Association between health system navigation factors and preventable trauma mortality in Western Cape, South Africa

BACKGROUND: Timely access to trauma care is critical to reducing injury mortality. In the Western Cape of South Africa, trauma care is delivered in a tiered system. Resource limitations at lower facility levels-such as limited imaging, surgical access, or after-hours support-necessitate transfers to higher levels for on-going care of serious injury. Delays-including delays from transfers-can impact mortality. This study quantitatively reexamines a cohort of trauma decedents to further elucidate system navigation factors associated with preventable trauma mortality. METHODS: In the Western Cape, an ongoing, observational cohort study, Epidemiology and Outcomes of Prolonged Trauma Care (EpiC), enrolls adult patients who experience major trauma. In 2024, a multi-disciplinary expert panel determined preventability of EpiC trauma deaths. Injury details and process indicators (e.g., time of arrival, length of stay, interfacility transfers (IFT)) for each case were captured by the EpiC study. Characteristics of preventable versus non-preventable cases were compared using Chi-square, Wilcoxon signed rank tests, and logistic regression analysis to assess associations between health system navigation factors and preventable trauma mortality. RESULTS: A total of 160 cases were included: 63 were preventable (39.4%) and 97 were non-preventable (60.6%). Though the median total health facility length of stay was found to be significantly higher in the preventable death cohort (39.7 h; IQR 5.7, 184.8) versus non-preventable (10.3 h; IQR 1.5, 59.1); p-value = 0.0024), the majority of deaths occurred in the emergency centre (EC) in both groups (54% preventable cohort, 68% non-preventable cohort, p-value = 0.2232). There was no statistically significant increased odds of preventable death when examining EC length of stay or arrival to an EC during a less resourced time. However, independent of injury severity and first EC length of stay, there was a significant association between patients receiving IFT and increased odds of dying from a preventable death (OR 2.94, 95%CI 1.09-7.87). CONCLUSION: These findings likely demonstrate IFT as a marker of increased trauma system complexity and extended exposure to system vulnerabilities across multiple phases of care. Tiered trauma systems in resource-constrained settings should account for this association in system design and operations.