KARACHI: A major public sector health facility receiving the largest number of road traffic injury patients also has the highest mortality figure in dealing with such cases, says a study recently published in the Journal of Pakistan Medical Association.

It also highlights that Karachi desperately needs a pre-hospital care system managed or coordinated by the municipal authorities so that patients are moved to hospitals that are not overcrowded and, thus, better able to serve them.

The study, titled `Difference in riskadjusted outcome of road traffic injuries in urban tertiary of Pakistan`, was conducted by Dr Amber Mehmood, Dr Junaid Abdul Razzak, Dr Mohammad Umer Mir and Dr Rashid Jooma.

It examined data of all road traffic injury victims (93,657) compiled by theRoad Traffic Injury Research and Prevention Centre from three state-run tertiary care centres (names are not mentioned) in Karachi from September 2006 to October 2009.

Those who were dead on arrival were excluded. Complete information was found missing in 6,458 cases. Of the total victims, 90pc were male, 74pc of them were aged between 16 and 45 years.

Experience from around the world, according to the study, shows that high volume centres have better outcomes for a range of critical conditions, including trauma. However, in Karachi, the public sector hospital (Centre 1) receiving the largest number of road traffic injury patients (43pc of the total cases) had the worst outcomes.

`Significant differences exist in the risk-adjusted survival of road trauma patients presenting to the three major public sector hospitals of Karachi.

These differences may point to variations in processes of care but, in addi-tion, the high-volume trauma centre may be burdened to a point of diminishing effectiveness, resulting in less than predicted survival outcomes,` it says.

The results show that the burden of road traffic injury patients to tertiary care hospitals is not only high but also poorly distributed and triaged. It also demonstrated that after adjusting for age, type of injury, injury severity, and time since injury and mode of transport, the hospital was the single most significant determinant of survival,` it says.

The findings showed that 1,693 patients died at the health facility that received the largest number of cases (40,903). More than 700 and 600 patients died at the other two centres, which received 28,302 and 24,452 cases, respectively.

`In the current study it is also noteworthy that the highest number of head and facial injuries were seen at Centre 1, which is the major referral centre forneuro-spinal trauma in the public sector. This centre operates a `no refusal` admission policy and with a lack of triage of head-injured patients from incident sites or other centres, is of ten overburdened with admissions and interfacility transfers.

`This could have caused a selection bias with patient crowding and associated poor outcomes. Recently, it has been documented that better outcomes of neuro-trauma have been reported with moderate patient volume, even in specialised centres,` it says.

According to the study, potential reasons for poor in-hospital survival could be manifold, but pre-hospital delays, inadequateinitialresuscitation,lack of trauma guidelines, as well as prolonged emergency stay and non-availability of experienced and senior staff to advise the management are cited as potential factors for a poor outcome of trauma patients.

Distribution of the injured, it says,needs to match the availability of clinical resources; hence trauma outcomes cannot be assessed accurately in care facilities without taking into account triage and pre-hospital care.

`Designation of trauma centres with commensurate trauma-care facilities and trained personnel in place is the key to improving trauma care at hospital level, but needs to be accompanied by development of triage and pre-hospital care systems.

Installing integrated trauma systems, it says, is far more effective than enhancing the capabilities of individual components and facilities. A continuous cycle of evaluation with regular assessment of quality of trauma-care and efficient trauma-care pathways is essential.

`What the paper says is that if you look at injuries of similar severity, then the survival varies according to the hospital that you go to in Karachi. There was a stark difference in survivalbetween the three public sector hospitals that we covered,` said Dr Jooma, senior neurosurgeon, who was part of the research.

In his opinion, the hospital with a high mortality rate was not staffed and equipped according to its needs and patient volumes and often the facility was overwhelmed, adversely impacting patient care.

Karachi, he said, didn`t have a prehospital care system managed or coordinated by the municipal authorities.

Thus, the field was left to private ambulance services with no operational guidelines or regulations.

`They compete for business and in this there is no triage of the injured and they are all rushed to the nearest hospital which in a major incident is soon saturated,` he said, adding that there was a pressing need for the municipal authority to regulate and coordinate the private ambulances and improve medical care at the city`s public hospitals.