The Trauma Registry as a Statewide Quality Improvement Tool

Characteristics of Patients Transported by a Paramedic-staffed Helicopter Emergency Medical Service in Victoria, Australia

OBJECTIVE

The optimal staffing of helicopter emergency medical services (HEMS) is uncertain. An intensive care paramedic-staffed HEMS has operated in the state of Victoria, Australia for over 28 years, with paramedics capable of performing advanced procedures, including rapid sequence intubation, decompression of tension pneumothorax, and cricothyroidotomy. Administration of a wide range of vasoactive, anesthetic, and analgesic medications is also permitted. We sought to explore the characteristics of patients transported by HEMS in Victoria, and describe paramedic utilization of their skill set in the prehospital environment.

METHODS

A retrospective data review was conducted of patients transported by the HEMS between 1 July 2012 and 30 June 2013. Data were sourced from the Ambulance Victoria data warehouse and the Victorian State Trauma Registry. Interhospital transfers were excluded.

RESULTS

HEMS attended 1,519 cases during the study period. A total of 825 primary transport cases were included in analyses. Most patients were male (69.5%) and the majority of cases involved trauma (86.1%). Rapid sequence intubation (RSI) was performed in 36.8% of pediatric and 29.9% of adult major trauma patients, with a procedural success rate of 100%. Ketamine was administered to 18.5% of all trauma patients. The proportion of patients with a severe pain score (≥7) decreased from 33.8 to 3.2% (p < 0.001) between initial and final paramedic assessments. A clinically significant pain reduction of ≥2 points was achieved by 87.0% (95% CI 82.9-90.4%) of adult trauma patients who had an initial pain score >2 points and a valid final pain score. In-hospital mortality following major-trauma was 7.6% (95% CI 5.0-11.0%).

CONCLUSIONS

The skill set of HEMS intensive care paramedics in Victoria is broad, including a large number of prehospital critical care procedures commonly utilized by physician-staffed HEMS in other jurisdictions. A high RSI procedural success rate was observed across the study period, as were significant improvements in patient physiological parameters and pain scores.

Epidemiology of in-hospital trauma deaths in a Brazilian university hospital

Background

The analysis of patterns of trauma deaths may improve the evaluation of a trauma system and identify areas that may benefit from more resources. The objective of this study was to analyze the epidemiology of trauma deaths in a Brazilian university hospital in order to assess the profile of these fatalities over a 16-year period.

Method

Retrospective study of time series using database records. The research subjects were in-hospital deaths from external causes during the years 1995, 2000, 2005 and 2010. The following variables were analyzed: cause of injury, trauma scores, time and cause of death.

Results

467 cases were studied, being 325 patients (69.6%) admitted with signs of life and 142 (30.4%) considered dead on arrival. The mean age was 35.35 ± 18.03 years. 85.4% were males. Blunt trauma occurred in 73.0% of cases and penetrating mechanism in 27.0%. There was a significant increase (p < 0.001) in deaths from motorcycle crashes over the years, which went from 7.3% in 1995 to 31.5% in 2010. In contrast, there was a significant decrease (p = 0.030) in firearm-injury victims; from 21.0% in 1995 to 9.6% in 2010. About 60% of deaths occurred less than 24 hours after admission. The main causes of death were lesions of the central nervous system (56.3% of the total), followed by hemorrhagic shock (18.1%) and sepsis/multiple organ dysfunction syndrome (17.1%). The mean Injury Severity Score (ISS) of patients with signs of life was 26.41 ± 9.00, 71.3% of whom had ISS >25. The mean Revised Trauma Score (RTS) was 5.24 ± 2.05. Only 25.8% of the deaths had TRISS <0.50.

Conclusion

There was a shift in the profile of causes of death from trauma in this university teaching hospital, with a large decrease in penetrating injuries and a higher incidence of deaths of motorcycle riders.

Financial and employment impacts of serious injury: a qualitative study

OBJECTIVES

To explore the financial and employment impacts following serious injury.

DESIGN

Semi-structured telephone administered qualitative interviews with purposive sampling and thematic qualitative analysis.

PARTICIPANTS

118 patients (18-81 years) registered by the Victorian State Trauma Registry or Victorian Orthopaedic Trauma Outcomes Registry 12-24 months post-injury.

RESULTS

Key findings of the study were that although out-of-pocket treatment costs were generally low, financial hardship was prevalent after hospitalisation for serious injury, and was predominantly experienced by working age patients due to prolonged absences from paid employment. Where participants were financially pressured prior to injury, injury further exacerbated these financial concerns. Reliance on savings and loans and the need to budget carefully to limit financial burden were discussed. Financial implications of loss of income were generally less for those covered by compensation schemes, with non-compensable participants requiring welfare payments due to an inability to earn an income. Most participants reported that the injury had a negative impact on work. Loss of earnings payments from injury compensation schemes and income protection policies, supportive employers, and return to work programs were perceived as key factors in reducing the financial burden of injured participants. Employer-related barriers to return to work included the employer not listening to the needs of the injured participant, not understanding their physical limitations, and placing unrealistic expectations on the injured person. While the financial benefits of compensation schemes were acknowledged, issues accessing entitlements and delays in receiving benefits were commonly reported by participants, suggesting that improvements in scheme processes could have substantial benefits for injured patients.

CONCLUSIONS

Seriously injured patients commonly experienced substantial financial and work-related impacts of injury. Participants of working age who were unemployed prior to injury, did not have extensive leave accrual at their pre-injury employment, and those not covered by injury compensation schemes or income protection insurance clearly represent participants "at risk" for substantial financial hardship post-injury. Early identification of these patients, and improved provision of information about financial support services, budgeting and work retraining could assist in alleviating financial stress after injury.

Missing patients in a regional trauma registry: incidence and predictors

BACKGROUND

Trauma systems have data registries in order to describe and evaluate (the quality of) trauma care. If results between centres and countries (benchmarking) are to be compared, data has to be accurate, reliable and complete. All trauma registries deal with incompleteness. A contributor to incompleteness of the data is failure to include patients that fulfil the criteria; the so-called missing patients. The aim of this study is to assess the number of missing patients in our regional trauma registry and to identify predictors for being missing from the trauma registry.

METHODS

A random sample was taken. Four calendar weeks from 2012 were selected and medical files of all consecutive presentations to the emergency department or trauma room during those weeks were studied. Patients who were already correctly included in the trauma registry were assigned to the 'included' group and patients who should have been but were not to the 'missing' group. Multivariable logistic regression analysis was performed to identify predictors for being missed from the trauma registry.

RESULTS

Of a total of 338 patients, 50 (15%) were identified as missing. Characteristics of the missing patients did not differ substantially from the included patients. Transfer to another hospital after initial assessment and presentation in a Level 3 hospital compared to a Level 1 hospital were independent predictors for being missed from the trauma registry, with an adjusted odds ratio of 5.86 (95% CI: 2.08-16.52) and 6.64 (95% CI: 1.86-23.78), respectively.

CONCLUSIONS

Overall, 15% of the patients who met the inclusion criteria of the trauma registry were not included in the registry. Special attention should be paid to patients who are transferred to other hospitals in the network after initial assessment and to registration in Level 3 hospitals.

A comparison of functional outcome in patients sustaining major trauma: a multicentre, prospective, international study

Objectives

To compare 6 month and 12 month health status and functional outcomes between regional major trauma registries in Hong Kong and Victoria, Australia.

Summary Background Data

Multicentres from trauma registries in Hong Kong and the Victorian State Trauma Registry (VSTR).

Methods

Multicentre, prospective cohort study. Major trauma patients and aged ≥18 years were included. The main outcome measures were Extended Glasgow Outcome Scale (GOSE) functional outcome and risk-adjusted Short-Form 12 (SF-12) health status at 6 and 12 months after injury.

Results

261 cases from Hong Kong and 1955 cases from VSTR were included. Adjusting for age, sex, ISS, comorbid status, injury mechanism and GCS group, the odds of a better functional outcome for Hong Kong patients relative to Victorian patients at six months was 0.88 (95% CI: 0.66, 1.17), and at 12 months was 0.83 (95% CI: 0.60, 1.12). Adjusting for age, gender, ISS, GCS, injury mechanism and comorbid status, Hong Kong patients demonstrated comparable mean PCS-12 scores at 6-months (adjusted mean difference: 1.2, 95% CI: −1.2, 3.6) and 12-months (adjusted mean difference: −0.4, 95% CI: −3.2, 2.4) compared to Victorian patients. Keeping age, gender, ISS, GCS, injury mechanism and comorbid status, there was no difference in the MCS-12 scores of Hong Kong patients compared to Victorian patients at 6-months (adjusted mean difference: 0.4, 95% CI: −2.1, 2.8) or 12-months (adjusted mean difference: 1.8, 95% CI: −0.8, 4.5).

Conclusion

The unadjusted analyses showed better outcomes for Victorian cases compared to Hong Kong but after adjusting for key confounders, there was no difference in 6-month or 12-month functional outcomes between the jurisdictions.

The imaging and classification of severe pelvic ring fractures: Experiences from two level 1 trauma centres

We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young-Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ. Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young-Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.

Establishing hospital-based trauma registry systems: lessons from Kenya

OBJECTIVE

In the developing world, data about the burden of injury, injury outcomes, and complications of care are limited. Hospital-based trauma registries are a data source that can help define this burden. Under the trauma care component of the Bloomberg Global Road Safety Partnership, trauma registries have been implemented at three sites in Kenya. We describe the challenges and lessons learned from this effort.

METHODS

A paper-based trauma surveillance form was developed, in collaboration with local hospital partners, to collect data on all trauma patients presenting for care. The form includes demographic information, pre-hospital care given, and patient care and clinical information necessary to calculate estimated injury surveillance. The type of data collected was standardized across all three sites. Frequent reviews of the data collection process, quality, and completeness, in addition to regular meetings and conference calls, have allowed us to optimize the process to improve efficiency and make corrective actions where required.

RESULTS

Trauma registries have been implemented in three hospitals in Kenya, with potential for expansion to other hospitals and facilities caring for injured patients. The process of establishing registries was associated with both general and site-specific challenges. Problems were identified in planning, data collection, entry processes, and analysis. Problems were addressed when identified, resulting in improved data quality.

CONCLUSIONS

Trauma registries are a key data source for defining the burden of injury and developing quality improvement processes. Trauma registries were implemented at three sites in Kenya. Problems and challenges in data collection were identified and corrected. Through the registry data, gaps in care were identified and systemic changes made to improve the care of the injured.

Validating and Improving Injury Burden Estimates Study: the Injury-VIBES study protocol

BACKGROUND

Priority setting, identification of unmet and changing healthcare needs, service and policy planning, and the capacity to evaluate the impact of health interventions requires valid and reliable methods for quantifying disease and injury burden. The methodology developed for the Global Burden of Disease (GBD) studies has been adopted to estimate the burden of disease in national, regional and global projects. However, there has been little validation of the methods for estimating injury burden using empirical data.

OBJECTIVE

To provide valid estimates of the burden of non-fatal injury using empirical data.

SETTING

Data from prospective cohort studies of injury outcomes undertaken in the UK, USA, Australia, New Zealand and The Netherlands.

DESIGN AND PARTICIPANTS

Meta-analysis of deidentified, patient-level data from over 40 000 injured participants in six prospective cohort studies: Victorian State Trauma Registry, Victorian Orthopaedic Trauma Outcomes Registry, UK Burden of Injury study, Prospective Outcomes of Injury study, National Study on Costs and Outcomes of Trauma and the Dutch Injury Patient Survey.

ANALYSIS

Data will be systematically analysed to evaluate and refine injury classification, development of disability weights, establishing the duration of disability and handling of cases with more than one injury in burden estimates. Developed methods will be applied to incidence data to compare and contrast various methods for estimating non-fatal injury burden.

CONTRIBUTION TO THE FIELD

The findings of this international collaboration have the capacity to drive how injury burden is measured for future GBD estimates and for individual country or region-specific studies.

Pilot study assessing functional outcome of tibial pilon fractures using the VSTORM method

INTRODUCTION

The importance of long-term function and quality of life after trauma is well recognised, but gathering data is difficult. The Victoria State Trauma Registry (VSTORM) collects patient-reported outcome data after major trauma using telephone interview, following prospective enrolment. Key components of the VSTORM interview include use of the Glasgow Outcome Scale-Extended (GOS-E), collection of pre-injury demographics, use of 12-Item Short Form Health Survey (SF-12) and EQ-5D instruments as well as a pain numerical rating scale. The aim of this pilot study was to determine whether this methodology would capture clinically relevant data for a population sustaining a severe fracture associated with a wide range of potential outcomes.

METHODS

Following ethical approval, patients with surgically managed tibial pilon fractures sustained between March 2002 and January 2010 were identified from the logbook of the senior author (IP) and contacted by post. After obtaining consent, a structured telephone interview was performed using the VSTORM questionnaire.

RESULTS

Twenty-six of 45 patients consented to interview and 23/26 patients were contactable (13 male, 10 female, mean age 44 years). There were 17 Arbeitsgemeinschaft für Osteosynthesefragen (AO) Type C fractures, six Type B and seven Grade III open injuries. The mean visual analogue scale (VAS) score for health pre-injury was 88.9 (range 50-100, median 92) versus 71.5 (range 35-100, median 75) post-injury. Seven of 18 patients in full-time employment prior to injury did not return to work. Only one patient returned to previous employment. Nine of 23 patients reported moderate - to-extreme pain interfering with work; 16/23 patients had problems with mobility; 9/23 reported problems climbing stairs; and 14/23 of patients could not resume regular social/leisure activities.

CONCLUSIONS

Prospective enrolment at the time of injury may improve follow-up. In those who participated, a credible range of outcomes were reported, comparable to recently published studies. This method appears efficient and acceptable to patients, and hence warrants larger-scale prospective evaluation.

Long-term mortality after admission to hospital for trauma: A review

Trauma is associated with significant acute morbidity and mortality. However, advances in the delivery of trauma care have resulted in considerable improvements in the short-term mortality from trauma. Recent studies have shown that survivors of trauma are at significant risk of delayed long-term mortality that is above that expected for a similar uninjured cohort of patients. Few studies have provided a detailed analysis of the determinants of this increased risk of death, and even fewer publications have examined the causes of death in these patients. This information is relevant because an increased number of patients will survive their injuries as acute trauma care continues to improve. It may also highlight opportunities for interventions that reduce the risk of delayed death in a population of patients that is generally young and healthy at the time of injury. As such, this article will review the literature on the long-term mortality rate and its determinants among patients who are hospitalized for severe injuries.

Comparison of the serious injury pattern of adult bicyclists, between South-West Netherlands and the State of Victoria, Australia 2001-2009

BACKGROUND

Head injury is the leading cause of death and long term disability from bicycle injuries and may be prevented by helmet wearing. We compared the pattern of injury in major trauma victims resulting from bicyclist injury admitted to hospitals in the State of Victoria, Australia and South-West Netherlands, with respective high and low prevalence of helmet use among bicyclists.

METHODS

A cohort of bicycle injured patients with serious injury (defined as Injury Severity Score>15) in South-West Netherlands, was compared to a cohort of serious injured bicyclists in the State of Victoria, Australia. Additionally, the cohorts of patients with serious injury admitted to a Dutch level 1 trauma centre in Rotterdam, the Netherlands and an Australian level 1 trauma centre in Melbourne, Australia were compared. Both cohorts included patients admitted between July 2001 and June 2009. Primary outcome was in-hospital mortality and secondary outcome was prevalence of severe injury per body region. Outcome was compared using univariate analysis and mortality outcomes were also calculated using multivariable logistic regression models.

RESULTS

A total of 219 cases in South-West Netherlands and 500 cases in Victoria were analyzed. Further analyses comparing the major trauma centres in each region, showed the percentage of bicycle-related death was higher in the Dutch population than in the Australian (n=45 (24%) vs n=13(7%); P<0.001). After adjusting for age, mechanism of injury, GCS and head injury severity in both hospitals, there was no significant difference in mortality (adjusted odds ratio 1.4; 95% confidence interval=0.6, 3.5). Patients in Netherlands trauma centre suffered from more serious head injuries (Abbreviated Injury Scale≥3) than patients in the Australian trauma centre (n=165 (88.2%) vs n=121 (62.4%); P<0.001). The other body regions demonstrated significant differences in the AIS scores with significantly more serious injuries (AIS≥3) of the chest, abdominal and extremities regions in the Australian group.

CONCLUSION

Bicycle related major trauma admissions in the Netherlands trauma centre, and in South-West Netherlands had a higher mortality rate associated with a higher percentage of serious head injuries compared with that in the Australian trauma centre and the State of Victoria.

Establishing a trauma registry in Bhutan: needs and process

BACKGROUND

Globally, trauma represents a growing and significant burden of disease. Many health systems have limited metrics with which to guide development and appropriately inform policy and management decisions with regard to trauma related health care delivery.

FINDINGS

This paper outlines the establishment of need for improved trauma related metrics in the country of Bhutan and the process of development of a trauma registry at Jigme Dorji Wangchuck National Referral Hospital to meet that need.

CONCLUSIONS

Trauma registries are important tools allowing health systems to respond to the shifting burden of disease; successful establishment of a trauma registry requires an understanding of the health system and broad institutional support.

[Trauma registries: a health priority, a strategic project for the SEMICYUC]

The most efficient approach to traumatologic disease is prevention, but physicians also must supervise care of the victims. An operational and effective trauma registry requires financial support, adequate software, a well-defined population, personnel committed to training, and a detailed process for data collection, reporting, validation and the maintenance of confidentiality. Above all, however, motivation is required. Registries can offer many benefits in relation to these highly prevalent disorders, with an impact in terms of health promotion and even advantages in the form of cost reductions, as well as relief from the suffering caused by trauma (mortality, disability)-contributing to improve the efficiency and quality of critical trauma care. The SEMICYUC has demonstrated its ability to establish and maintain records of national interest, and this should become a priority project.

Which patients have missing data? An analysis of missingness in a trauma registry

BACKGROUND

Trauma registry data are almost always incomplete. Multiple imputation can reduce bias in registry analyses but the ideal approach would be to improve data capture. The aim of this study was to identify, using multiple imputation, which type of patients were most likely to have incomplete data.

METHODS

An analysis of prospectively collected regional trauma registry data over one year was performed. Analyses were conducted following complete data estimation using multiple imputation. Variables necessary for TRISS analysis and with incomplete data were analysed. For each variable, logistic regression analyses were performed to identify predictors of missingness. A p-value of less than 0.05 was considered to be statistically significant.

RESULTS

There were 2520 cases. The variables with the greatest proportion of missing observations were respiratory rate, GCS, Qualifier (of GCS and respiratory rate) and systolic blood pressure. The Qualifier variable described whether or not the patient was intubated and mechanically ventilated at the time the first hospital GCS and respiratory rate were recorded. GCS and respiratory rate were more likely to be missing (imputed) when abnormal (unadjusted ORs: 8.6 (p<0.001) and 2.1 (p=0.02), respectively). The most important determinant of a valid GCS or respiratory rate was the Qualifier. There was no association between whether the systolic blood pressure and Qualifier were missing (imputed) and whether they were estimated to be abnormal. Following multivariable analysis, data for all four variables were more likely to be missing when the patient died in hospital. Additional independent predictors of a missing GCS or respiratory rate were an abnormal pre-hospital GCS and severe chest injury. The Qualifier and systolic blood pressure were more likely to be missing where the patient was transferred from the primary hospital.

CONCLUSION

The major independent predictor of missing primary hospital physiological variables was death in hospital. An abnormal GCS was more likely to be missing from the regional trauma registry dataset. Predictors of a missing GCS or respiratory rate included whether the patient was intubated, an abnormal pre-hospital GCS and severe chest injury. Augmenting resources to record the initial observations of the more severely injured patients would improve data quality. Multiple imputation can be used to inform data capture.

Quality indicators used by trauma centers for performance measurement

BACKGROUND

To describe the quality indicators (QIs) that trauma centers use for quality measurement and performance improvement. Measuring and reporting quality of care is a critical step to improve the quality of care. QIs compare actual trauma care against ideal criteria and identify patients in whom care may have been suboptimal and should be further reviewed.

METHODS

Three hundred thirty verified trauma centers in the United States, Canada, Australia, and New Zealand had their websites reviewed and leadership surveyed regarding QI use. The indicators identified were classified according to definition specifications, phase of care, Institute of Medicine aims, and contents.

RESULTS

Two hundred fifty-one centers responded to the survey (76%) and the majority (97%) indicated that they use QIs. We obtained 10,587 QIs from 262 centers (survey responses and website review) of which 1,102 were unique indicators. The QIs primarily assessed the safety (49%), effectiveness (32%), efficiency (27%), and timeliness (22%) of hospital processes (64%) and outcomes (24%). The majority of indicators were used by a small number of centers (551 of 1,102 unique indicators used by single centers).

CONCLUSION

Our study provides the first description of the QIs used by verified trauma centers in four high-income countries with similar systems of trauma care. The majority of trauma centers measure QIs designed to examine the safety, effectiveness, efficiency, and timeliness of hospital processes and outcomes. Opportunities exist to standardize existing QIs to allow broader implementation and develop new QIs to examine patient-centered care and equality of care.

Level of agreement between patient and proxy responses to the EQ-5D health questionnaire 12 months after injury

BACKGROUND

Health-related quality of life represents a patient's experiences and expectations and should be collected from the patient. In trauma, collection of information from the patient can be challenging, particularly for subgroups where cognitive impairment is prevalent, increasing reliance on proxy reporting. This study assessed the agreement between patient and proxy reporting of health-related quality of life 12 months after injury.

METHODS

The Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry collect EQ-5D data at 12 months after injury. Cases where data were collected from the patient and proxy were extracted. Agreement between patient and proxy responses was compared using kappa (K) coefficients for the individual EQ-5D items, and Bland-Altman plots and Wilcoxon signed-rank tests for the EQ-5D summary score and visual analog scale (VAS).

RESULTS

Agreement between patient and proxy respondents was substantial for the mobility (K = 0.61) and personal care items (K = 0.67) and moderate for the usual activities (K = 0.50), pain/discomfort (K = 0.42), and anxiety/depression items (K = 0.47). The mean difference between proxy and patient-reported scores for the VAS (0.74, 95% confidence interval: -2.73, 4.21) and the EQ-5D summary score (-0.02, 95% confidence interval: -0.07, 0.03) was small, but the limits of agreement were wide (-34.22 to 35.71 for VAS and -0.55 to 0.51 for summary score), suggesting no systematic bias.

CONCLUSIONS

Although proxy and patient responses for the EQ-5D VAS may differ, the differences show random variability rather than systematic bias. Group comparisons using proxy responses are unlikely to be biased, but proxy responses should be used with caution when assessing individual patient recovery.

Injury in China: a systematic review of injury surveillance studies conducted in Chinese hospital emergency departments

BACKGROUND

Injuries represent a significant and growing public health concern in China. This Review was conducted to document the characteristics of injured patients presenting to the emergency department of Chinese hospitals and to assess of the nature of information collected and reported in published surveillance studies.

METHODS

A systematic search of MEDLINE and China Academic Journals supplemented with a hand search of journals was performed. Studies published in the period 1997 to 2007 were included and research published in Chinese was the focus. Search terms included emergency, injury, medical care.

RESULTS

Of the 268 studies identified, 13 were injury surveillance studies set in the emergency department. Nine were collaborative studies of which eight were prospective studies. Of the five single centre studies only one was of a prospective design. Transport, falls and industrial injuries were common mechanisms of injury. Study strengths were large patient sample sizes and for the collaborative studies a large number of participating hospitals. There was however limited use of internationally recognised injury classification and severity coding indices.

CONCLUSION

Despite the limited number of studies identified, the scope of each highlights the willingness and the capacity to conduct surveillance studies in the emergency department. This Review highlights the need for the adoption of standardized injury coding indices in the collection and reporting of patient health data. While high level injury surveillance systems focus on population-based priority setting, this Review demonstrates the need to establish an internationally comparable trauma registry that would permit monitoring of the trauma system and would by extension facilitate the optimal care of the injured patient through the development of informed quality assurance programs and the implementation of evidence-based health policy.

Predictors of mortality following severe pelvic ring fracture: results of a population-based study

INTRODUCTION

Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system.

METHODS

Cases aged≥15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated.

RESULTS

There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged≥65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15-34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres).

CONCLUSIONS

The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.

Modelling long term disability following injury: comparison of three approaches for handling multiple injuries

Background

Injury is a leading cause of the global burden of disease (GBD). Estimates of non-fatal injury burden have been limited by a paucity of empirical outcomes data. This study aimed to (i) establish the 12-month disability associated with each GBD 2010 injury health state, and (ii) compare approaches to modelling the impact of multiple injury health states on disability as measured by the Glasgow Outcome Scale – Extended (GOS-E).

Methods

12-month functional outcomes for 11,337 survivors to hospital discharge were drawn from the Victorian State Trauma Registry and the Victorian Orthopaedic Trauma Outcomes Registry. ICD-10 diagnosis codes were mapped to the GBD 2010 injury health states. Cases with a GOS-E score >6 were defined as “recovered.” A split dataset approach was used. Cases were randomly assigned to development or test datasets. Probability of recovery for each health state was calculated using the development dataset. Three logistic regression models were evaluated: a) additive, multivariable; b) “worst injury;” and c) multiplicative. Models were adjusted for age and comorbidity and investigated for discrimination and calibration.

Findings

A single injury health state was recorded for 46% of cases (1–16 health states per case). The additive (C-statistic 0.70, 95% CI: 0.69, 0.71) and “worst injury” (C-statistic 0.70; 95% CI: 0.68, 0.71) models demonstrated higher discrimination than the multiplicative (C-statistic 0.68; 95% CI: 0.67, 0.70) model. The additive and “worst injury” models demonstrated acceptable calibration.

Conclusions

The majority of patients survived with persisting disability at 12-months, highlighting the importance of improving estimates of non-fatal injury burden. Additive and “worst” injury models performed similarly. GBD 2010 injury states were moderately predictive of recovery 1-year post-injury. Further evaluation using additional measures of health status and functioning and comparison with the GBD 2010 disability weights will be needed to optimise injury states for future GBD studies.

Trauma registries: history, logistics, limitations, and contributions to emergency medicine research

Trauma registries have been designed to serve a number of purposes, including quality improvement, injury prevention, clinical research, and policy development. Since their inception over 30 years ago, there are increasingly more institutions with trauma registries, many of which submit data to a national trauma registry. The goal of this review is to describe the history, logistics, and characteristics of trauma registries and their contribution to emergency medicine and trauma research. Discussed in this review are the limitations of trauma registries, such as variability in quality and type of the collected data, absence of data pertaining to long-term and functional outcomes, prehospital information, and complications as well as other methodologic obstacles limiting the utility of registry data in clinical and epidemiologic research.

Comparison of mortality following hospitalisation for isolated head injury in England and Wales, and Victoria, Australia

Background

Traumatic brain injury (TBI) remains a leading cause of death and disability. The National Institute for Health and Clinical Excellence (NICE) guidelines recommend transfer of severe TBI cases to neurosurgical centres, irrespective of the need for neurosurgery. This observational study investigated the risk-adjusted mortality of isolated TBI admissions in England/Wales, and Victoria, Australia, and the impact of neurosurgical centre management on outcomes.

Methods

Isolated TBI admissions (>15 years, July 2005–June 2006) were extracted from the hospital discharge datasets for both jurisdictions. Severe isolated TBI (AIS severity >3) admissions were provided by the Trauma Audit and Research Network (TARN) and Victorian State Trauma Registry (VSTR) for England/Wales, and Victoria, respectively. Multivariable logistic regression was used to compare risk-adjusted mortality between jurisdictions.

Findings

Mortality was 12% (749/6256) in England/Wales and 9% (91/1048) in Victoria for isolated TBI admissions. Adjusted odds of death in England/Wales were higher compared to Victoria overall (OR 2.0, 95% CI: 1.6, 2.5), and for cases <65 years (OR 2.36, 95% CI: 1.51, 3.69). For severe TBI, mortality was 23% (133/575) for TARN and 20% (68/346) for VSTR, with 72% of TARN and 86% of VSTR cases managed at a neurosurgical centre. The adjusted mortality odds for severe TBI cases in TARN were higher compared to the VSTR (OR 1.45, 95% CI: 0.96, 2.19), but particularly for cases <65 years (OR 2.04, 95% CI: 1.07, 3.90). Neurosurgical centre management modified the effect overall (OR 1.12, 95% CI: 0.73, 1.74) and for cases <65 years (OR 1.53, 95% CI: 0.77, 3.03).

Conclusion

The risk-adjusted odds of mortality for all isolated TBI admissions, and severe TBI cases, were higher in England/Wales when compared to Victoria. The lower percentage of cases managed at neurosurgical centres in England and Wales was an explanatory factor, supporting the changes made to the NICE guidelines.

Reducing ethnic disparities in the quality of trauma care: an important research gap

OBJECTIVE

To identify interventions for reducing ethnic disparities in the quality of trauma care.

BACKGROUND

Variation in the quality of health care is recognized as an important contributor to ethnic disparities in many domains of health. Although recent articles document ethnic variations in the quality of trauma care in several countries, strategies that address these disparities have received little attention.

METHODS

Systematic review of intervention studies designed to reduce ethnic disparities in trauma care.

RESULTS

Our systematic literature review revealed no evaluations of interventions designed to reduce ethnic disparities in trauma care. A scan of the equivalent literature in other health care settings revealed 3 types of strategies that could serve as promising interventions that warrant further investigation in the trauma care setting: (1) improving cultural competency of service providers, (2) addressing the effects of health literacy on the quality of trauma care, and (3) quality improvement strategies that recognize equity as a key dimension of quality. The trauma coordinator role may help address some aspects relating to these themes although reducing disparities is likely to require broader system-wide policies.

CONCLUSIONS

The implementation and robust evaluation of strategies designed to reduce ethnic disparities in trauma care are long overdue.

Professional Practice and Innovation: Level of Agreement between Coding Sources of Percentage Total Body Surface Area Burnt (%TBSA)

The percentage of total body surface area burnt (%TBSA) is a critical measure of burn injury severity and a key predictor of burn injury outcome. This study evaluated the level of agreement between four sources of %TBSA using 120 cases identified through the Victorian State Trauma Registry. Expert clinician, ICD-10-AM, Abbreviated Injury Scale, and burns registry coding were compared using measures of agreement. There was near-perfect agreement (weighted Kappa statistic 0.81–1) between all sources of data, suggesting that ICD-10-AM is a valid source of %TBSA and use of ICD-10-AM codes could reduce the resource used by trauma and burns registries capturing this information.

The Trauma and Injury Severity Score (TRISS) revised

BACKGROUND

The Trauma and Injury Severity Score (TRISS) remains the most commonly used tool for benchmarking trauma fatality outcome. Recently, it was demonstrated that the predictive power of TRISS could be substantially improved by re-classifying the component variables and treating the variable categories nominally. This study aims to develop revised TRISS models using re-classified variables, to assess these models’ predictive performances against existing TRISS models, and to identify and recommend a preferred TRISS model.

MATERIALS AND METHODS

Revised TRISS models for blunt and penetrating injury mechanism were developed on an adult (aged 15 years) sample from the National Trauma Data Bank National Sample Project (NSP), using 5-category variable classifications and weighted logistic regression. Their predictive performances were then assessed against existing TRISS models on the unweighted NSP, National Trauma Data Bank (NTDB), and New Zealand Database (NZDB) samples using area under the Receiver Operating Characteristic curve (AUC) and Bayesian Information Criterion (BIC) statistics.

RESULTS

The weighted NSP sample included 1,124,001 adults with blunt or penetrating injury mechanism events and known discharge status, of whom 1,061,709 (94.5%) survived to discharge. Complete information for all TRISS variables was available for 896,212 (79.7%). Revised TRISS models that included main-effects and two-factor interaction terms had superior AUC and BIC statistics to main effects models and existing TRISS models for patients with complete data in NSP, NTDB and NZDB samples. Predictive performance decreased as the number of variables with missing values included within revised TRISS models increased, but model performances generally remained superior to existing TRISS models.

DISCUSSION

Revised TRISS models had importantly improved predictive capacities over existing TRISS models. Additionally, they were easily computed, utilised only those variables already collected for existing TRISS models, and could be applied and produce meaningful survival probabilities when one or more of the predictor variables contained missing values. The preferred revised TRISS model included main-effects and two-factor interaction terms and allowed for missing values in all predictor variables. A strong case exists for replacing existing TRISS models in trauma scoring systems benchmarking software with this preferred revised TRISS model.

Trauma and Injury Severity Score (TRISS): is it time for variable re-categorisations and re-characterisations?

BACKGROUND

Despite its limitations, the Trauma and Injury Severity Score (TRISS) continues to be the most commonly used tool for benchmarking trauma outcome. Since its inception, considerable energy has been devoted to improving TRISS. However, there has been no investigation into the classification or characterisation of the TRISS variables. Using a major nationally representative database, this study aims to explore the adequacy of the existing TRISS model by investigating variable re-categorisations and alternative characterisations in a logistic model used to predict survival in adults after traumatic injury.

MATERIALS AND METHODS

Data were obtained from the National Trauma Data Bank National Sample Project (NSP). Each variable in the TRISS model was related to discharge status and various categorisations considered using weighted logistic regression. Categorisations were treated nominally,using a series of indicator variables. For each variable and classification level, the best category combination was ascertained using the Bayesian Information Criterion (BIC). All best 5-category classified TRISS variables were combined, as were all best 10-category classified TRISS variables, and their predictive performance assessed against two conventionally defined TRISS models on the unweighted NSP sample using area under the Receiver Operating Characteristic curve (AUC) and BIC statistics.

RESULTS

Overall, the weighted sample included 1,124,001 adults with injury events and known discharge status, of whom 1,061,709 (94.5%) were alive at discharge. When separately related to discharge status, each re-classified TRISS variable yielded a superior BIC statistic to its original specification. When investigating predictive performance, complete information was available for 167,239 (79.9%) adults with blunt and 20,643 (82.3%) adults with penetrating injury mechanisms. AUC and BIC estimates for the re-classified TRISS models were superior to the conventionally defined TRISS models. While having better predictive precision, the complexity associated with the best 10-category model resulted in the best 5-category model being preferred for penetrating mechanism injuries and being negligibly inferior for blunt mechanism injuries.

DISCUSSION

Substantial improvements in the predictive power of TRISS were demonstrated by reclassifying the component variables and treating the variable categories nominally. However, before anew TRISS model with updated coefficients can be published, variable interactions and the effect of missing data needs thorough statistical evaluation.

Missing in action: a case study of the application of methods for dealing with missing data to trauma system benchmarking

BACKGROUND

Trauma registry data are usually incomplete. Various methods for dealing with missing data have been used, some of which lead to biased results. One method that reduces bias, multiple imputation (MI), has not been widely adopted. There is no standardization of the approach to missing data across trauma registries.

OBJECTIVES

This study examined the effect of using selected methods for handling missing data on a recognized trauma outcome measure.

METHODS

Data from the Victorian State Trauma Registry (VSTR) were used for the period July 2003 to June 2008. Three methods for handling missing data were investigated: complete case analysis, single imputation, and MI. The latter was applied using five distinct models, each with a different combination of variables (Trauma and Injury Severity score [TRISS] variables; prehospital Glasgow Coma Scale [GCS], respiratory rate, and systolic blood pressure; arrival by ambulance; transfer to a second hospital; and whether the GCS was "legitimate" according to the TRISS definition). For each method, TRISS analysis (comparing actual and expected deaths) was performed; the W-score and Z-statistic were derived. A Z-statistic greater than 1.96 in absolute value was considered statistically significant.

RESULTS

Of 10,180 cases, 2,398 (24%) were missing at least one of the component variables necessary for TRISS analysis. With the use of complete case analysis, the W-score was 0.54 unexpected survivors for every 100 cases, with a Z-statistic of -1.96. Using two approaches to single imputation, the W-scores were -1.41, with Z-statistics of -5.19 and -5.30. Applying four of the five combinations of variables used for MI, there was a statistically significant number of unexpected survivors (W = -0.60, Z = -2.23; W = -0.52, Z = -1.97; W = -0.53, Z = -1.97; W = -0.63, Z = -2.24). However, using MI confined to TRISS variables only, there was a statistically significant number of unexpected deaths (W = +0.52, Z = +1.98).

CONCLUSIONS

Missing data methods can influence the assessment of trauma care performance and need to be reported in all analyses. It is important that validated standardized approaches to dealing with missing data are universally adopted and reported.

Applying composite performance measures to trauma care

BACKGROUND

To investigate the association between a number of hospital level composite index methodologies developed from trauma indicators with inhospital mortality.

METHODS

Data from January 2001 to December 2006 were extracted from the Victorian State Trauma Registry (Australia) and the Trauma Audit and Research Network (United Kingdom). Three composite methods were explored, including two denominator-based weight approaches and a factor analysis technique. The association between the composite measures and the count of inhospital mortality was investigated using Poisson regression models adjusting for expected deaths per hospital using the Trauma Injury Severity Score methodology.

RESULTS

Composite scores were calculated per hospital, per year. The composite score was entered in statistical models as a raw score, and the mortality difference across the central 50% of the composite index was ascertained. In total, 9,218 patients were included and were distributed across 14 hospitals. Composite scores demonstrated an inverse relationship with risk-adjusted inhospital mortality. From the 25th to the 75th percentile of each composite, mortality decreased by 11.99%, 13.58%, and 16.13% (p < 0.05).

CONCLUSION

Trauma composite indices demonstrate construct validity when used as measures of hospital level process and represent potentially useful methods of analyzing and reporting quality indicators.

Towards a national trauma registry for the United Arab Emirates

BACKGROUND

Trauma is a major health problem in the United Arab Emirates (UAE) as well as worldwide. Trauma registries provide large longitudinal databases for analysis and policy improvement. We aim in this paper to report on the development and evolution of a national trauma registry using a staged approach by developing a single-center registry, a two-center registry, and then a multi-center registry. The three registries were established by developing suitable data collection forms, databases, and interfaces to these databases. The first two registries collected data for a finite period of time and the third is underway. The steps taken to establish these registries depend on whether the registry is intended as a single-center or multi-center registry.

FINDINGS

Several issues arose and were resolved during the development of these registries such as the relational design of the database, whether to use a standalone database management system or a web-based system, and the usability and security of the system. The inclusion of preventive medicine data elements is important in a trauma registry and the focus on road traffic collision data elements is essential in a country such as the UAE. The first two registries provided valuable data which has been analyzed and published.

CONCLUSIONS

The main factors leading to the successful establishment of a multi-center trauma registry are the development of a concise data entry form, development of a user-friendly secure web-based database system, the availability of a computer and Internet connection in each data collection center, funded data entry personnel well trained in extracting medical data from the medical record and entering it into the computer, and experienced personnel in trauma injuries and data analysis to continuously maintain and analyze the registry.

Development of a regional database for studying epidemiology of maxillofacial trauma

This article discusses the development of the first regional computerized database for the epidemiological evaluation of maxillofacial trauma and tests its usefulness by evaluating the appropriateness and completeness of the resulting information.The database was developed using Microsoft Access, implemented using Visual Basic. Data were entered in the database by 4 different maxillofacial specialists, one from each of the 4 main regional hospitals where maxillofacial trauma is treated. Clinical information was taken from 100 complete records of patients hospitalized for maxillofacial fractures at the Maxillofacial Division of San Giovanni Battista Hospital in Turin from January to June 2009.Thirteen database fields were used: general information, cause and mechanism of injury, fracture site, Facial Injury Severity Scale, head and neck examination, associated injuries, timing and type of surgery, and days of hospitalization.Overall, the data entered were 99.45% complete and 99.5% accurate. Thus, our regional maxillofacial database can be considered complete and accurate. Some of the errors, mainly in the fields "fracture site" and "Facial Injury Severity Scale," were attributable to an incorrect interpretation of facial fracture diagnoses, based on the medical records that were provided.

A 5-year Profile of Trauma Admissions to the Surgical Intensive Care Unit of a Tertiary Hospital in Singapore

Introduction: This retrospective pilot study provides information on trauma admissions to the Surgical Intensive Care Unit (SICU) of a tertiary hospital in Singapore. The aim was to use the data collected to generate awareness and interest in this area. The authors also wish to use the information to advocate subsequent in-depth collection and analysis of data and the development of a Trauma Registry. As this was a pilot study, the data collected were by no means exhaustive and only descriptive analysis was applied. Materials and Methods: Trauma admissions to the SICU for the period between January 2001 and December 2005 were identified from the admissions logbook maintained in the unit. The physical case-notes or electronic-records for the identified cases were retrieved and the relevant data and parameters were entered into the data collection sheet. Descriptive analysis was applied to the data collected. Results: A total of 503 cases over the 5-year period fulfilled our criteria. Motor vehicle accidents were the greatest contributor of trauma admissions to the SICU (53%). The length of stay (LOS) in the unit ranged from 1 to 59 days. The anatomical area most frequently injured was the head (68%). Out of the 132 mortalities, male patients accounted for 84%. Two-thirds (67%) of injury-related mortality occurred in young patients aged less than 45 years. Motor vehicle accidents accounted for nearly half (47%) of injury-related mortality. Motorcyclists accounted for almost half (46%) of motor vehicle accident deaths. Conclusion: The preponderance of young people involved in motor vehicle accidents with head injuries has a large impact on society and on the hospital workload. The authors hope that this pilot study will generate awareness and interest in the area of trauma injuries. They recommend that a nationwide trauma registry be established to look closer into this “disease”, as other developed countries have done. Key words: Critical care, Data, Registry

Trauma systems and early management of severe injuries in Scandinavia: review of the current state

INTRODUCTION

Scandinavian countries face common challenges in trauma care. It has been suggested that Scandinavian trauma system development is immature compared to that of other regions. We wanted to assess the current status of Scandinavian trauma management and system development.

METHODS

An extensive search of the Medline/Pubmed, EMBASE and SweMed+ databases was conducted. Wide coverage was prioritized over systematic search strategies. Scandinavian publications from the last decade pertaining to trauma epidemiology, trauma systems and early trauma management were included.

RESULTS

The incidence of severe injury ranged from 30 to 52 per 100,000 inhabitants annually, with about 90% due to blunt trauma. Parts of Scandinavia are sparsely populated with long pre-hospital distances. In accordance with other European countries, pre-hospital physicians are widely employed and studies indicate that this practice imparts a survival benefit to trauma patients. More than 200 Scandinavian hospitals receive injured patients, increasingly via multidisciplinary trauma teams. Challenges remain concerning pre-hospital identification of the severely injured. Improved triage allows for a better match between patient needs and the level of resources available. Trauma management is threatened by the increasing sub-specialisation of professions and institutions. Scandinavian research is leading the development of team- and simulation-based trauma training. Several pan-Scandinavian efforts have facilitated research and provided guidelines for clinical management.

CONCLUSION

Scandinavian trauma research is characterised by an active collaboration across countries. The current challenges require a focus on the role of traumatology within an increasingly fragmented health care system. Regional networks of predictable and accountable pre- and in-hospital resources are needed for efficient trauma systems. Successful development requires both novel research and scientific assessment of imported principles of trauma care.

[<<RETRATO>> (REgistro de TRAuma grave de la provincia de TOledo): general view and mortality]

OBJECTIVE

To analyze the management and progression of the critical trauma patient.

DESIGN

A retrospective, descriptive analysis.

SETTING

The ICU in the province of Toledo.

PATIENTS

All patients with traumatic injury admitted during the 2001-2007 period (7 years).

MAIN VARIABLES OF INTEREST

These include the variables at the scene of the accident, pre-hospitalization, during transportation, variables on admission and during development until discharge or death.

RESULTS

A total of 1090 trauma patients admitted were included. Of these, 79.5% were male, with an average age of 36.5 years (16% ≥ 65 years). There was a progressive decrease of patients from 2001 (142 patients) to 2007 (133 patients), with 46.9% admissions between May and September. A total of 29.4% did not belong to the health area. The causes were car accident (43.3%), fall from a height/fall (20.8%), motorcycle accident (13.8%), pedestrian being run over (6.6%). There were 2172 injuries; 30.1% had 3 injuries and 8.4% ≥ 4. The most frequently occurring injury was a head injury (33.7%), followed by thoracic trauma (20.2%) and orthopedic trauma (15.6%). 36.4% required surgery on the first day. Average length of stay in the ICU was 10.4+/-13.2 days. Time on mechanical ventilation was 7.3+/-12 days (median 1 day). Fifteen percent died in the ICU. This remains within the multivariable ICU mortality prediction model, including the pre-hospitalization variables: age (OR 1.05; 95% CI: 1.03-1.06), mydriasis (OR 2.6; 95% CI: 1.3-5.3), motor component of the Glascow Coma Score (GCS) (OR 0.7; 95% CI: 0.6-0.8), pre-hospitalization shock (OR 3.2; 95% CI: 1.8-5.5) and Injury Severity Score (ISS) (OR 1.1; 95% CI: 1.05-1.1).

CONCLUSIONS

The use of multicenter trauma registers gives an overall view of trauma management and helps improve the care.

Inter-hospital transfer: the crux of the trauma system, a curse for trauma registries

The inter-hospital transfer of patients is crucial to a well functioning trauma system, and the transfer process may serve as a quality indicator for regional trauma care. However, the assessment of the transfer process requires high-quality data from various sources. Prospective studies and studies based on single-centre trauma registries may fail to capture an appropriate width and depth of data. Thus the creation of inclusive regional and national trauma registries that receive information from all of the services within a trauma system is a prerequisite for high quality inter-hospital transfer studies in the future.

The long term effects of early analysis of a trauma registry

BACKGROUND

We established a trauma registry in 2003 to collect data on trauma patients, which is a major cause of death in the United Arab Emirates (UAE). The aim of this paper is to report on the long term effects of our early analysis of this registry.

METHODS

Data in the early stages of this trauma registry were collected for 503 patients during a period of 6 months in 2003. Data was collected on a paper form and then entered into the trauma registry using a self-developed Access database. Descriptive analysis was performed.

RESULTS

Most were males (87%), the mean age (SD) was 30.5 (14.9). UAE citizens formed 18.5%. Road traffic collisions caused an overwhelming 34.2% of injuries with 29.7% of those involving UAE citizens while work-related injuries were 26.2%. The early analysis of this registry had two major impacts. Firstly, the alarmingly high rate of UAE nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. Second, the equally alarming high rate of work-related injuries led to collaboration with a Preventive Medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention.

CONCLUSION

Analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention.

Predictors of in-hospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) is the single largest cause of death and disability following injury worldwide. While TBI in older adults is less common, it still contributes to significant morbidity and mortality in this group. Understanding the patient characteristics that result in good and poor outcome after TBI is important in the clinical management and prognosis of older adult TBI patients. This population-based study investigated predictors of mortality and longer term functional outcomes following serious TBI in older adults.

METHODS

All older adults (aged>64 years), isolated moderate to severe TBI cases from the population-based Victorian State Trauma Registry for the period July 2005 to June 2007 (inclusive) were extracted for analysis. Demographic, injury event, injury diagnosis, management and comorbid status information were obtained and the outcomes of interest were in-hospital mortality, and the Glasgow Outcome Scale-Extended (GOS-E) score at 6 months post-injury. Multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality and independent living (GOS-E>4) status at 6 months.

RESULTS

Of the 428 isolated, older adult TBI cases, the majority were the result of a fall (88%), male (55%), and aged>74 years (76%). The in-hospital death rate was 28% and increasing age (p=0.009), decreasing GCS (p<0.001) and injury type (p=0.002) were significant independent predictors of in-hospital mortality. Of the 310 patients who survived to discharge, 65% were successfully followed-up 6 months following injury. There was no difference between patients lost to follow-up and those successfully followed-up with respect to the key population indicators of age, gender, or head injury severity. Younger (<75 years) patients, and those with an SBP on arrival at hospital of 131-150mmHg, were at increased odds of living independently at follow-up. No patients with a GCS<9 had a good 6-month outcome, and most of them died. The survival rate for brainstem injury was also low (21%).

CONCLUSION

In this population-based study, we found that age, GCS, brainstem injury, and systolic blood pressure were the most important factors in predicting outcome in older adults with an isolated moderate to severe TBI.