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Time to death and its predictors among traumatic brain injury patients admitted to East Amhara comprehensive specialized hospitals, Ethiopia: retrospective cohort study

BMC Neurology volume 24, Article number: 370 (2024) Cite this article

Abstract

Background

Globally, 64–74 million individuals around the world are estimated to sustain traumatic brain injury every year. Moderate and severe traumatic brain injury can lead to a lifetime physical, cognitive, emotional, and behavioral changes. There were limited studies conducted in Ethiopia regarding to traumatic brain injury mortality.

Methods

An institutional based retrospective cohort study was conducted on 429 randomly selected traumatic brain injury patients aged 18 to 64 years who were admitted to East Amhara Comprehensive Specialized Hospitals from January 1, 2016 to December 31, 2021. Kobo toolbox was applied for data collection and exported to Stata version 17 for data processing and analysis. To estimate death free time, a Kaplan Meier failure curve was used. The Cox proportional hazards regression model was used at the 5% level of significance to determine effect of predictor variables on time to death.

Result

A total of 429 traumatic brain injury patients aged 18 to 64 years were included with response rate of 91.3% and 145(33.8%) were dead. Open injuries (AHR = 0.25; 95% CI: 0.18–0.36), co-existing injuries (AHR = 0.40; 95% CI: 0.24–0.66), ICU admission (AHR = 0.42; 95% CI: 0.29–0.60), arrival within 4–24 h (AHR = 3.48; 95% CI: 2.01–6.03), arrival after 24 h (AHR = 6.69; 95% CI: 3.49–12.28), subdural hematoma (AHR = 2.72; 95% CI: 1.77–4.19), serum albumin < 3.5 g/dL (AHR = 0.66; 95% CI: 0.49–0.94), moderate (AHR = 0.56; 95% CI: 0.21–0.89), and mild traumatic brain injury (AHR = 0.43; 95% CI: 0.29–0.56) were predictors of traumatic brain injury mortality.

Conclusion

The finding of this study showed that the mortality was 1/3rd of the total patients. Open injuries, co-existing injuries, ICU admission, arrival time (4–24 h and > 24 h), subdural hematoma, serum albumin < 3.5 g/dL and severity of traumatic brain injury (mild and moderate) were predictors of traumatic brain mortality. Therefore, working on these factors to reduce the morality of traumatic brain injury patients is very important.

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Background

Traumatic brain injury (TBI) is a non-degenerative, non-congenital insult to the brain caused by an external mechanical force, potentially leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, along with an associated diminished or altered state of consciousness [1]. According to the American Association of Neurological Surgeons, TBI disrupts the normal function of the brain and can result from a blow, bump, or jolt to the head, the head suddenly and violently hitting an object, or an object piercing the skull and entering brain tissue [2]. Modifiable risk factors, such as hypoxia, hypotension, hypertension, and abnormal random blood glucose levels, as well as non-modifiable risk factors, including age, GCS score at admission, and pupillary reactivity, increase TBI mortality [3]. A blood test to evaluate mild TBI in adults was approved by the United States Food and Drug Administration in February 2018. Despite this advancement, about 50% of people with TBI may experience further decline in their daily lives or die within five years of their injury [4, 5].

Approximately 64 to 74 million individuals are estimated to sustain TBI annually worldwide, with the highest burden in the Southeast Asian and Western Pacific regions [6]. TBI is a significant health and socioeconomic issue globally, affecting individuals of all ages in both low- and high-income countries [7]. The incidence of TBI among the elderly is rising in high-income countries, while the burden from road traffic accidents is increasing in low- and middle-income countries (LMICs). Across all ages, TBI accounts for 30 to 40% of all injury-related deaths, and neurological injury is expected to remain the leading cause of disability from neurological diseases—two to three times higher than that for Alzheimer’s disease or cerebrovascular disorders—until 2030 [8].

LMICs experience a TBI burden three times greater than that of high-income countries. More than 90% of trauma mortality occurs in LMICs, especially in sub-Saharan Africa [9]. The majority of TBI cases in Africa occur among young individuals aged 19 to 40 years, with men being the most affected [10]. In Ethiopia, there are 659 TBI cases per 100,000 people, accounting for approximately 10.8% of TBI cases in sub-Saharan Africa and 28% in eastern sub-Saharan Africa [11].

TBI is the leading cause of disability in individuals under the age of 40, resulting in significant social and economic consequences due to the high costs of treatment, rehabilitation, long-term care, and lost contributions to society [12]. Moderate and severe TBI can lead to long-term physical, cognitive, emotional, and behavioral problems, significantly impacting a person’s ability to function in daily life. Even after surviving a moderate or severe TBI and receiving inpatient rehabilitation services, individuals may have a life expectancy that is nine years shorter. Many TBI patients, particularly those with moderate to severe injuries, experience considerable long-term neurobehavioral sequelae. These sequelae and changes in quality of life observed after severe TBI are associated with an increased risk of death long after hospital discharge [5, 13, 14].

Despite the limited studies conducted in Ethiopia, important factors that may affect TBI mortality, such as increased ICP, blood transfusion, coagulation profile, serum electrolytes, and organ function tests, have not been adequately addressed. Therefore, the aim of this study was to assess the time to death and its predictors among traumatic brain injury patients admitted to East Amhara Comprehensive Specialized Hospitals.

Methods

Study design, area and period

A multi-centered, hospital-based retrospective cohort study was conducted from January 1, 2016, to December 31, 2021, at comprehensive specialized hospitals in East Amhara: Dessie, Woldia, and Debre Birhan. Actual data was collected from August 1 to September 1, 2022. Dessie Comprehensive Specialized Hospital, located 400 km from Addis Ababa, is the only referral hospital in South Wollo, serving approximately 8 million people with a capacity of about 400 beds and 800 health professionals. Debre Birhan Comprehensive Specialized Hospital, situated 130 km from Addis Ababa and 517 km from Bahir Dar, serves over 2.8 million people in North Shoa, Oromia, and Afar. Woldia Comprehensive Specialized Hospital, located 520 km from Addis Ababa and 360 km from Bahir Dar, provides services for more than 3 million people, including parts of Afar and Tigray.

Eligibility criteria

All traumatic brain injury patients aged 18 to 64 who were admitted to East Amhara Comprehensive Specialized Hospitals from January 1, 2016, to December 31, 2021, were included in the study. Adult traumatic brain injury patients with incomplete baseline data, those whose medical records were unavailable during data collection, and those transferred in with incomplete baseline data were excluded.

Population

All patients admitted to East Amhara comprehensive specialized hospitals with the diagnosis of TBI were considered as source population, whereas all adult patients admitted to East Amhara comprehensive specialized hospitals with the diagnosis of TBI study period and whose chart were available were study population.

Sample size determination and sampling procedure

The sample size was calculated using Stata version 17 and the initial Glasgow Comma Scale (GCS) score yielded the largest sample size of 470. Proportional allocation was performed for each hospital based on the number of admitted TBI patients, and study participants were selected using a computer-generated simple random sampling technique (Fig. 1).

Fig. 1
figure 1

Schemic presentation of sampling procedure to select study participants among admitted traumatic brain injury patients in East Amhara Comprehensive Specialized Hospitals

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Operational definition

Traumatic brain Injury

An alteration in brain function manifesting as confusion, altered level of consciousness, and coma due to external forces, diagnosed as TBI [15, 16].

Mild traumatic brain Injury

an injury to the head when Glasgow coma scale is between 13 and 15 [17].

Moderate traumatic brain Injury

an injury to the head when Glasgow coma scales between 9 and 12 [17].

Severe traumatic brain Injury

an injury to the head when Glasgow coma scale is less than or equal to 8 [17].

Time to death

Calculated in days between the date of TBI diagnosis and the date of death.

Censored

Patients with TBI who did not die during the follow-up period, including those who were transferred to other services, lost to follow-up, or still receiving treatment in the hospital [15].

Event

The occurrence of death from the first confirmed diagnosis of traumatic brain injury to the end of the study [15].

Incomplete patient chart

When the outcome variable and major independent variables (GCS, CT scan findings, age, sex) are not recorded.

Overall failure function

the probability of occurrence event of interest (Death).

Estimated cumulative failure

Estimated cumulative failure means the total risk of death over time.

Rural

Areas located outside cities and towns, typically characterized by low population density and large open spaces and Limited access to services and amenities (e.g., healthcare, education).

Urban

Areas that are densely populated and characterized by extensive infrastructure and availability of various services (public transportation, healthcare, entertainment).

Data collection tool, procedure and quality control

Data was collected from patient chart reviews using an English version of a data extraction checklist adapted from previous studies [15, 18]. The checklist included five sections: socio-demographic characteristics, institutional factors, injury-related factors, clinical questions, and laboratory/radiological findings. Three BSc nurses, supervised by two MPH professionals, extracted the data using Kobo Toolbox version 2022.1.2 software. The data collectors and supervisors received one day of training on the extraction tool, ethical conduct, confidentiality, and software use to ensure consistency. A pre-test involving 5% of participants at Debre Tabor Comprehensive Specialized Hospital was conducted, and experts verified the checklist for face and content validity.

Data processing and analysis

The collected data was exported to Stata version 17 for data processing and analysis. The Kaplan-Meier survival curve was used to estimate death free time.

The necessary assumptions of the Cox proportional hazards model were verified using log-minus-log plots and Schoenfeld residual plots. Multi-collinearity was assessed with the variance inflation factor. Variables with p-values less than 0.25 from bivariable Cox regression were included in the multivariable Cox regression analysis to identify associations between predictors and the outcome variable. Predictors with p-values less than 0.05 at a 95% confidence interval and adjusted hazard ratios were considered significantly associated with time to death from traumatic brain injury. Finally, the results were presented using text, tables, and graphs.

Results

Socio-demographic characteristics

Among 470 eligible study participants, 429 TBI patient charts were reviewed, resulting in a response rate of 91.3%. The mean age of patients admitted to the hospital was 34.9 years, with a standard deviation of 12.1. More than three-quarters (77.4%) of the study participants were male. During their admission, 171 (39.9%) of the participants were aged 25–34 years. Additionally, 348 (81.1%) of the study participants came from rural areas (Table 1).

Table 1 Socio-demographic characteristics of TBI patients admitted to East Amhara comprehensive specialized hospitals from 1st January 2016 to 31st December 2021(n = 429)
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Institutional related factors

Among the study participants, 188 (53.3%) were referred by primary care hospitals, 171 (39.9%) received surgical treatment, and 152 (88.8%) underwent elevation as a type of surgical management, while 131 (30.5%) stayed for seven days after admission (Table 2).

Table 2 Institutional related characteristics of TBI patients admitted to East Amhara comprehensive specialized hospitals from 1st January 2016 to 31st December 2021 (n = 429)
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Mechanisms of injury related characteristics

Among the study participants, 189 (44.1%) were injured in road traffic accidents, while 177 (38.9%) were admitted due to assaults. A majority, 266 (75.3%), arrived by ambulance, and 63 (17.8%) came by private or public car. Additionally, 299 (69.7%) had open injuries, and 246 (57.3%) arrived within 4 to 24 h of their injury (Table 3).

Table 3 Mechanisms of injury related characteristics of TBI patients admitted to East Amhara comprehensive specialized hospitals from 1st January 2016 to 31st December 2021 (n = 429)
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Clinical related characteristics

Among the study participants, 327 (76.2%) had an oxygen saturation of less than 90% during admission, and 49 (11.4%) developed increased intracranial pressure (ICP). Additionally, 151 (35.2%) had a severe TBI and among them almost half (49.7%) died, while 329 (76.7%) presented with co-existing injuries. Furthermore, 126 (29.4%) were admitted to the ICU, and 89 (20.7%) developed aspiration pneumonia (Table 4).

Table 4 Clinical related characteristics of TBI patients admitted to East Amhara comprehensive specialized hospitals from 1st January 2016 to 31st December 2021 (n = 429)
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Laboratory and radiological finding

Among the study participants, 244 (56.9%) had normal random blood sugar levels upon admission, and 258 (60.2%) had a platelet count exceeding 150,000 per microliter of blood. Additionally, 131 (30.5%) had a prothrombin time greater than 13 s, while 264 (61.5%) had a serum sodium level between 135 and 145 mEq/L. Furthermore, 303 (70.6%) had a baseline serum albumin level of ≥ 3.5 g/dL, and based on radiological findings, 187 (43.5%) were diagnosed with a depressed skull fracture (Table 5).

Table 5 Laboratory and radiological characteristics of TBI patients admitted to East Amhara comprehensive specialized hospitals from 1st January 2016 to 31st December 2021 (n = 429)
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Status of traumatic brain injury patients

Overall, 145 (33.8%) of the 429 traumatic brain injury patients experienced death during the follow-up period (95% CI: 29.1–38.3%). Among those who were censored, 113 (39.7%) were discharged with full recovery, 79 (27.8%) were discharged with a disability, 52 (18.3%) were transferred to another health institution, 21 (7.3%) were lost to follow-up, and 19 (6.7%) left against medical advice (Fig. 2).

Fig. 2
figure 2

Status of traumatic injury patients admitted to East Amhara comprehensive specialized hospitals from 1st January 2016 to 31st December 2021 (n = 429)

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Overall failure function of traumatic brain Injury patients

In this study, 429 traumatic brain injury patients were followed retrospectively for a minimum of 1 day and a maximum of 61 days. The overall mortality rate during the 6,131 person-days of observation (PDO) was 2.36 per 100 person-days (95% CI: 20.10-27.83) of follow-up. The median time to death was 27 days and Inter-Quartile Range of 12 days. Among the 429 patients, 145 died, resulting in a cumulative incidence of death of 33.8% during the follow-up period. The estimated cumulative failure rates were 5.13% (95% CI: 3.41–7.68) within the first day, 12.1% (95% CI: 9.38–15.60) within 3 days, 30.54% (95% CI: 26.41–35.43) within the first 7 days, 52.21% (95% CI: 47.58–57.01) within 14 days, and 93.94% (95% CI: 91.41–95.93) within 30 days of follow-up. Overall mortality rates on the first, third, seventh, fourteenth, and thirtieth days were 3.4%, 8.1%, 17.2%, 24.2%, and 33.1%, respectively. This study found that the highest mortality rate occurred between the third and seventh days of hospitalization (Fig. 3).

Fig. 3
figure 3

Over all Kaplan –Meier estimation of failure functions of traumatic brain injury patients admitted to East Amhara comprehensive Specialized hospitals from 1st January 2016 to 31st December 2021(n = 429)

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Predictors of time to death of TBI patients

In bivariate Cox-proportional hazard regression analysis, the following factors were found to be associated with TBI mortality at a p-value of less than 0.25: mode of admission, blood transfusion, types of injury, presence of co-existing injuries, ICU admission, pulmonary edema, serum sodium level, time of arrival to the hospital, severity of TBI, aspiration pneumonia, serum albumin, elevation, and subdural hematoma.

In the multivariable analysis, the following factors were significantly associated with mortality at a p-value of less than 0.05: open injury, presence of co-existing injuries, ICU admission, time of arrival (4–24 h and > 24 h), subdural hematoma, severity of TBI (mild and moderate), and serum albumin of less than 3.5 g/dL.

TBI patients with open (penetrating) types of injury had 75% lower hazard of death than those with closed (blunt) types of injury (AHR = 0.25; 95% CI: 0.18–0.36). Patients without any co-existing injuries (isolated traumatic brain injury) had 60% lower hazard of death than those with co-existing injuries (AHR = 0.40; 95% CI: 0.24–0.66). Patients who were not admitted to the ICU had 58% lower hazard of death than those who were admitted to the ICU during their hospital stay (AHR = 0.42; 95% CI: 0.29–0.60).

Patients who arrived at the hospital between 4 and 24 h after injury had 3.4 times higher hazard of death than those who arrived within 4 h (AHR = 3.48; 95% CI: 2.01–6.03). Similarly, those who arrived after 24 h had 6.7 times higher hazard of death than those who arrived within 4 h (AHR = 6.69; 95% CI: 3.49–12.28).

Patients with mild TBI had 57% lower hazard of death than those with severe TBI (AHR = 0.43; 95% CI: 0.29–0.56) and those with moderate TBI had 44% lower hazard of death than those with severe (AHR = 0.56; 95% CI: 0.21–0.89).

Patients with serum albumin levels ≥ 3.5 g/dL had 34% lower hazard of death than those with serum albumin levels of less than 3.5 g/dL (AHR = 0.66; 95% CI: 0.49–0.94). Patients who developed subdural hematoma had 2.7 times higher hazard of death than those who did not develop subdural hematoma (AHR = 2.72; 95% CI: 1.77–4.19) (Table 6).

Table 6 Bivariate and multivariable Cox proportional hazard regression analysis of traumatic brain injury patients admitted to East Amhara comprehensive Specialized hospitals from 1st January 2016 to 31st December 2021(n = 429)
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Test of proportional hazard assumptions

A proportional hazards assumption test was conducted, specifically using the Schoenfeld residuals to evaluate the proportional hazard assumption for each covariate and p-value greater than 0.05 was considered to fulfill the assumption. In this study, each covariate had a p-value greater than 0.05, with a global test p-value of 0.82 (> 0.05). Therefore, all covariates met the proportional hazard assumption (Table 7).

Table 7 Goodness of fit test assesses proportional hazard assumption for time to death and its predictors among traumatic brain injury patients admitted to East Amhara comprehensive Specialized hospitals from 1st January 2016 to 31st December 2021(n = 429)
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Discussion

This retrospective cohort study aimed to assess the time to death and predictors of mortality among admitted TBI patients. At the end of the follow-up, 33.8% had died after the diagnosis of TBI and open injury, presence of co-existing injuries, ICU admission, time of arrival (4–24 h and > 24 h), subdural hematoma, severity of TBI (mild and moderate), and serum albumin < 3.5 g/dl were identified as predictors of TBI mortality.

The finding of this study was consistent with the findings of those of studies conducted in India (34.5%) [19], Malawi (30.9%) [20]and(32.3%) [9], Tanzania(34.8%) [21], Addis Ababa(39.2%) [18] and Bahir Dar (30.4%) [15].

However, the finding of this study was lower than the finding of study conducted in USA(50%) [22] and the possible reason for this discrepancy might be due to the differences in study participants, study design and sample size difference. In the USA, the study was conducted prospectively with 670 patients who had hemorrhagic shock, which could contribute to an increased mortality rate.

In contrast, the finding of this study was higher than the findings of those studies conducted in USA in 2015 (11.3%) [23], Iran (14%) [24],Japan (26.3%) [25],USA in 2017 (25.2%) [26], Iran in 2013 to 2016 (4.8%) [27], Canada(15.8%) [28], Saudi Arabia (2.5%) [29],Nigeria (4.7%) [30], Malawi, Kamuzu Central Hospital (16.4%) [31], Uganda (9.6%) [32], Mulago hospital Uganda (2.7%) [33],Rwanda(9.3%) [34], Tanzania (8.9%) [35], Addis Ababa Tikur Anbesa hospital (10.9%) [36] and Wolaita Sodo, Southern Ethiopia (12.2%) [37].

The possible reason for this discrepancy might be due to difference in sample size, study design, study population, socio-demographic characteristics, study setting, the tool used and the health care system. The healthcare systems in the USA, Japan, Iran, Canada, and Saudi Arabia are more advanced compared to that of Ethiopia and the study conducted in Iran was observational and involved 185 patients, using acuity scoring tools, while the study in Japan employed a machine learning (ML) model.

The finding of this study showed that the overall 3 days mortality after hospital admission was 8.1%, which was lower than the finding of study from Pennsylvania(11.62%) [38]. The possible reason for the discrepancy might be due to difference in the study design, tool and study setting. In Pennsylvania, only patients with blunt injury, GCS score ≤ 8, and who had serum cerebrospinal fluid analysis were included, which might makes the mortality high.

The finding of this study showed that the overall mortality within 30 days of hospital admission was 33.1%, which was higher than the finding of the study done in Finland(19%) [39] but lower than the finding of study from Sweden(36%) [40]. The possible reason for the discrepancy might be due to difference in study population, sample size, tool, socio-demographic characteristics and study setting differences.

The finding of this study revealed that TBI patients who had open (penetrating) types of injury had 75% lower hazard of death than those who had closed (blunt) types of injury. The possible justification might be closed (blunt) types of injury might causes the activation of coagulation process and disseminated intravascular coagulation syndrome may be developed, additionally penetrating injuries often result in more targeted damage, which can sometimes be more effectively managed surgically compared to the diffuse damage associated with blunt trauma.

The finding of this study showed that patients who were not admitted to ICU had 58% lower hazard of death than those who were admitted to ICU during their hospital stay.

The possible reason for this difference might be that patients requiring ICU admission generally present with more severe conditions, which inherently increases their risk of mortality. Additionally, factors such as the quality of care, the nature of the underlying illnesses, and the complexity of cases might further explain the lower mortality rate among patients who did not require ICU care.

The finding of this study showed that patients with mild TBI had 57% lower hazard of death than those with severe TBI, similarly patients with moderate TBI had 44% lower hazard of death than those with severe TBI. The finding of this study was supported by study conducted in Canada [41]. The possible reason might be patients with severe TBI might had significantly damaged brain, lower GCS score, development of different complications and low chance of brain recovery compared to mild and moderate TBI patients.

The finding of this study showed that patients whose serum albumin ≥ 3.5 g/dl had 34% lower hazard of death than those whose serum albumin was less than 3.5 g/dl. This finding was supported by study conducted in China [42]. The possible reason might be higher serum albumin levels are indicative of better nutritional status and overall health, and lower albumin shows the severity of the injury, all of which can increase the risk of mortality.

The finding of this study showed that patients who had developed subdural hematoma had 2.7 times higher hazard of death than those who didn’t develop subdural hematoma. This finding was supported by study from Malawi [43]. The possible reason might be subdural hematomas can lead to elevated intracranial pressure, brain tissue compression, and subsequent neurological damage. Additionally, patients with subdural hematomas may have experienced more severe head trauma or other underlying health issues.

Limitations of the study

Since the study was conducted retrospectively, behavioral, psychological, social, and occupational factors that may influence TBI mortality were not addressed. Due to the exclusion of incomplete charts, some important factors may have been missed, and the pre-hospital care of the patients was not evaluated since the study was retrospective.

Conclusion

Almost one-third of the admitted TBI patients died. This indicates that the burden of TBI mortality is still high. Open types of injury, absence of co-existing injuries, severity of TBI(mild and moderate), not being admitted to the ICU, and serum albumin levels greater than 3.5 g/dL were negative predictors of TBI mortality. In contrast, times of arrival within 4–24 h and after 24 h of injury, as well as the presence of subdural hematoma, were positive predictors of TBI mortality. It is strongly recommended that special attention be given to these patients, primarily by health professionals.

Data availability

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AHR:

Adjusted Hazard Ratio

BSc:

Bachelor of Science

CI:

Confidence Interval

GCS:

Glasgow Coma Scale

ICP:

Intracranial Pressure

ICU:

Intensive Care Unit

LMIC:

Low and middle income countries

MPH:

Master of public health

PDO:

Person- days of observation

TBI:

Traumatic Brain Injury

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Acknowledgements

We would like to thank all hospitals quality unit, emergency, surgical, ICU, card room officers and staffs, data collectors and supervisors for their cooperation for this research.

Funding

The study was funded by Wollo University for MSc thesis for Abdurehman Ayele.

Author information

Authors and Affiliations

  1. Department of Comprehensive Nursing, School of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia

    Abdurehman Ayele, Arega Abebe Lonsako & Alemayehu Anley

  2. Department of Adult Health Nursing, School of Nursing and Midwifery, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

    Samuel Anteneh & Fatuma Seid Degu

  3. Department of Adult Health Nursing, School of Health Science, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

    Getenet Dessie

  4. Medical and Surgical unit, Dessie Comprehensive Specialized Hospital, Dessie, Ethiopia

    Gizew Beyene

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  1. Abdurehman Ayele
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Contributions

AA, SA, FSD, GD, AAL, AA and GB were involved in the conception, design, analysis, interpretation, report, and draft manuscript writing. AA, SA, FSD, GD, AAL, AA and GB were involved in the medical records screening and final manuscript writing. All authors read and approved the final manuscript. All authors reviewed, read, edited, and approved the manuscript.

Corresponding author

Correspondence to Abdurehman Ayele.

Ethics declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Institutional Review Board (IRB) of Wollo University, College of Medicine and Health Sciences (Approval Letter Number CMHS/09/14, dated 18-11-2014 E.C.). Due to the retrospective nature of the study, no individual consent was required, and it was waived by the Ethical Review Committee of Dessie, Woldia, and Debre Birhan Comprehensive Specialized Hospitals to review the medical records of traumatic brain injury patients. Confidentiality was maintained throughout the study by excluding the names and medical record numbers of the patients during data extraction. All methods applied in this research were in accordance with relevant guidelines, principles, and ethical standards of the Declaration of Helsinki.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Ayele, A., Anteneh, S., Degu, F.S. et al. Time to death and its predictors among traumatic brain injury patients admitted to East Amhara comprehensive specialized hospitals, Ethiopia: retrospective cohort study. BMC Neurol 24, 370 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12883-024-03886-8

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Keywords

BMC Neurology

ISSN: 1471-2377

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