Study highlights need for smarter, locally tailored trauma-care systems

A study of almost 9,000 injury patients across Africa and South Asia has found that nearly half were dead or disabled after three months - highlighting the need for smarter, locally tailored trauma-care systems. 

Publishing its findings today (7 Oct) in The Lancet Global Health, the international research group led by University of Birmingham experts, reveal that the biggest influences on survival and recovery are not just the injuries themselves, but how people move through the healthcare system. 

Injuries cause an estimated 4.4 million deaths annually worldwide, with 90% occurring in LMICs. This is the first large multi-country study to examine mortality and disability outcomes among hospitalized injury patients across Low- or Middle-Income Countries (LMIC). The study reveals that access to appropriate care, the route patients take to hospital, and the type of services available all play an important role in these outcomes. 

Analyzing data from 8,858 patients treated in 19 urban and rural hospitals across Ghana, Pakistan, Rwanda and South Africa, the NIHR-funded Global Health Group on Equitable Access to Quality Health Care for Injured People in Four Low- or Middle-Income Countries (Equi-injury) reveals an enormous and often overlooked global health burden: 

• 47.6% of patients either died or were left with moderate-to-severe disability within three months of hospital discharge. 

• 6.1% died in hospital, 9.7% had died within three months, and 40.6% were living with moderate-to-severe disability three months after discharge. 

• Patients arriving at hospital by ambulance had significantly worse outcomes, with 86% higher odds of death or disability and more than double the odds of mortality within three months compared with those using other forms of transport. 

Lead author Professor Justine Davies, from the University of Birmingham, said: "One of our most surprising findings was that measures often assumed to improve outcomes - such as ambulance transport and rapid transfer to major hospitals which are similar to highly centralized trauma services - were not consistently linked with better recovery or survival. 

"This does not mean that ambulances cause worse outcomes but suggests that investment in ambulance systems alone is unlikely to improve outcomes unless services are coordinated and appropriately resourced." 

The findings challenge assumptions that healthcare models developed in wealthier countries can simply be copied elsewhere. Instead, the study argues that countries should develop trauma and injury-care systems based on local evidence, resources, and patient needs. 

Corresponding author Dr Leila Ghalichi, from the University of Birmingham, said: "This does not mean ambulances or specialist trauma centres are ineffective. Rather, it suggests that simply investing in expensive emergency systems is not enough. 

"LMICs should be cautious about investing heavily in ambulance services and specialist, centralized, trauma centres without ensuring they are well coordinated, properly staffed, and supported by strong health systems. Better data and further research are needed to understand which trauma-care investments improve patient outcomes." 

The study notes that stopping first at a nearby hospital for emergency stabilization may sometimes be beneficial, especially if a specialist hospital is far away. If a major trauma hospital is close by, going directly there may improve outcomes. 

Researchers found no evidence that reaching a hospital more quickly reduced the risk of death. Patients who experienced some delays were less likely to be disabled later - challenging the common belief that faster treatment always leads to better outcomes after injury. 

Age was linked to worse outcomes, but gender, wealth and education had little effect on survival while patients were in hospital. However, once out of hospital wealthier and better-educated patients tended to recover better, suggesting that access to rehabilitation and follow-up care may play an important role. 

Ninety per cent of global injury deaths occur in LMICs and are estimated to account for around 10% of the global burden of disease. Yet trauma care receives far less attention than infectious diseases or chronic conditions in global health policy. 

Country-level differences were striking. Patients in South Africa had the lowest odds of disability but the highest odds of mortality, while patients in Rwanda experienced the lowest odds of mortality. Meanwhile, patients in Pakistan experienced substantially higher odds of the combined outcome of death or disability than those in Ghana. 

The study population reflects the demographics of injury worldwide. Median age was 31 years, 76.8% were male, and road traffic collisions accounted for 50% of all injuries recorded. Orthopaedic injuries were the most common injury type, affecting 39.2% of patients.