Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania

J. Holler, Abigail Cortez, S. Challa, E. Eliezer, Billy Hoanga, Saam Morshed, D. Shearer
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引用次数: 2

Abstract

Background: Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. Methods: We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures. Results: Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission. Conclusions: Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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坦桑尼亚开放性胫骨骨折延迟住院和手术治疗的危险因素
背景:开放性骨折,尤其是胫骨骨折,需要及时干预以达到最佳的治疗效果。虽然开放性胫骨干骨折是低收入和中等收入国家(LMICs)常见的损伤,但缺乏文献研究在资源匮乏的情况下对这些损伤进行手术治疗的延误。本研究调查了坦桑尼亚开放性胫骨骨折延迟治疗的危险因素。方法:我们对2015年至2017年在坦桑尼亚一家三级转诊中心参加前瞻性观察研究的成年患者进行了临时分析。采用多变量模型分析胫骨骨干开放性骨折患者延迟住院≥2小时、受伤至治疗医院的中位时间、入院后延迟手术治疗≥12小时的危险因素。结果:249例患者符合纳入标准。只有12%的患者使用了救护车,41%的患者在第一家医院就诊时延迟≥2小时,75%的患者接受了机构间转诊,10%的患者在入院后延迟手术≥12小时。在调整损伤严重程度后,有保险(调整优势比[aOR] = 0.48;95%可信区间[CI] = 0.24 ~ 0.96)和皮肤边缘近似的伤口(aOR = 0.37;95% CI = 0.20 ~ 0.66)与延迟住院的风险降低相关。机构间转介(比无转介多2.3小时);P = 0.015),农村损伤部位比城市损伤部位长10.9小时;P < 0.001)与治疗入院的中位数时间较大相关。老年(aOR = 0.54 / 10年;95% CI = 0.31 ~ 0.95),单人家庭(与≥8人相比aOR = 0.12;95% CI = 0.02 ~ 0.96),且教育水平高于学前教育(aOR = 0.16;95% CI = 0.04 ~ 0.62)与入院后延迟手术≥12小时的患者较少相关。结论:院前网络和社会经济特征与坦桑尼亚胫骨骨折开放治疗的延迟有关。减少机构间转诊和实施手术成本降低策略可能有助于减少中低收入国家开放骨折护理的延误。证据等级:预后III级。有关证据水平的完整描述,请参见作者说明。
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