Third delay in traumatic brain injury: time to management as a predictor of mortality.

Objective: Traumatic brain injury (TBI) is a global epidemic with an increasing incidence in low- and middle-income countries (LMICs). The time from arrival at the hospital to receiving appropriate treatment ("third delay") can vary widely in LMICs, although its association with mortality in TBI remains unknown.

Methods: A retrospective cohort analysis with multivariable logistic regression was conducted using the Toward Improved Trauma Care Outcomes in India database, which contains data from 4 urban trauma centers in India from 2013-2015.

Results: There were 6278 TBIs included in the cohort. The patients' median age was 39 years (interquartile range 27-52 years) and 80% of patients were male. The most frequent mechanisms of injury were road traffic accidents (52%) and falls (34%). A majority of cases were transfers from other facilities (79%). In-hospital 30-day mortality was 27%; of patients who died, 21% died within 24 hours of arrival. The median third delay was 10 minutes (interquartile range 0-60 minutes); 34% of cases had moderate third delay (10-60 minutes) and 22% had extended third delay (≥ 61 minutes). Overall 30-day mortality was associated with moderate third delay (OR 1.3, p = 0.001) and extended third delay (OR 1.3, p = 0.001) after adjustment by pertinent covariates. This effect was pronounced for 24-hour mortality: moderate and extended third delays were independently associated with ORs of 3.4 and 3.8, respectively, for 24-hour mortality (both p < 0.001).

Conclusions: Third delay is associated with early mortality in patients with TBI, and represents a target for process improvement in urban trauma centers.