Third Delay in Traumatic Brain Injury: Time to Management as a Predictor of Mortality

Abstract

Background: Traumatic brain injury (TBI) is a global epidemic with an increasing incidence in low-and-middle income countries (LMICs). The time from arrival to the hospital to receiving appropriate treatment (“third delay”) can vary widely in LMICs, though its association with mortality in TBI remains unknown. Methods: A retrospective cohort analysis with multivariable logistic regression was conducted with the Towards Improved Trauma Care Outcomes in India database, which contains data from 4 urban trauma centers in India from 2013-2015. Results: There were 6,278 TBIs included in the cohort. The median age was 39 (IQR 27-52) and 81% of patients were male. The most frequent mechanisms of injury were road traffic accidents (52%) and falls (34%). A majority of cases were transfers from outside facilities (79%). In-hospital 30-day mortality was 27%; of patients who died, 21% died within 24 hours of arrival. The median third delay was 10 minutes (IQR 0-60 minutes); 34% of cases had moderate third delay (10-60 minutes) and 22% had extended third delay (61+ minutes). Overall 30-day mortality was associated with moderate third delay (OR 1.3, p = 0.001) and extended third delay (OR 1.3, p = 0.001) after adjustment by pertinent co-variates. This effect was pronounced for 24-hour mortality: moderate and extended third delay were independently associated with odds ratios of 3.4 and 3.8 for 24-hour mortality, respectively (both p < 0.001). Discussion: Third delay is associated with early mortality in TBI and represents a target for process improvement in urban trauma centers.