The Utility of The Kampala Tra

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World J Surg (2015) 39:356–362

DOI 10.1007/s00268-014-2830-6

ORIGINAL SCIENTIFIC REPORT

The Utility of the Kampala Trauma Score as a Triage Tool


in a Sub-Saharan African Trauma Cohort
Bryce Haac • Carlos Varela • Andrew Geyer •

Bruce Cairns • Anthony Charles

Published online: 15 October 2014


Ó Société Internationale de Chirurgie 2014

Abstract
Background Trauma scoring systems have been developed to assess injury severity and may have triage potential.
We sought to evaluate the ability of the Kampala trauma score (KTS) to assess injury severity and its potential as an
outcome predictive tool in Malawi.
Methods This is a prospective cohort study of trauma patients presenting to Kamuzu Central Hospital in 2012. We
recorded admission KTS and Revised trauma score (RTS), emergency department disposition, and hospital length of
stay (LOS) and survival. Logistic regression and ROC curve analyses were used to compare the KTS to the widely
accepted RTS.
Results 15,617 patients presented with trauma. 2,884 (18 %) were admitted, of which 2,509 (95 %) survived. The
mean admission KTS was 14.5 ± 0.6, and RTS was 11.9 ± 0.3. For KTS and RTS, the odds of admission with each
increment increase in score was 0.44 and 0.3, respectively. Similarly, odds of mortality is 0.48 and 0.36. Neither KTS
(p = 0.96, ROC area 0.5) nor RTS (p = 0.25, ROC area 0.5) correlated significantly with hospital LOS. KTS and
RTS performed equally well as predictors of mortality, but KTS was a better predictor of need for admission (KTS
ROC area 0.62, RTS ROC area 0.55, p \ 0.001).
Conclusions Both the KTS and RTS were significantly associated with need for admission and final outcome on
logistic regression analysis; however, they may not be strong enough predictors to merit their use as a screening tool
in our setting.

Introduction
B. Haac  B. Cairns  A. Charles (&)
Department of Surgery,UNC School of Medicine, University of
North Carolina at Chapel Hill, 4008 Burnett Womack Building, Traumatic injury is a significant cause of morbidity and
Chapel Hill 7228, USA mortality globally. The WHO estimates that injuries con-
e-mail: anthchar@med.unc.edu stitute 16 % of the global burden of disease [1]. This
translates into 5.8 million injury-related deaths at a rate of
C. Varela
Department of Surgery, Kamuzu Central Hospital, Lilongwe, 97.9 per 100,000 worldwide. Injuries further account for
Malawi between 10 and 30 % of all hospital admissions and render
at least 78 million people disabled each year [2, 3]. The
A. Geyer burden resulting from injuries tends to be higher in low- to
Air Force Institute of Technology (AFIT/ENC),
Wright-Patterson AFB, OH, USA middle-income countries (LMICs) and communities.

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World J Surg (2015) 39:356–362 357

Approximately 87.9 % of all road traffic deaths and 88.3 % Methods


of lost disability-adjusted life years (DALYs) were from
LMICs [4]. Despite the heavy burden from the human Study setting, design and population
immunodeficiency virus and the acquired immune defi-
ciency syndrome (HIV/AIDS), malaria, and other infec- KCH has five surgical wards with 235 adult surgical beds,
tious diseases in LMIC’s, injuries were still responsible for over 5,000 surgical admissions a year, and an average of
19.93 % of all deaths of those between the ages of 15 and 15,000 trauma patients seen each year. The hospital serves
59 years, and for nearly one in every four deaths of those a catchment of 800,000 from the capital city, Lilongwe,
between 15 and 29 years. Most of these deaths resulted and referrals from the country’s entire central region (pop.
from road traffic injuries, wars, and interpersonal violence. 5 million). The vast majority of trauma patients present to
Sub-Saharan Africa has some of the highest mortality the casualty department for evaluation, but a few patients
rates and the greatest number of disability-adjusted life are evaluated in the orthopedic outpatient clinic and never
years lost from injury [5]. At the same time, this region pass through the casualty department. The General Surgical
suffers from a dearth of resources with only 3 % of the Staff available at KCH during the study period included
world’s health care workers and less than 1 % of health four full-time general surgery consultants, one urologist,
care resources [6]. Malawi is one of the poorest countries in and sixteen full-time clinical officers. Also operating dur-
Sub-Saharan Africa, and, despite offering universal free ing the study period was eleven Malawian general and
health care, the country’s total health care expenditure is orthopedic surgical residents and two American general
only $23 per capita [7]. At the same time, injury is the surgery residents. The main operating theater at KCH has
second most common non-communicable cause of mor- four fully functional operating rooms with one anesthesi-
tality in Malawi and accounts for 9 % of deaths [8]. ologist and six clinical officer anesthetists.
Inadequate pre-hospital and emergency healthcare systems We conducted a prospective cohort study of patients
contribute to the devastation of injury in this resource- presenting to KCH with trauma from January 1 through
limited setting. December 31, 2012. All adult patients presenting with
With such a great trauma disease burden in a resource- trauma to the KCH casualty department were eligible.
poor setting, it is imperative that protocols be developed Trauma patients who were admitted directly through the
to strategically allocate resources in a manner that max- orthopedic outpatient clinic were also eligible once found
imizes patient survival and minimizes injury-related on the surgical wards. Patients admitted through outpatient
morbidity. Many predictive scoring systems have been orthopedics were included in the trauma registry, but only
developed and used in high-income countries to aid with had an admission KTS calculated if all the necessary vital
injury description, triage, and outcome prediction since signs were documented in the chart by the admitting cli-
the 1970s including the revised trauma score (RTS), nician. Due to lack of pediatric blood pressure cuffs,
injury severity score (ISS), and the trauma and ISS trauma scores could not be calculated for pediatric patients.
(TRISS) [9–11]. These scoring tools perform well in
industrialized nations, but their calculation can be com- Data collection
plex and can require diagnostic tools not available in
resource-poor settings [12]. The Kampala trauma score Trauma registry clerks collected all data. Clerks were lay
(KTS) was developed in 1996 in Uganda to address this people who had completed secondary school or higher and
difficulty [13]. The scoring system combines the RTS and were able to read and write in both English and Chichewa,
the ISS using both anatomic and physiologic data to the local language. The former trauma registry form as
create a score similar to TRISS but simplified to be useful described in Samuel et al. was revised to include a section
in sub-Saharan Africa. In Uganda, the KTS has been for KTS and RTS scoring [15].
shown to be a good predictor of need for hospital We held an initial 3-hour training to orient the clerks to
admission, hospital length of stay (LOS) greater than the updated trauma registry form and the KTS and RTS
2 weeks, and death [13, 14]. scoring systems. In addition, we taught the clerks to check
We sought to evaluate the utility of the KTS at Kamuzu a manual blood pressure, heart rate, and respiratory rate.
Central Hospital (KCH), a tertiary care referral hospital in They were also educated on how to calculate the AVPU
Lilongwe, Malawi and compare the performance of the neurologic score. The clerks were given a chart with nor-
KTS to the RTS in predicting the outcomes of hospital mal vital sign ranges and guidelines for contacting a nurse
admission, LOS greater than 2 weeks, and mortality in our or clinician if an abnormal vital sign is found. Registry
setting. Finally, we examined the feasibility of training lay clerks completed a take home test with example patient
people to calculate the score; a system that could aid in problems following the training. We reviewed any calcu-
triage in settings where clinicians are scarce. lation errors individually with each clerk.

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358 World J Surg (2015) 39:356–362

Table 1 Coding values and calculation of the Kampala trauma score (KTS) and revised trauma score (RTS) KTS coded value
Age (years) A. __________
B5 1
6–55 2
[ 55 1
Number of serious Injuries B. ___________
None 3
One 2
Two or more 1
Systolic blood pressure (mmHg) C. __________
[ 89 4
50–89 3
1–49 2
Undetectable 1
Respiratory rate (breath/min) D. __________
10–29 3
C 30 2
B9 1
Neurological status (AVPU system) E. ___________
Alert 4 KTS Total:
Responds to verbal stimuli 3 A ? B?C ? D?E = ______________
Responds to painful stimuli 2
Unresponsive 1
Glasgow coma scale Systolic blood pressure Respiratory rate RTS Coded value

13–15 [89 10–29 4


9–12 76–89 [29 3
6–8 50–75 6–9 2
4–5 1–49 1–5 1
3 0 0 0

After orientation but prior to the study period, a US- orthopedic surgeons made all decisions regarding need for
trained medical student or surgery resident rounded with admission, discharge, and surgical interventions. For
the trauma clerks daily on the wards and verified all patients admitted directly through outpatient orthopedics,
manually taken vital signs for 2 weeks at which point the clerks completed the registry form when the patient was
measurements taken by the clerks corresponded to those identified on the hospital wards, usually on admission day
taken by the resident or student. The medical student or 2. KTS and RTS were only calculated for these patients if
resident continued to spot check vital signs including the admitting physician recorded admission vital signs. All
rechecking any abnormal vital signs for 2 additional weeks. scores were retrospectively re-calculated by a US-trained
During the study, clerks were provided with and trained to physician to confirm correct calculations for the purposes
use automatic OmronBP760 7 Series Upper Arm Blood of analysis. (Table 1).
Pressure Monitor machines to measure vital signs. If the The second stage of data collection occurred on the
machines failed, clerks were instructed to revert to manual hospital wards. Trauma clerks rounded daily on the surgi-
vital sign measurements. The clerks collected respiratory cal wards to collect outcome data including final disposi-
rate manually. tion and LOS on all registry patients and to identify any
Data were collected in two stages. First, on presentation trauma patients missed in the casualty department.
to the casualty department patient demographic informa-
tion, injury description, initial vital signs, KTS, RTS, and Data analysis
patient disposition were recorded on the trauma registry
form. Trauma clerk coverage was provided 24 h a day, Trauma registry forms were pre-numbered to give each
7 days a week in the casualty department. General and patient admission a unique identifier and prevent

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World J Surg (2015) 39:356–362 359

Table 2 Basic demographic characteristics of admitted trauma Table 3 Mechanisms of Injury for Presenting Trauma Patients
patients
Mechanism of injury Number of Percentage of total
Characteristic Number and percentage injuries injuries (%)

Age (years) Road Traffic accidents: 3,704 24


Mean, range 24 (0–96) Pedestrian hit by:
Missing values 9 Car 777 5
Gender Bicycle 181 1
Male 2,096 (73 %) Motorcycle 30 \1
Female 786 (27 %) Minibus/pickup 145 1
Missing values 2 Bus/lorry 37 \1
Head injuries (includes head, skull, eyes, ears, nose, jaw/mandible) Ox Cart 14 \1
No 1,870 (65 %) Other 1 \1
Yes 1,002 (35 %) Driver/passenger in a:
Missing values 12 Car 598 4
Chest injuries Cab of lorry 62 \1
Yes 2,662 (93 %) Minibus 253 2
No 209 (7 %) Bus 36 \1
Missing values 13 Open bed of lorry 335 2
Spinal injuries (includes neck, cervical, lumbar and thoracic spine Motorcycle 119 \1
injuries) Bicycle 1,060 7
Yes 347 (12 %) Ox Cart 56 \1
No 2,524 (88 %) Animal bite 493 3
Missing values 13 Human bite 67 \1
Abdominal Injuries Gun shot wound 36 \1
Yes 282 (10 %) Foreign body 527 3
No 2,589 (90 %) Fall 4,740 31
Missing values 13 Electric shock/ 22 \1
Pelvic Injuries lightening
Yes 65 (2 %) Occupational injury/ 130 \1
No 2,806 (98 %) machine
Missing values 13 Burn 681 4
Extremity Injuries Assault 3,681 24
Yes 1,818 (63 %) Collapsed structure 829 5
No 1,053 (37 %) Drowning 70 \1
Missing values 13 Laceration (non- 507 3
assault)
Final Outcome
Discharged 2,423 (86 %)
Absconded 84 (3 %) Validation of KTS was done using ROC (receiver
Died 127 (5 %) operating characteristics) curves to assess the overall per-
Transferred 2 (0.1 %) formance of the score assuming equal importance of sen-
Missing values 71 sitivity and specificity. Separate ROC curves were
Surgical Procedure performed constructed to compare the performance of KTS to the
Yes 1,149 (42 %) more widely used RTS in prediction of each outcome
No 1,595 (58 %) variable: mortality and LOS greater than 2 weeks. Areas
Missing values 110 under the curve and 95 % confidence intervals were com-
pared. Treating each score as a continuous variable, odds of
death and hospitalization at 2 weeks was calculated using
logistic regression. Two weeks were used as a marker for
duplication. Data were entered into Access 2007 and ana- consistency with other published papers that have used that
lyzed using Stata 11. Duplicates were removed and outlier time frame to determine score association with LOS [14].
variables were verified manually. Two-dimensional scatter plots were generated for each

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360 World J Surg (2015) 39:356–362

Table 4 Injury setting for presenting trauma patients in 2012

1.00
Place where injury Number of Percentage of patients
occurred patients (%)

0.75
Sensitivity
Home 7,066 46
Work 1,239 8

0.50
Road/street 5,184 33
School 489 3

0.25
Farm 136 \1
Sport/recreation 498 3

0.00
Public space 740 5
0.00 0.25 0.50 0.75 1.00
Lake/river 58 \1
1-Specificity
Field/forest 39 \1
Other 10 \1 KTS ROC area: 0.6904 RTS ROC area: 0.6703
Reference

Fig. 1 Comparison of ROC curves of KTS and RTS as predictors


Table 5 KTS and RTS as predictors of outcome. odds of death for of death for all presenting traumas
every one-point increase in the trauma score
OR 95 % CI p value

All traumas
*KTS 0.26 0.20–0.33 \0.001 1.00
*RTS 0.18 0.13–0.25 \0.001
0.75

Admitted traumas only


Sensitivity

*KTS 0.48 0.36–0.64 \0.001


0.50

*RTS 0.35 0.26–0.49 \0.001


0.25

trauma score component. Patient demographic data point


0.00

was color-coded based on patient mortality outcome. This


was a way to separate patients who lived or died based on 0.00 0.25 0.50 0.75 1.00

any single or combination of trauma score components or 1-Specificity


patient demographic information. If the two populations of KTS ROC area: 0.5929 RTS ROC area: 0.6371
Reference
patients were separated in any dimension on these plots, it
would be considered a good indicator that a statistical
Fig. 2 Comparison of ROC curves of KTS and RTS as predictors
classifier such as logistic regression can be used effectively of death for all admitted traumas
to find the relationship between trauma score and patient
mortality.
causes of injury were fall (31 %, n = 4,740), road traffic
Ethics accident (24 %, n = 3,704), and assault (24 %, n = 3,681)
(Table 1). The most common locations where injury
Both the Malawi National Health Science Research occurred were at the patient’s home (46 %, n = 7,066) and
Council and the University of North Carolina IRB com- on the road (34 %, n = 5,184) (Table 3 and 4).
mittees approved this study. The mean age of all presenting trauma patients was
23 ± 16 years, (range 0–97). The majority of trauma
patients (72 %, n = 11,129) were male. Alcohol was a
Results contributing factor in 5 % (n = 731) of traumas. The mean
delay in presentation from time of injury was
From January 1st 2012 to December 31st 2012, a total of 1.3 ± 7.5 days, with the majority of patients presenting on
15,617 patients presented with trauma, 2,884 (18 %) of the same day of injury (median and mode 0 days, range
which were admitted to the hospital wards. The basic 0–366 days). The mean KTS was 14.5 ± 0.6 (range 9–16,
demographic description of admitted trauma patients is n = 9180), and the mean RTS was 11.9 ± 0.3, (range
described in Table 2. Of these traumas, the most common 5–12, n = 8,921) for all presenting traumas.

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World J Surg (2015) 39:356–362 361

For admitted patients, the mean KTS was 14.2 ± 0.7 anatomic variables (age and number of injuries) are likely
(range 10–16, n = 1,350), and the mean RTS was to factor into a clinician’s decision to admit a patient.
11.8 ± 0.5 (range 8–12, n = 1,305) on presentation. Of Patients with a larger number of injuries and normal vital
admitted patients with a recorded final outcome, 2,509 signs might be admitted for observation due to concern for
(95 %) lived (2,423 were discharged, 84 absconded and 2 missed injury or more serious trauma mechanism. Older
were transferred). 177 patients were recorded as lost to and younger patients with less severe injuries may be
follow-up and were excluded from the final outcome ana- admitted out of concern for decreased physiologic reserve.
lysis. The mean LOS was 12 ± 16 days (range 0-16, Neither the KTS nor the RTS was good indicators of
median 5 days). 761 (27 %) of patients had a LOS greater prolonged hospitalization in our population. Multiple fac-
than 2 weeks. tors affect LOS in a resource-poor setting. Poor patient
Both the KTS and RTS trauma score were significantly follow-up, minimal infrastructure, high cost of transporta-
associated with final outcome (Table 5). In admitted tion, and increasing distances between home and the hos-
patients, for every one-point increase in the admission pital, compounded by a dearth of health care workers and
KTS, the odds of death was halved (OR 0.48, 95 % other unknown cultural norms can all increase LOS. Sim-
CI = 0.36–0.64, p \ 0.001). Similarly, for every one-point ilarly, social factors including a patient’s support network
increase in the admission RTS, odds of death was reduced at home or a patient’s need to return to a work may reduce
by approximately one third (OR 0.36, 95 % CI 0.26-0.49, LOS. For example, 84 patients in our study absconded
p \ 0.001). There was no significant correlation between suggesting they left the hospital before a physician deemed
LOS greater than two weeks and KTS (p = 0.96, area them medically appropriate for discharge. As a result, LOS
under the ROC curve 0.5) or RTS (p = 0.25, area under the is often influenced by subjective data that cannot be
ROC curve 0.5). accounted for in a scoring tool making the predictive
KTS and RTS performed equally well as predictors of probability for LOS of the KTS or the RTS in our envi-
death. There was no significant difference in ROC curves ronment unreliable.
for KTS and RTS as predictors of death in all trauma Incremental increases in both scores were significantly
patients (p = 0.56, Fig. 1) and in admitted traumas only associated with decreased need for admission and
(p = 0.23, Fig. 2). Some patients with low trauma scores decreased mortality according to the logistic regression
survived and multiple patients with high trauma scores models, consistent with previous studies [13, 14, 16].
died; however, resulting in ROC curves that do not vary However, the ROC curves for these outcomes did not vary
greatly from the no-discrimination line. Consistent with significantly from the line of no discrimination, suggesting
these findings, preliminary scatter plot analysis indicated that they may not be strong enough predictors to merit their
that the population of patients who died was not separated use as a screening tool in our setting. Multiple factors not
from the population who lived for any individual or com- accounted for by the trauma scores likely affect survival in
bination of trauma score components or patient demo- our setting. The aforementioned obstacles to care, poor
graphic information. The two populations of patients were nutritional reserve, poor patient monitoring, and reliance
intermixed in all graphs, indicating that there may not be a on family members to alert health workers on critical
strong statistical relationship between the trauma score and changes in clinical status, increasing clinical complica-
patient mortality in the sample data. Further statistical tions, and ultimately failure to rescue can all affect sur-
analysis using the corrected Akaike Information Criterion vival. Unlike the validation studies in Uganda, we followed
(AICc) was performed on both RTS and KTS. The AICc patients until discharge or death, which was often longer
for RTC and KTS were is 612.981 and 635.136, respec- than their two-week follow-up. With longer follow-up
tively. AICc showed no difference in model performance. comes increased potential for complications and deaths. In
addition, potentially lethal injuries can be missed on
admission or in the initial stages of treatment. Neither of
Discussion these scores account for the anatomy of injury, medical
comorbidities, or potential injuries that could be caused by
The performance of KTS was similar to the universally blunt mechanisms; all of which factor into a patient’s
accepted RTS as a predictor of mortality based on the ROC overall prognosis and are important for triage decisions.
curve analysis in this study, but KTS was a statistically These factors could account for some of the deaths we saw
significantly better predictor of need for admission. The in patients with less severe injury as defined by their
superior performance of KTS in predicting need for admission trauma score.
admission may be attributable to the score components. The mean KTS and RTS of our population are relatively
KTS includes data on the number of injuries unlike the high. The lack of a structured emergency response system
RTS, which only includes physiologic data points. The in Malawi can make it difficult for trauma patients to get to

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by the Doris Duke Charitable Foundation; The UNC Institute of (RTS), injury severity score (ISS) and the TRISS method in a
Global Health and Infectious Diseases; the UNC Center for AIDS Ugandan trauma registry: is equal performance achieved with
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