Association Between Prehospital Emergency Care (Pec) Factors and Traumatic Brain Injury (Tbi) Mortality in Kiambu and Nairobi Counties, Kenya

Abstract

Background: Traumatic Brain Injury (TBI) is a major cause of trauma burden, accounting for over 69 million injuries globally. Low- and middle-income countries (LMICs) account for approximately three times the burden of TBIs compared to High-Income Countries (HIC). This significant burden is primarily attributed to the weak capacity of prehospital emergency care (PEC) systems in LMICs. In Kenya, all forms of trauma, including TBIs, have become a leading cause of death. Many of these avoidable deaths are due to delays in accessing quality PEC. However, there is limited local evidence to guide evidence-based life-saving interventions at this level of care. Objective: The objective of this study was to determine the association between PEC system factors and traumatic brain injury mortality in Kiambu and Nairobi counties, Kenya. Methods: A retrospective case-control study was conducted with a sample of 316 TBI patients comprising 158 cases and 158 controls. The cases and controls were randomly selected using an Excel list. Data was abstracted from patient medical records for the period of January 2017 to March 2019 from three tertiary trauma care facilities in Kenya. A logit model was used to analyze the association between PEC factors and TBI mortality, while adjusting for patient characteristics and other potential confounders. Qualitative data from 38 purposively sampled key informants were thematically analyzed to complement the quantitative data using the convergent triangulation method. Results: The study population was predominantly youthful with 73%, of the patients being under 40 years old, and mainly males. Road traffic injuries (RTIs) accounted for 58% of all forms of trauma patterns, with blunt trauma comprising 71% of the injuries. More than half (58%) of the patients did not access PEC, while nearly three-quarters (75%) were transferred directly to a tertiary trauma hospital. Female gender (OR=2.65; 95%CI: 1.19-5.92; P=.017);

severe trauma (GCS 13-15) (OR=4.00; 95%CI: 2.10-7.66; P=.001); under-triaging emergency cases (OR=3.01; 95%CI: 1.46-6.24; P=.003); hypoxemia (OR=5.95; 95%CI: 3.09-11.45; P=.001), and comorbidity (OR=1.27; 95%CI: 0.81-5.26; P=.041) were significantly associated with an increased risk of TBI mortality. The type of trauma mechanism (RTI) and type of injury (blunt trauma) were also significantly associated with mortality. The risk of death for patients sustaining RTIs was 2.83 times higher compared to non-RTI patients [OR=2.83, 95% CI; 1.62-4.93, p=0.001], while sustaining blunt trauma had a 1.23 times higher risk of TBI mortality compared to sustaining penetrating trauma (OR=1.23; 95%CI: 1.01-1.50; P=.044). Access to PEC (OR=0.52; 95%CI: 0.03-9.32; P=.659) and the type of patient transfer system used (direct transfer to a tertiary hospital) (OR=1.49; 95%CI: 0.27-8.20; P=.659) were not significantly associated with TBI mortality. However, transferring patients to a tertiary public facility was associated with a 2.82 times higher risk of death compared to a private facility (OR=2.82; 95%CI: 1.51-5.29; P=.001). Gaps in the PEC system include, access to few ill-equipped ambulances, lack of dedicated trauma calls or coordination centers, patient mishandling by untrained lay rescuers, absence of relevant policy frameworks, weak governance structures, and weak critical trauma care capacity in public primary health facilities among others. Conclusion: In traumatic brain injuries (TBIs), various patient characteristics such as gender, trauma severity, triaging ranks, and oxygen concentration levels (presence of hypoxemia) are crucial in designing and implementing locally responsive TBI life-saving protocols at the prehospital emergency care (PEC) level. Road Traffic Injuries (RTIs) significantly contribute to the mortality burden associated with TBIs in Kenya. However, access to PEC and the type of patient transfer pathway do not provide any mortality benefits to TBI patients due to inherent

weaknesses in the PEC system’s capacity. The main reason for the increased risk of TBI mortality in public trauma care facilities is the lack of critical care capacity. To address the identified gaps at the PEC level, it is recommended to implement the approved Kenya Emergency Medical Care Policy 2020-2030 guidelines on the design, implementation, and management of emergency care services. Specifically, to mitigate TBI risks for patients, the study suggests several priority interventions at the PEC level: (i) Review, enhance capacity, and expand the use of gender-sensitive Glasgow Coma Scale (GCS) as a triaging protocol for TBI responses, (ii) Scale-up training programs for TBI triaging and diagnostic capacity, and (iii) Improve the supply and training related to oxygen supplementation. To mitigate TBI risks associated with RTIs, the study recommends the development and adoption of a RTI risks map that shows risk profiles, which can support public trauma sensitization campaigns. Additionally, it suggests supporting effective coordination between ambulance services and dispatch centers, connected to well-equipped facilities. To strengthen the capacity of Emergency Medical Services (EMS) systems, facilities, and infrastructure to deliver quality PEC care, the study recommends; (i) Establishing functional trauma command centers at all levels, both county and national, (ii) Enhancing access to well-staffed, coordinated, and equipped ambulances, (iii) Training and deploying resourced community-based emergency response teams. Finally, to provide advanced critical TBI care along the referral pathway as an extension of PEC, the study recommends strengthening the functional capacity of public hospitals, especially primary facilities.