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Accepted Manuscript

Title: A standardized trauma care protocol decreased mortality


of patients with severe traumatic brain injury at a teaching
hospital in a middle-income country

Author: Matthew R. Kesinger Lisa R. Nagy Denise J.


Sequeira Jose D. Charry Juan C. Puyana Andres M. Rubiano

PII: S0020-1383(14)00204-6
DOI: http://dx.doi.org/doi:10.1016/j.injury.2014.04.037
Reference: JINJ 5725

To appear in: Injury, Int. J. Care Injured

Received date: 6-11-2013


Revised date: 8-4-2014
Accepted date: 18-4-2014

Please cite this article as: Kesinger MR, Nagy LR, Sequeira DJ, Charry JD, Puyana JC,
Rubiano AM, A standardized trauma care protocol decreased mortality of patients with
severe traumatic brain injury at a teaching hospital in a middle-income country, Injury
(2014), http://dx.doi.org/10.1016/j.injury.2014.04.037

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TITLE PAGE

Complete title:
A standardized trauma care protocol decreased mortality of patients with severe traumatic brain
injury at a teaching hospital in a middle-income country

Corresponding Author:

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Matthew R. Kesinger BA

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University of Pittsburgh School of Medicine
Kesingermr2@upmc.edu

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Lisa R. Nagy RN
University of Pittsburgh School of Nursing

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lisarnagy7@gmail.com

Denise J. Sequeira BS
University of Pittsburgh

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Des103@pitt.edu

Jose D. Charry BS
Universidad Surcolombiana
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danielcharry06@hotmail.com

Juan C. Puyana MD
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University of Pittsburgh School of Medicine


puyajc@upmc.edu
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Andres M. Rubiano MD
Universidad Surcolombiana
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rubianoam@gmail.com
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Keywords: Quality Improvement in LMIC, trauma, severe TBI, outcomes

Please send correspondence to


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Matthew Kesinger
University of Pittsburgh
Department of Surgery
200 Lothrop St.
Suite F1263.3
Pittsburgh, PA 15213
kesingermr2@upmc.edu 
 
The authors have no conflicts of interest 
The authors received no funding for this work. 
 
 

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ABSTRACT 
Introduction: 
Standardized trauma protocols (STP) have reduced morbidity and in‐hospital mortality in 
mature trauma systems. Most hospitals in Low‐ and Middle‐Income Countries (LMICs) have 

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not implemented STPs, often because of financial and logistic limitations. We report the 

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impact of an STP designed for the care of trauma patients in the emergency department 
(ED) at an LMIC hospital on patients with severe traumatic brain injury (STBI). 
 

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Methods: 
We developed an STP based on generally accepted best practices and damage control 

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resuscitation for a level I trauma center in Colombia. Without a pre‐existing trauma 
registry, we adapted an administrative electronic database to capture clinical information 
of adult patients with TBI, a head abbreviated injury score (AIS) ≥3, and who presented 
≤12 hours from injury. Demographics, mechanisms of injury, and injury severity were 

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compared. Primary outcome was in‐hospital mortality. Secondary outcomes were Glasgow 
Coma Score (GCS), length of hospital and ICU stay, and ED interventions recommended in 
the STP. Logistic regression was used to control for potential confounders. 
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Results: 
The pre‐STP group was hospitalized between August 2010 and August 2011, the post‐STP 
group between September 2011 and June 2012. There were 108 patients meeting inclusion 
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criteria, 68 pre‐STP implementation and 40 post‐STP. The pre‐ and post‐STP groups were 
similar in age (mean 37.1 vs. 38.6, p=0.644), head AIS (median 4.5 vs. 4.0, p=0.857), Injury 
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Severity Scale (median 25 vs. 25, p=0.757), and initial GCS (median 7 vs. 7, p=0.384). Post‐
STP in‐hospital mortality decreased (38% vs. 18%, p=0.024), and discharge GCS increased 
(median 10 vs. 14, p=0.034). After controlling for potential confounders, odds of in‐hospital 
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mortality post‐STP compared to pre‐STP were 0.248 (95%CI: 0.074–0.838, p=0.025). 
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Hospital and ICU stay did not significantly change. Many ED interventions increased post‐
STP, including bladder catheterization (49% vs. 73%, p=0.015), hypertonic saline (38% vs. 
63%, p=0.014), arterial blood gas draws (25% vs. 43%, p=0.059), and blood transfusions 
(3% vs. 18%, p=0.008). 
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Conclusions: 
An STP in an LMIC decreased in‐hospital mortality, increased discharge GCS, and increased 
use of vital ED interventions for patients with STBI. An STP in an LMIC can be implemented 
and measured without a pre‐existing trauma registry. 

Keywords: Quality Improvement in LMIC, trauma, severe TBI, outcomes

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Introduction:

Injury is a major health problem on a global scale, leading to approximately 5.8 million deaths

worldwide each year and causing disability in millions more1. Ninety percent of trauma deaths

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occur in low- and middle-income countries (LMICs)2. Nearly 2,000,000 lives could be saved

annually in LMICs through improvements in global trauma care3.

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The burden of traumatic brain injury (TBI) is disproportionally high in LMICs, especially

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in Latin America4,5. There are many factors that contribute to this, one of which is a lack of

adherence to evidence-based practices. Trauma centers in high-income countries are often

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required by governmental accreditation agencies to ensure that all emergency medical physicians

and trauma surgeons maintain active certification of training and competences from an
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organization that offer continued medical education in the care of trauma patients6. The
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Advanced Trauma Life Support (ATLS) course, created by the Committee on Trauma of the
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American College of Surgeons, has become the most used and recognized certification and has

been advocated as the “gold standard” in basic trauma care in USA and Europe as well as several
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other countries. Though there is no Class I evidence (RCT trials), studies performed on the
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effectiveness of teaching and using such standardized trauma care protocols have shown
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improved patient outcomes and indirect measures associated with improved outcomes in both

mature trauma systems as well as a in LMICs7-12.

Several assessments of trauma systems in LMICs have found that a significant number of

the physicians caring for the injured have not had adequate training and have never completed a

certification such as ATLS or similar courses. These assessments have generated

recommendations calling for increased training in either ATLS or similar education that teaches

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the fundamentals of trauma care in a methodical and systematic way13-18. Unfortunately, the

financial and logistic burdens associated with offering ATLS certification in LMICs have

constituted a significant barrier to extend physician training in much of the world where it is

most needed2,13,16-18. For instance, in the hospital where our study took place, a physician would

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have to travel to the capital city and pay approximately one month’s salary to become certified in

ATLS.

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On September 1, 2011, Neiva University Hospital (NUH), in Neiva, Colombia instituted

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system-wide changes in the emergency department (ED) as part of a trauma quality improvement

initiative. Drawing on military trauma care protocols designed for austere environments, as well

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as generally accepted best practices in trauma care19,20, a set of evidence based algorithms for the

initial care and resuscitation of injured patients was developed, adapted and customized to the
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resources available at NUH. Collectively, we refer to the algorithms as a standardized trauma
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protocol (STP). The STP described and standardized treatments for patients with severe trauma
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from the time of arrival at the ED until the time of ED departure to either the operating room or

the intensive care unit (ICU). Examples of specific standardizations include the use of arterial
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blood gas tests to guide transfusion decisions, medication choices in rapid intubation, small
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volume resuscitation, requiring physician presence in intra-hospital transportation of severely


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injured patients, and the use of a short checklist in the trauma bay, among others. The

implementation was preceded by two courses designed to teach the STP to all physicians in the

ED with half of the providers participating in each course. There were no changes in physical or

human resources in the ED or anywhere else in the hospital during the study period. The STP

was only applicable to the ED.

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We hypothesized that after implementation, there would be increased utilization of ED

interventions recommended in the STP, decreased in-hospital mortality, and decreased length of

hospital stay (LOS) in an LMIC teaching hospital. Here we examined those outcomes in patients

with severe traumatic brain injury (STBI) before and after STP implementation.

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Materials and Methods:

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Approval from the NUH quality improvement office was obtained prior to STP implementation.

Approval from the institutional review boards of NUH and the University of Pittsburgh were

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obtained prior to conducting this retrospective study.
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Patient Population
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NUH is a 504 bed, level I trauma center and tertiary referral hospital in southern Colombia. NUH
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admits approximately 2,000 adult trauma patients per year and has 30 adult ICU beds. The

hospital is the primary trauma center for 3.2 million inhabitants living in an area extending over
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60,000 square miles. Its radius of care extends far into the Amazonian region, where the most
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intense fighting between rebel groups, cocaine traffickers and government forces has taken place
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for over 40 years.

At this institution, patients are treated in the adult ED if they are over 13 years of age.

Patients were included in the study if they were 14 years or older, had an ICD-10 diagnosis

indicating TBI, had an Abbreviated Injury Score (AIS) ≥ 3, presented within 12 hours of injury,

and had been treated in the ICU between Aug. 2010 and Jun. 2012. Criteria for ICU admission at

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NUH include GCS ≤ 8, cervical spinal cord injury, respiratory failure requiring mechanical

ventilation, patients requiring dialysis, shock, sepsis, hepatic failure or pancreatic failure.

A GCS ≤ 8 is the most common way of defining STBI. GCS is a measure of

unconsciousness, however, and part of the reason it is so widely accepted is because it is easy to

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use and there is low inter-rater variability21. Furthermore, GCS cannot control for confounding

associated with non-traumatic causes of decreased brain function, including alcohol, drugs,

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sedatives used in initial hospitals before transport to trauma center, shock, extreme hypoxia,

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hypoglycemia, and metabolic acidosis. Multiple injured patients may present with a low GCS in

the setting of only minor head trauma, for instance in the setting of an assault with blunt trauma

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to the head and penetrating trauma to other body regions causing hypovolemic shock. This is a

common presentation in locations with endemic violence like Neiva. Finally, large retrospective
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trials have shown potential difficulties when using GCS to define STBI in multiple injured

patients23, which was a very common presentation in this study cohort. Only detailed medical
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records or robust trauma registries with dedicated full-time employees, which do not exist in

LMICs, can control for this confounding. AIS, however, was obtained based on injury
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description and diagnostic imaging which is present and recorded at NUH.


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Data Source

This was a retrospective cohort study. Injury severity, patient demographics, mechanism of, LOS

and in-hospital mortality were determined by chart review. Like most LMIC trauma centers,

there was no trauma registry at NUH. Therefore we identified an electronic database within

NUH designed for tracking financial information. In fact, a growing number of hospitals in

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middle-income countries have begun to use electronic databases to manage financial records

before implementation of any other form of electronic medical records. At NUH, these records

include fee-for-service scheduling for all supplies and procedures. The same service may cost a

different amount depending on the location of use—e.g., bladder catheterization in the ICU vs.

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bladder catheterization in the ED—and therefore the location of all billable materials is included.

In this study, we were able to use these distinctions to obtain information about interventions

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used in the ED pre- and post-implementation of the STP.

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Records were analyzed for all patients who met inclusion criteria to determine trends in

mortality, LOS, and the prevalence of interventions between the pre- and post-STP groups. The

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frequency of blood transfusions, arterial blood gas draws, catheterization of the bladder, use of

hypertonic fluids, use of prophylactic antibiotics, administration of the tetanus vaccine in the
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case of penetrating trauma, use of early analgesics, and spinal immobilization were examined in
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the pre-STP and post-STP groups. Categorical variables were analyzed with Pearson’s Chi
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Squared and Fisher’s exact tests, and 95% confidence intervals were determined. Continuous

variables were analyzed with a student’s t-test. Logistic regression analysis was used to
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investigate the effect of the STP on in-hospital mortality while controlling for potential
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confounders of age, sex, ISS, initial Glasgow Coma Scale (GCS), transfer status, mechanism of
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injury, surgical status, and blood transfusion. LOS was further analyzed controlling for age, sex,

transfusion status, ISS, initial GCS, and mechanism of injury using linear regression. p values

less than or equal to 0.05 were considered statistically significant. All analysis was conducted

with SPSS 20 (Kansas City, MO).

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Results

Demographic data:

One hundred eight patients over 13 years of age with STBI were admitted to NUH and treated in

the ICU between Aug. 1, 2010 and Jun. 30, 2012, 68 in the pre-STP group and 40 in the post-

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STP group (5.2 vs. 5.0 mean per month). The pre- and post-STP groups were similar in age

(mean 37.1 vs. 38.6, p=0.644), transfer status (67% vs. 50%, p=0.095), time from injury to

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presentation (mean 4.0 hours vs. 3.4, p=0.326), and mechanism of injury with motor vehicle

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accidents being the predominant cause (82% vs. 90%, p=0.284). In the pre-STP group 31

patients had multiple injuries and 25 in the post-STP group (46% vs. 63%, p=0.089) There were

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more males in the pre-STP group (92% vs. 77%). (Table 1) The pre- and post-STP groups were

also similar in injury severity as measured by head Abbreviated Injury Score (AIS) (median 4.5
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vs. 4.0, p=0.857), Injury Severity Scale (ISS) (median 25 vs. 25, p=0.757), and initial GCS
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(median 7 vs. 7, p=0.384). (Table 2) Patient data was complete except for four missing values for
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initial GCS.
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Use of trauma care interventions in the ED:


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Several early interventions in the ED increased after STP implementation: The use of bladder
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catheterization increased, (49% vs. 73%, p=0.015), resuscitation with 7.5% hypertonic saline

increased (38% vs. 63%, p=0.014), arterial blood gas draws (25% vs. 43%, p=0.059), spinal

immobilization (25% vs. 40%, p=0.104), administration of the tetanus vaccine to patients with

penetrating trauma (13% vs. 30%, p=0.034), prophylactic antibiotics (16% vs. 28%, p=0.161),

and blood transfusions begun in the ED (3% vs. 13%, p=0.008). (Figure 1)

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Mortality, Discharge GCS and Length of Stay:

After STP implementation, in-hospital mortality decreased (38% vs. 18%, p=0.024), and

discharge GCS increased from median 10 to median 14 (p=0.034). We used logistic regression to

investigate the STP’s effect on in-hospital mortality, controlling for age, sex, ISS, initial GCS,

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transfer status, hours from injury until presentation, surgical status, and blood transfusion at any

time during hospital stay. Age, ISS, and STP independently predicted in-hospital mortality.

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(Table 3) Odds ratio of in-hospital mortality after STP was 0.248 (95%CI: 0.074 – 0.838,

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p=0.025). Goodness of fit was measured with Hosmer and Lemeshow test (p=0.819). Median

hospital LOS increased 17 (IQR: 6 – 32) days to 29.5 (IQR: 16 – 36) (mean 28.6 days vs. 30.2,

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p=0.822). Similarly, median number of days in the ICU increased from 11 (IQR: 6 – 18) days to

13 (IQR: 7 – 21) (mean 13.3 days vs. 15.5, p=0.381). (Table 2). Controlling for age, sex, ISS,
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initial GCS, transfer status, blood transfusion at any time during hospitalization, surgical status
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linear regression showed that surgical status was the only independent predictor of LOS and days
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in the ICU in both the full patient group and with the outliers removed.
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Discussion
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The odds of in-hospital mortality of patients with STBI was 4 times greater before the STP.

Despite wide spread use of ATLS in the world, because of the high costs and difficult logistics

associated with offering the course, most hospitals and physicians caring for injured patients in

LMICs are unable to obtain such training13,15,23. In fact, regionalized trauma systems do not exist

in most LMICs and implementation of evidence-based standards of trauma practice either

through ATLS dissemination or using an alternative to ATLS is at best spotty and varies

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tremendously from region to region within the same country13-18. Despite the enormous success

and wide dissemination of the ATLS program, it has not been widely implemented in the

countries that need them most, where 90% of trauma-related mortality in the world occurs.

Although ATLS has been taught in over 60 countries and though more than a million people

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have received ATLS courses24, the challenge continues to be that in most LMICs the hospitals

that bare the burden of caring for large numbers of injured patients are not always in the

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metropolitan areas, and their physicians, nurses and emergency care providers do not have

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training in trauma care nor do they have readily available and low cost access to ATLS or other

formalized training programs. The widespread institution of ATLS in North America, Europe,

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and other high-income countries has lead to improvements in outcomes in those countries7-12,

and are now mandated by regional and national organizations in charge of trauma center
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certification. The current state of healthcare in most LMICs financially limits the ability of
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emergency physicians, trauma surgeons, and the hospitals where they work to become ATLS
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certified2,13,16-18. We do not contend the Neiva STP is an equally effective or ideal alternative to

ATLS. However in the absence of widespread availability to ATLS-like training and


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certification, we created a similar STP, which was carefully adapted to the local needs of NUH.
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The implementation of this particular STP in an LMIC emergency department was associated
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with decreased mortality and increases the use of evidence-based interventions. Patients were

four times as likely to die while in the hospital before the implementation of the STP.

It has been shown elsewhere that tailored advanced trauma care courses in austere

environments can be effective in educating local providers, and even on a national level25,26. The

Neiva Protocol is an example of a low-cost STP based on generally accepted best practices as

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well as military guidelines for trauma care designed for austere environments. It was created to

be applicable with the limited resources available at NUH.

The implementation of the STP was not free of difficulties. Attempting to change the

behavior and the professional culture of people with several years of non-standardized practice

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was a real challenge. Medical staff in most Colombian hospitals are overburdened. This often

leads to low morale in both nurses and physicians. In that environment, our first step was to

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engage physicians and nurses, inviting all the ER staff to periodical meetings and soliciting

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advanced input from general surgery, anesthesiology, critical care, neurosurgery and orthopedics.

This process also included education on how similar protocols have impacted outcomes in other

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austere environments25,26. Surgery residents, under the direction and guidance of the ED director,

reviewed the evidence for the STP, and this greatly increased the general enthusiasm as it gave
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the surgeons who would be primarily taking care of these patients a greater ownership. Hospital
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administrators did not initially support the STP, but their opinion changed once it was presented
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to them as a means for improving patient safety by the hospital’s office of Quality Improvement.

This study has significant limitations. Firstly, this was a single center, retrospective study
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and is subject to the biases of studies of this type. There was no opportunity for long-term
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follow-up, therefore we have no data on long-term disability or mortality. The collection period
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was slightly asymmetrical reflecting record accessibility at NUH. August 2010 was the first

month that the NUH managers of the administrative database were collecting information

relevant to this study. In August 2012, NUH implemented a new software platform for their

financial records system. The implementation had many difficulties including large losses of

data. In effect, the analysis here is of the longest continuous time period that we are able to

investigate. Though trauma admissions can be seasonal, the number of patients per month that

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met inclusion criteria were similar (5.2 vs. 5). Furthermore, the total number of admissions per

month was similar in both time periods (186.9 vs. 189.3). There was no mechanism to allow for

determination of physician non-adherence. This limits the ability to measure the full effect size

of the STP. A prospective study is currently underway to determine the level of non-adherence to

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the STP at NUH.

The sample size is relatively small. The primary reason is the inclusion criterion of 12

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hours or less after injury. Though NUH is the designated trauma center for the region, there are

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many other hospitals in the area. Ambulance companies are owned by the individual hospitals

and the ambulance crews are only obliged to use their best judgment in determining hospital

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destination. Furthermore, the Colombian government has a special payment mechanism in place

for the care of victims of motor vehicle accidents. This payment, approximately $5,000 US
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dollars, is paid before a private insurance company has any financial responsibility. In practice, it
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is much easier for a hospital to collect this supplemental payment. Non-trauma hospitals have
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this added financial incentive to treat the injured patient initially and then transfer to NUH rather

than immediate transfer. The sample size poses limitation on logistic regression because of the
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number of variables being fitted for the number of observations. It has not been possible to check
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whether the linear assumptions for continuous variables such as ISS are strictly true and the
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confidence intervals are necessarily wide. Despite these limitations we were able to show that the

introduction of STP was an independent factor in reducing mortality.

The increase in total LOS and ICU stay is not surprising. The patients in this study were

severely injured and the in-hospital mortality rate of this cohort before the STP was 38.2%. We

hypothesize that the relative increase in LOS and ICU stays are because severely injured patients

that would have otherwise died without the STP necessitated an extended recovery time.

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The increase of some interventions recommended by the Neiva STP did not reach

statistical significance. This may be due to the relatively small sample size of this study, but the

need for continued training and surveillance is also a possibility. It has been shown elsewhere

that this STP is associated with dramatic increases in the use of early interventions for traumas of

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all causes [27]. Further work is needed to determine if the Neiva STP is associated with

improved outcomes in other types of serious injury.

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Future Implications

The STP will be available in both Spanish and English in an open source format (Currently under

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review). A concerted effort for dissemination and expansion will be initiated through the local

trauma societies and local PAHO offices in several countries in Latin America.
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Conclusions:

The implementation of an STP at a university hospital in an LMIC decreased in-hospital


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mortality and increased discharge GCS scores for patients with STBI. It also led to increased
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uses of early interventions in the treatment of these patients. The STP was associated with an
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increase in LOS for this cohort and an upward trend in ICU stay. More studies are needed to

analyze the impact on specific groups of trauma patients, such as patients with penetrating injury

or traumatic amputation. Furthermore, more work is necessary to determine if the effects of this

STP are reproducible in other LMIC hospitals.

The authors have no conflicts of interest 

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The authors received no funding for this work.  

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Table 1: Patient demographics, transfer status, time to presentation at NUH, and mechanism of

Injury before and after STP initiation

Pre-STCP Post-STCP p
(N=68) (N=40)
Age, mean (SD) 37.1 (16) 38.6 (18) 0.644

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Sex (Males), N (%) 63 (92) 31 (77) 0.024

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Hours from Injury to NUH, mean (SD) 4.0 (3.2) 3.4 (3.2) 0.326
Transferred from another hospital, N (%) 46 (67) 20 (50) 0.095

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Motor Vehicle Accident, N (%) 56 (82) 36 (90) 0.284
Assault, N (%) 1 (2) 2 (5) 0.616
Fall, N (%) 5 (7) 2 (5) 0.966

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Multiple injuries, N (%) 25 (63) 32 (46) 0.089

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Table 2: Injury severity, length of stay, and mortality before and after STP initiation

Pre-STCP Post-STCP p
(N=68) (N=40)
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AIS Head, median (IQR) 4.5 (4-5) 4 (4-5) 0.857
ISS, median (IQR) 25 (16-26) 25 (17-29) 0.757
Initial Glasgow Coma Scale, median, (IQR)* 7 (4-8) 7 (4-8.5) 0.384
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Final Glasgow Coma Scale, median (IQR) 10 (3-15) 14 (10-15) 0.034


Transfusion During Hospitalization, N (%) 31 (46) 24 (60) 0.167
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Length of stay, mean (SD) 28.6 (39.0) 30.2 (23.8) 0.822


Length of stay, median (IQR) 17 (6–32) 29.5 (16-36)
Length of ICU Stay, mean (SD) 13.3 (11.5) 15.5 (13.2) 0.381
p

Length of ICU Stay, median (mean) 11 (6-18) 13 (7–21)


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Mortality, N (%) 26 (38) 7 (18) 0.024


* Owing to missing values, N = 104
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Table 3: Logistic Regression Analysis of Predictors of In-Hospital Mortality

Odds Ratio* p 95%CI


Age (years) 1.032 0.042 1.001 ‐ 1.064
Sex 3.86 0.11 0.738 ‐ 20.194
Initial Glasgow Coma Scale 0.849 0.057 0.717 ‐ 1.005

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ISS 1.139 0.001 1.055 ‐ 1.229
Transferred from OSH 2.864 0.123 0.751 ‐ 10.925
Surgical Procedure 0.725 0.682 0.155 ‐ 3.381

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Time from Injury to Presentation (hours) 0.883 0.234 0.720 ‐ 1.084
Transfusion During Hospitalization 0.587 0.309 0.210 ‐ 1.638

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STP 0.248 0.025 0.074 ‐ 0.838
* High numbers indicate higher probability of in-hospital mortality

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Figure 1: The use of 7 interventions in the emergency department (ED) and in‐hospital 
mortality before and after the implementation of a standard trauma protocol (STP). * 
Indicates p value < 0.05. Error bars represent 95%CI. 
 

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Conflict of Interest.  
 
 
None of the authors have any potential conflicts of interest. 

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No funding was received for this work.

Author Contributions

MRK: study design data collection, data analysis, data interpretation, writing

LRN: data collection, critical revision

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DJS: data collection, critical revision

JDC: data collection, critical revision

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AMR: study design, data interpretation, and critical revision

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JCP: study design, writing, critical revision

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Figure

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