete or the patient was transferred to another hospital and therefore outcome could not be established. Sufficient data was available to perform survival analysis in 1056 patients.

Demography shows the majority to be

Discussion

In this study, the quality of trauma care in a Level I trauma centre was evaluated using the TRISS methodology. The outcome of these patients were compared to those of the MTOS patients studied by Champion et al.6 This is represented in Table 3.

The majority of the victims were young male subjects. While past studies have shown that 40% of the trauma victims are between 16 and 30 years of age,18 we found 32% patients in this age group. Most of the injuries encountered were blunt, resulting from

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