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The Utility of The Kampala Tra
The Utility of The Kampala Tra
The Utility of The Kampala Tra
DOI 10.1007/s00268-014-2830-6
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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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
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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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 (%)
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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
All traumas
*KTS 0.26 0.20–0.33 \0.001 1.00
*RTS 0.18 0.13–0.25 \0.001
0.75
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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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362 World J Surg (2015) 39:356–362
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Acknowledgments The authors wish to thank Jared Tomlinson MD 14. MacLeod JBA, Kobusingye O, Frost C et al (2003) A comparison
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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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