The evolution of an integrated State Trauma System in Victoria, Australia

A 12-year experience in the management of traumatic bladder rupture at an Australian level 1 trauma centre

Objective:

To review the contemporary bladder trauma epidemiology, diagnosis and management over a 12-year period at a level 1 trauma centre in Australia.

Patients and Methods:

From July 2001 through June 2013, 97 multi-trauma patients at a level 1 trauma centre in Australia were identified to have sustained bladder rupture. Data on demographics, clinical presentation, diagnosis, management and complications were extracted from the TraumaNET database, medical records and health-coding database.

Results:

Of the 97 patients, 98% of bladder ruptures resulted from blunt trauma mostly from road accidents. There was a male preponderance of 64%. Intra-peritoneal bladder rupture (51%) was the most common type of injury followed by extra-peritoneal bladder ruptures (42%) and combined intra- and extra-peritoneal bladder ruptures (7%). Concomitant pelvic fractures occurred in 78% of patients and concurrent intra-abdominal injuries in 68%. Initial imaging missed 28% of bladder ruptures, with computed tomography with intravenous contrast missing 65% of bladder ruptures. The majority of intra-peritoneal bladder ruptures and 56% of extra-peritoneal bladder ruptures were repaired surgically, with 83% of repairs performed in conjunction with another surgical procedure. The in-hospital mortality rate was 9%, and all deaths were due to concomitant injuries.

Conclusion:

Traumatic bladder rupture is associated with a 9% mortality rate due to the frequently associated significant concurrent injuries. Computed tomography cystogram or plain cystogram is the imaging modality of choice in diagnosing bladder rupture. Intra-peritoneal bladder ruptures should be repaired surgically, while extra-peritoneal bladder ruptures can be treated conservatively in selected patients. The timing of surgical repair should be coordinated with other specialties.

Level of evidence:

4

Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients

INTRODUCTION

Amongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality.

METHODS

The Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury.

RESULTS

Overall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults.

CONCLUSION

In ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.

Preventable deaths following road traffic collisions in Botswana: A retrospective review

Road traffic collisions (RTC) are a major cause of mortality and morbidity in Botswana. To our knowledge no research has been conducted in Botswana to investigate preventable deaths that occur as a result of RTCs. The aim of this study is to establish the rate of preventable deaths from RTCs in the greater Gaborone area in Botswana. This was a 5-year retrospective study conducted at the forensic pathology department for the greater Gaborone area, in Botswana. Nine hundred and nine (909) forensic pathology reports were retrieved. Sixty-eight percent (68.2%) of RTC deaths were considered preventable. Head injury in isolation and in combination with other injuries accounted for 87.6% (796/909) of deaths. Haemorrhagic shock was present in 70.2% (638) of all documented injuries. Another documented injury contributing to fatal RTCs was high spinal cord injury. This injury was documented in 13.1% (119/909) of all deaths. We recommend the implementation of a comprehensive trauma system in Botswana to reduce the number of deaths from RTCs.

Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers

Background

Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers.

Methods

We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit.

Results

We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92–0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%).

Conclusions

Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00487-3.

Does Direct Helicopter Retrieval Improve Survival of Severely Injured Trauma Patients From Rural Western Australia?

OBJECTIVE

In remote Western Australia, mortality from major trauma is more than 4 times higher than mortality rates from major trauma in the capital city of Perth. The objective of this study was to determine whether direct helicopter emergency medical service (HEMS) retrieval from an incident scene within the zone 50 to 250 km of Perth to a tertiary hospital improves survival in severely injured trauma patients. Direct HEMS retrieval was compared with indirect retrieval whereby patients were transferred by ambulance to a nearby rural hospital before retrieval to a tertiary hospital in Perth.

METHODS

A retrospective analysis (2006-2015) was undertaken of all Western Australia trauma registries, and coronial data were collected for all major trauma patients who died before retrieval to a tertiary hospital in Perth.

RESULTS

A total of 1,374 major trauma patients (indirect retrieval = 1,031 and direct HEMS = 343) met the study inclusion criteria. There was a 51% increased risk of death in the indirect patients compared with the direct HEMS patients (15.3% vs. 10.2%, P ≤ .001).

CONCLUSION

Direct HEMS retrieval from the incident scene to a tertiary hospital substantially improves the chances of survival for severely injured trauma patients in rural locations in the zone 50 to 250 km of Perth.

Feasibility study for implementation of resuscitative balloon occlusion of the aorta in peri-arrest, exsanguinating trauma at an adult level 1 Australian trauma centre

OBJECTIVE

This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients.

METHODS

Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or hypovolaemic cardiac arrest) were eligible for recruitment and followed up until hospital discharge (ACTRN12618000550202).

RESULTS

During the 14-month study period (17 January 2015 to 12 March 2016) 3032 patients were admitted direct from scene with an overall mortality of 97 (3.71%). Of these patients 3019 had trauma centre vital signs recorded in the data set (99.57%) and 1523 were between the ages of 18-60, including 143 patients with a shock index of >1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment.

CONCLUSIONS

Despite considerable training and resource allocation to ensure 24-h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14-month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit.

The relationship between geographic location and outcomes following injury: A scoping review

INTRODUCTION

Globally, injury incidence and injury-fatality rates are higher in regional and remote areas. Recovery following serious injury is complex and requires a multi-disciplinary approach to management and community re-integration to optimise outcomes. A significant knowledge gap exists in understanding the regional variations in hospital and post-discharge outcomes following serious injury. The aim of this study was to review the evidence exploring the association between the geographic location, including both location of the event and place of residence, and outcomes following injury.

MATERIALS AND METHODS

A scoping review was used to investigate this topic and provide insight into geographic variation in outcomes following traumatic injury. Seven electronic databases and reference lists of relevant articles were searched from inception to October 2018. Studies were included if they measured injury-related mortality, outcomes associated with hospital admission, post-injury physical or psychological function and analysed these outcomes in relation to geographic location.

RESULTS

Of the 2,213 studies identified, 47 studies were included revealing three key groups of outcomes: mortality (n = 35), other in-hospital outcomes (n = 8); and recovery-focused outcomes (n = 12). A variety of measures were used to classify rurality across studies with inconsistent definitions of rurality/remoteness. Of the studies reporting injury-related mortality, findings suggest that there is a greater risk of fatality in rural areas overall and in the pre-hospital phase. For those patients that survived to hospital, the majority of studies included identified no difference in mortality between rural and urban patient groups. In the small number of studies that reported other in-hospital and recovery outcomes no consistent trends were identified.

CONCLUSION

Rural patients had a higher overall and pre-hospital mortality following injury. However, once admitted to hospital, there was no significant difference in mortality. Inconsistencies were noted across measures of rurality measures highlighting the need for more specific and consistent international classification methods. Given the paucity of data on the impact of geography on non-mortality outcomes, there is a clear need to develop a larger evidence base on regional variation in recovery following injury to inform the optimisation of post-discharge care services.

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

Comparing the outcomes of isolated, serious traumatic brain injury in older adults managed at major trauma centres and neurosurgical services: A registry-based cohort study

BACKGROUND

The incidence of older adult traumatic brain injury (TBI) is increasing in both high and middle to low-income countries. It is unknown whether older adults with isolated, serious TBI can be safely managed outside of major trauma centres. This registry based cohort study aimed to compare mortality and functional outcomes of older adults with isolated, serious TBI who were managed at specialised Major Trauma Services (MTS) and Metropolitan Neurosurgical Services (MNS).

METHOD

Older adults (65 years and over) who sustained an isolated, serious TBI following a low fall (from standing or ≤ 1 m) were extracted from the Victorian State Trauma Registry from 2007 to 2016. Multivariable models were fitted to assess the association between hospital designation (MTS vs. MNS) and the two outcomes of interest: in-hospital mortality and functional outcome, adjusting for potential confounders. Functional outcomes were measured using the Glasgow Outcome Scale Extended at six months post-injury.

RESULTS

From 2007-2016, there were 1904 older adults who sustained an isolated, serious TBI from a low fall who received definitive care at an MTS (n = 1124) or an MNS (n = 780). After adjusting for confounders, there was no mortality benefit for patients managed at an MTS over an MNS (OR = 0.84; 95% CI: 0.65, 1.08; P = 0.17) or improvement in functional outcome six months post-injury (OR = 1.13; 95% CI: 0.94, 1.36; P = 0.21).

CONCLUSION

For older adults with isolated, serious TBI following a low fall, there was no difference in mortality or functional outcome based on definitive management at an MTS or an MNS. This confirms that MNS without the added designation of a major trauma centre are a suitable destination for the management of isolated, serious TBI in older adults.

Biopsychosocial barriers affecting recovery after a minor transport-related injury: A qualitative study from Victoria

Objective

The aim of the study was to understand the recovery phenomena and to explore participants' perspectives on the biopsychosocial facilitators and barriers affecting their recovery after a minor transport injury.

Methods

A qualitative method was used involving semi‐structured interviews with 23 participants who sustained a minor transport injury. Interviews and analysis were guided by the biopsychosocial model (BPS) of health. The outcomes were themes capturing biopsychosocial barriers to, and personal experiences of, recovery using a previously defined framework.

Results

The themes indicate that recovery is a multifaceted phenomenon affected by comorbidities such as chronic pain, depression and anxiety. A range of subsequent complexities such as the inability to self‐care and undertaking daily domestic duties, and incapacity to participate in recreational activities were major barriers to recovery. These barriers were found to be an on‐going source of frustration, dissatisfaction and a perceived cause of depressive symptomatology in many participants. Most participants reported mixed feelings of the care received. Other common issues raised included a lack of understanding of the assessment time, regular follow‐up, guidance and on‐going support.

Conclusion

This study revealed that recovery after a minor transport‐related injury was a challenging, complex, demanding and a long‐term process for the individuals in this study. Findings from this limited cohort suggested that, for participants to return to their pre‐accident health status, a more coordinated approach to information and care delivery may be required.

Australasian general surgical training and emergency medical teams: a review

Emergency medical teams (EMTs) have provided surgical care in sudden-onset disasters in low- and middle-income countries. General surgeons have been heavily involved in many EMTs due to their traditional broad set of surgical skills and experience. With the increased subspecialization of general surgical training in many high-income countries, including Australia and New Zealand, finding general surgeons with adequately broad experience is becoming more challenging. Furthermore, it is now considered standard for EMTs deploying to a sudden-onset disaster to have undergone credentialing, demonstrating sufficient training of their deployed members. The purpose of this review was to highlight the challenges and potential solutions facing those involved in training and recruiting general surgeons for EMTs in Australasia.

Low major trauma confidence among emergency physicians working outside major trauma services: Inevitable result of a centralised trauma system or evidence for change?

OBJECTIVE

Regionalised civilian trauma systems improve patient outcomes, but may deskill clinicians outside major trauma services (MTSs). We aimed to characterise experience and confidence in trauma management among emergency physicians working in MTS to those working elsewhere.

METHODS

Emergency physicians working within the Victorian State Trauma System were surveyed about their pre- and post-fellowship training experience, their estimated hours per fortnight in different centres, the frequency of performance/supervision of critical emergency skills and their confidence in a range of trauma skills.

RESULTS

The 138 respondents analysed represented 33% of active Victorian FACEMs. The cohort were mostly males (69.6%), younger than 50 (75.4%) and were generally (69.6%) six or more years post-fellowship. FACEMs working in a MTS were more likely to have been a trauma registrar prior to fellowship (13.3% vs 3.7%, P = 0.046). MTS clinicians performed more, supervised more and were more confident in trauma team leading, traumatic airway management and rapid infusion catheter and multi-access catheters. Confidence in trauma team leading was only associated with exposure to performance or supervision of trauma team leading. Performance of trauma team leading was more common in clinicians at a MTS (odds ratio 3.19, 95% CI 1.00-10.20, P = 0.05).

CONCLUSION

Exposure to major trauma is associated with time spent working in a MTS and exposure is associated with confidence. A mature inclusive trauma system must ensure clinicians across the system gain the experience or training to provide trauma care that will result in similar outcomes for patients regardless of initial presenting hospital.

Prevalence of a definitive airway in patients with severe traumatic brain injury received at four urban public university hospitals in India: a cohort study

AIM

To estimate the proportion of patients arriving with a Glasgow Coma Scale (GCS) less than 9 who had a definitive airway placed prior to arrival.

METHODS

We conducted a retrospective analysis of the data from a multicentre, prospective observational research project entitled Towards Improved Trauma Care Outcomes in India. Adults aged ≥18 years with an isolated traumatic brain injury (TBI) who were transferred from another hospital to the emergency department of the participating hospital with a GCS less than 9 were included. Our outcome was a definitive airway, defined as either intubation or surgical airway, placed prior to arrival at a participating centre.

RESULTS

The total number of patients eligible for this study was 1499. The median age was 40 years and 84% were male. Road traffic injuries and falls comprised 88% of the causes of isolated TBI. The number of patients with GCS<9 who had a definitive airway placed before reaching the participating centres was 229. Thus, the proportion was 0.15 (95% CI 0.13 to 0.17). The proportions of patients with a definitive airway who arrived after 24 hours (19%) were approximately double the proportion of patients who arrived within 6 hours (10%) after injury to the definitive care centre.

CONCLUSION

The rates of definitive airway placement are poor in adults with an isolated TBI who have been transferred from another health facility to tertiary care centres in India.

Pelvic trauma mortality reduced by integrated trauma care

OBJECTIVES

A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography (FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period.

METHODS

A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis.

RESULTS

There were 1213 patients with a serious pelvic injury (Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 (P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10; 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders.

CONCLUSIONS

Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes.

Natural history of medial clavicle fractures

BACKGROUND

Fractures of the medial third of the clavicle comprise less than 3% of all clavicle fractures. The natural history and optimal management of these rare injuries are unknown. The aim of our study is to describe the demographics, management and outcomes of patients with medial clavicle fractures treated at a Level 1 Trauma Centre.

METHODS

A retrospective review was conducted of patients presenting to our institution between January 2008 and March 2013 with a medial third clavicle fracture. Clinical and radiographic data were recorded including mechanism of injury, fracture pattern and displacement, associated injuries, management and complications. Functional outcomes were assessed using the Glasgow Outcome Scale Extended (GOS-E) scores from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Shoulder outcomes were assessed using two patient reported outcomes scores, the American Shoulder and Elbow Society Score (ASES) and the Subjective Shoulder Value (SSV).

RESULTS

Sixty eight medial clavicle fractures in 68 patients were evaluated. The majority of patients were male (n=53), with a median age of 53.5 years (interquartile range (IQR) 37.5-74.5 years). The most common mechanism of injury was motor vehicle accident (n=28). The in-hospital mortality rate was 4.4%. The fracture pattern was almost equally distributed between extra articular (n=35) and intra-articular (n=33). Fifty-five fractures (80.9%) had minimal or no displacement. Associated injuries were predominantly thoracic (n=31). All fractures were initially managed non-operatively, with a broad arm sling. Delayed operative fixation was performed for painful atrophic delayed union in two patients (2.9%). Both patients were under 65 years of age and had a severely displaced fracture of the medial clavicle. One intra-operative vascular complication was seen, with no adverse long-term outcome. Follow-up was obtained in 85.0% of the surviving cohort at an average of three years post injury (range 1-6 years). The mean ASES score was 80.3 (SD 24.8, range 10-100,), and the mean SSV score was 77.0 (SD 24.6, range 10-100).

CONCLUSION

Sixty eight patients with medial clavicle fractures were identified over a 5year period, with excellent functional results seen following conservative management.

Return to Work and Functional Outcomes After Major Trauma: Who Recovers, When, and How Well?

OBJECTIVE

To describe the long-term outcomes of major trauma patients and factors associated with the rate of recovery.

BACKGROUND

As injury-related mortality decreases, there is increased focus on improving the quality of survival and reducing nonfatal injury burden.

METHODS

Adult major trauma survivors to discharge, injured between July 2007 and June 2012 in Victoria, Australia, were followed up at 6, 12, and 24 months after injury to measure function (Glasgow Outcome Scale-Extended) and return to work/study. Random-effects regression models were fitted to identify predictors of outcome and differences in the rate of change in each outcome between patient subgroups.

RESULTS

Among the 8844 survivors, 8128 (92%) were followed up. Also, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% (adjusted odds ratio 1.27, 95% confidence interval [CI] 1.19-1.36) higher compared with 6 months, and 9% (adjusted odds ratio 1.09, 95% CI, 1.02-1.17) higher at 24 months compared with 12 months. The adjusted relative risk (RR) of returning to work was 14% higher at 12 months compared with 6 months (adjusted RR 1.14, 95% CI, 1.12-1.16) and 8% (adjusted RR 1.08, 95% CI, 1.06-1.10) higher at 24 months compared with 12 months.

CONCLUSIONS

Improvement in outcomes over the study period was observed, although ongoing disability was common at 24 months. Recovery trajectories differed by patient characteristics, providing valuable information for informing prognostication and service planning, and improving our understanding of the burden of nonfatal injury.

Reduced population burden of road transport-related major trauma after introduction of an inclusive trauma system

This population-based study found that since the introduction of an inclusive, regionalized trauma system in Victoria, Australia, the burden of road transport–related serious injury has decreased. Hospitalized major trauma cases increased, but disability burden per case declined. Increased survival did not result in an overall increase in nonfatal injury burden.

Objective:

To describe the burden of road transport–related serious injury in Victoria, Australia, over a 10-year period, after the introduction of an integrated trauma system.

Background:

Road traffic injury is a leading cause of death and disability worldwide. Efforts to improve care of the injured are important for reducing burden, but the impact of trauma care systems on burden and cost of road traffic injury has not been evaluated.

Methods:

All road transport–related deaths and major trauma (injury severity score >12) cases were extracted from population-based coroner and trauma registry data sets for July 2001 to June 2011. Modeling was used to assess changes in population incidence rates and odds of in-hospital mortality. Disability-adjusted life years, combining years of life lost and years lived with disability, were calculated. Cost of health loss was calculated from estimates of the value of a disability-adjusted life year.

Results:

Incidence of road transport–related deaths decreased (incidence rate ratio 0.95, 95% confidence interval: 0.94–0.96), whereas the incidence of hospitalized major trauma increased (incidence rate ratio 1.03, 95% confidence interval: 1.02–1.04). Years of life lost decreased by 43%, and years lived with disability increased by 32%, with an overall 28% reduction in disability-adjusted life years over the decade. There was a cost saving per case of A$633,446 in 2010–2011 compared with the 2001–2002 financial year.

Conclusions:

Since introduction of the trauma system in Victoria, Australia, the burden of road transport–related serious injury has decreased. Hospitalized major trauma cases increased, whereas disability burden per case declined. Increased survival does not necessarily result in an overall increase in nonfatal injury burden.

Norwegian trauma care: a national cross-sectional survey of all hospitals involved in the management of major trauma patients

BACKGROUND

Approximately 10% of the Norwegian population is injured every year, with injuries ranging from minor injuries treated by general practitioners to major and complex injuries requiring specialist in-hospital care. There is a lack of knowledge concerning the caseload of potentially severely injured patients in Norwegian hospitals. Aim of the study was to describe the current status of the Norwegian trauma system by identifying the number and the distribution of contributing hospitals and the caseload of potentially severely injured trauma patients within these hospitals.

METHODS

A cross-sectional survey with a structured questionnaire was sent in the summer of 2012 to all Norwegian hospitals that receive trauma patients. These were defined by number of trauma team activations in the included hospitals. A literature review was performed to assess over time the development of hospitals receiving trauma patients.

RESULTS

Forty-one hospitals responded and were included in the study. In 2011, four trauma centres and 37 acute care hospitals received a total of 6,570 trauma patients. Trauma centres received 2,175 (33%) patients and other hospitals received 4,395 (67%) patients. There were significant regional differences between health care regions in the distribution of trauma patients between trauma centres and acute care hospitals. More than half (52.5%) of the hospitals received fewer than 100 patients annually. The national rate of hospital admission via trauma teams was 13 per 10,000 inhabitants. There was a 37% (from 65 to 41) reduction in the number of hospitals receiving trauma patients between 1988 and 2011.

CONCLUSIONS

In 2011, hospital acute trauma care in Norway was delivered by four trauma centres and 37 acute care hospitals. Many hospitals still receive a small number of potentially severely injured patients and only a few hospitals have an electronic trauma registry. Future development of the Norwegian trauma system needs to address the challenge posed by a scattered population and long geographical distances. The implementation of a trauma system, carefully balanced between centres with adequate caseloads against time from injury to hospital care, is needed and has been shown to have a beneficial effect in countries with comparable challenges.

Caputo L, D. Sanddal N, Salottolo K, Sabin M, W. Bourg P, W. Mains C. Integrating care: the experience of a US healthcare organization

Purpose

– The purpose of this paper is to describe an American healthcare organization's experience creating the first multi-facility trauma system managed by a private, nonprofit organization.

Design/methodology/approach

– A leadership structure was established to initiate the first steps of system development, followed by needs assessments that identified key components essential to creating the interconnected system. The key components were applied as a result of evidence-based system development. After system implementation, early benefits were explored.

Findings

– Data collection and research, prehospital support, system-wide quality improvement, rural outreach, communication, and system evaluation were identified as key components essential to creating an interconnected trauma system. The system currently connects 12 trauma centers throughout the state of Colorado while working within the parameters of an established statewide system. Early benefits included improved designation review results, the utilization of system-wide best practice protocols, a rich trauma registry, and closer relations with rural, out-of-network facilities.

Practical implications

– This study describes the process undertaken to implement a unique medical system that provides regionalized care and complements an existing statewide trauma system. The authors hope their experience may serve as a roadmap for healthcare professionals wishing to develop an integrated, patient-centered model of care.

Originality/value

– The development of this multi-facility trauma system within a private, not-for-profit healthcare organization is the first of its kind.

Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population

BACKGROUND

Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not.

METHODS

Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW.

RESULTS

MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9-95.8). The area under the receiver operating characteristic curve for the model was 0.859.

CONCLUSION

From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation.

LEVEL OF EVIDENCE

Prognostic study, level III.

Outcomes of different health care contexts for direct transport to a trauma center versus initial secondary center care: a systematic review and meta-analysis

INTRODUCTION

Within a trauma system, pre-hospital care is the first step in managing the trauma patient. Timely and appropriate transport of the injured patient to the most appropriate facility is important. Many trauma systems mandate that serious trauma cases are transported directly to a level I trauma center unless transfer to a closer hospital is deemed necessary to resuscitate and stabilize the patient prior to onward transfer to definitive care. Statistical and clinical heterogeneity is often high and is likely to be influenced by the heath care context.

METHODS

We conducted a systematic review and meta-analysis to compare patient outcomes for patients with serious trauma transported directly to a Level I/II trauma center ('direct' group) to those transported to a healthcare facility before transfer to the Level I/ II trauma center ('transfer' group). A search of bibliographic databases and secondary sources that focus on trauma was made. Studies were grouped by region: United States of America, Canada, Europe, Asia, Australia and New Zealand and South Africa.

RESULTS

The review included 43,554 patients from the 30 studies that met the selection criteria. Heterogeneity of the studies was high (I(2) 71%) overall but low for European, Asian, and Australian and New Zealand studies. There was considerable variation between studies in the structure, policies and practices of the respective trauma systems. The effect of "directness" on patient outcomes was inconsistent.

CONCLUSION

The current research evidence does not support nor refute a position that all serious trauma patients be routinely transported directly to a level I/II trauma center. As this is a complex issue, local health-care context and injury profile influence trauma policy and practice.

The impact of specialist trauma service on major trauma mortality

INTRODUCTION

Trauma services throughout the world have had positive effects on trauma-related mortality. Australian trauma services are generally more consultative in nature rather than the North American model of full trauma admission service. We hypothesized that the introduction of a consultative specialist trauma service in a Level I Australian trauma center would reduce mortality of the severely injured.

METHODS

A 10-year retrospective study (January 1, 2002-December 31, 2011) was performed on all trauma patients admitted with an Injury Severity Score (ISS) > 15. Patients were identified from the trauma registry, and data for age, sex, mechanism of injury, ISS, survival to discharge, and length of stay were collected. Mortality was examined for patients with severe injury (ISS > 15) and patients with critical injury (ISS > 24) and compared for the three periods: 2002-2004 (without trauma specialist), 2005-2007 (with trauma specialist), and 2008-2011 (with specialist trauma service).

RESULTS

A total of 3,869 severely injured (ISS > 15) trauma patients were identified during the 10-year period. Of these, 2,826 (73%) were male, 1,513 (39%) were critically injured (ISS > 24), and more than 97% (3,754) were the victim of blunt trauma. Overall mortality decreased from 12.4% to 9.3% (relative risk, 0.75) from period one to period three and from 25.4% to 20.3% (relative risk, 0.80) for patients with critical injury. A 0.46% per year decrease (p = 0.018) in mortality was detected (odds ratio, 0.63; p < 0.001). For critically injured (ISS > 24), the trend was (0.61% per year; odds ratio, 0.68; p = 0.039).

CONCLUSION

The introduction of a specialist trauma service decreased the mortality of patients with severe injury, the model of care should be considered to implement state- and nationwide in Australia.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Rural and urban distribution of trauma incidents in Scotland

Background

Trauma systems reduce mortality and improve functional outcomes from injury. Regional trauma networks have been established in several European regions to address longstanding deficiencies in trauma care. A perception of the geography and population distribution as challenging has delayed the introduction of a trauma system in Scotland. The characteristics of trauma incidents attended by the Scottish Ambulance Service were analysed, to gain a better understanding of the geospatial characteristics of trauma in Scotland.

Methods

Data on trauma incidents collected by the Scottish Ambulance Service between November 2008 and October 2010 were obtained. Incident location was analysed by health board region, rurality and social deprivation. The results are presented as number of patients, average annual incidence rates and relative risks.

Results

Of the 141 668 incidents identified, 72·1 per cent occurred in urban regions. The risk of being involved in an incident was similar across the most populous regions, and decreased slightly with increasing rurality. Social deprivation was associated with greater numbers and risk. A total of 53·1 per cent of patients were taken to a large general hospital, and 38·6 per cent to a teaching hospital; the distribution was similar for the subset of incidents involving patients with physiological derangements.

Conclusion

The majority of trauma incidents in Scotland occur in urban and deprived areas. A regionalized system of trauma care appears plausible, although the precise configuration of such a system requires further study.

An emergency system to improve ambulance dispatching, ambulance diversion and clinical handover communication-a proposed model

Effective communication in healthcare is important and especially critical in emergency situations. In this paper we propose a new comprehensive emergency system which facilitates the communication process in emergency cases from ambulance dispatch to the patient's arrival and handover in the hospital. The proposed system has been designed to facilitate and computerize all the processes involved in an accident from finding the nearest ambulance through to accessing a patient's online health record which can assist in pre-hospital treatments. The proposed system also locates the nearest hospital specializing in the patient's condition and will communicate patient identification to the emergency department. The components of the proposed system and the technologies used in building this system are outlined in this paper as well as the challenges expected and proposed solutions to these challenges.

Evaluation of the Victorian state adult pre-hospital trauma triage criteria

BACKGROUND

Pre-hospital trauma triage criteria are used to expedite the transport of severely injured patients to major trauma services. The current Victorian adult pre-hospital trauma triage criteria consist of physiological, anatomical and mechanistic elements. The purpose of this study was to evaluate the performance of the current triage criteria and, if necessary propose refined criteria to improve the under and over-triage rates.

METHODS

The study was conducted in Melbourne, Victoria, which has a fully integrated State Trauma System. Trauma data was sourced from the pre-hospital Victorian Ambulance Clinical Information System and the Victorian State Trauma Registry. Confirmed major trauma was defined at hospital discharge as one or more of death, ISS>15, ICU ventilation or urgent surgery. Data was matched through probabilistic linkage. The triage criteria were evaluated using multivariate logistic regression and classification tree modelling. Diagnostic statistics, including sensitivity and specificity were calculated to assess triage performance.

RESULTS

Over 12-months there were 1166 'confirmed major trauma' patients and 44,166 'non-major trauma' patients. Evaluation showed the current triage criteria needed refinement, and multiple revised pre-hospital trauma triage models were constructed. Based on the best overall combination of diagnostic statistics, a revised model was chosen with a sensitivity of 97.8% (vs. 95.3% in the current model), a specificity of 82.7% (vs. 62.7%) and an accuracy of 83.0% (vs. 63.4%). The over-triage rate was 17.3% (vs. 37.3%) and the under-triage rate was 2.2% (vs. 4.7%).

CONCLUSIONS

Evaluation showed that the specificity and sensitivity of the current trauma triage criteria could be improved. The implementation of a revised triage model should identify more confirmed major trauma patients. Likewise, over-triage of non-major trauma patients to major trauma services would be significantly reduced. The refined criteria should also decrease discretionary decision-making by paramedics in the field.

Trauma systems: Do trauma teams make a difference?

This review describes the various components of a trauma team, and emphasises its value as one of many parts of a trauma system. The evidence for the team is weak and based on expert opinion and experience. Nevertheless, the evidence that high quality trauma systems improve survival, and that a trauma team is a vital component of all such systems is compelling. There is no evidence that a particular component of the team is essential. The trauma team is likely to have most impact on patients with moderate severity of trauma and probability of survival.

Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria

BACKGROUND

There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines ('potential major trauma') with trauma patients who are identified as 'confirmed major trauma patients' at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.

METHODS

For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as 'confirmed major trauma patients' and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the 'potential major trauma' group. Non-major trauma patients (N=27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.

RESULTS

The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.

CONCLUSIONS

While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.

Major trauma deaths at Perth secondary hospitals

OBJECTIVE

Some major trauma (Injury Severity Score [ISS] >15) patients transported to a secondary hospital in Perth do not survive. We sought to describe this cohort and assess preventability.

METHODS

A cohort study from a previously developed cohort of trauma deaths in Western Australia from 1 July 1997 to 30 June 2006. A preformatted data sheet was used to collect a range of descriptive, time, physiological, and autopsy data. Trauma scores were calculated. Preventability was assessed using three approaches, based on ISS, Trauma Revised Injury Severity Score (TRISS) and individual case review.

RESULTS

There were 74 major trauma deaths, mean age 55.6 ± 26.3 years (range 3-95). Thirty-seven (50%) were motor vehicle crashes. The mean Revised Trauma Score was 3.84 ± 3.09 (0-7.84), median ISS 31 (interquartile range [IQR] 25-51), median TRISS 0.127 (IQR 0.031-0.772) and median time to death was 80 min (IQR 20 min-10 h 8 min). Severe head and chest injuries were the most common. Almost half (36, 48.6%) were receiving CPR on arrival to the hospital. The crude proportion of potentially preventable deaths, based on ISS, TRISS and case review, were 16.2%, 32.4% and 6.7%, respectively. However, these were predominantly elderly patients and a decision against resuscitation was recorded in 54%.

CONCLUSIONS

The proportion of potentially preventable major trauma deaths at Perth secondary hospitals is low. The most notable group were the elderly after falls, and trauma system efforts should be focused on this group. Primary prevention of major trauma represents the biggest opportunity for improvements in trauma survival.

A synthetic haemoglobin-based oxygen carrier and the reversal of cardiac hypoxia secondary to severe anaemia following trauma

We report a case of compassionate use of a haemoglobin-based oxygen carrier in a severely injured Jehovah's Witness patient, for whom survival was considered unlikely. Severe anaemia and cardiac hypoxia were reversed after slow infusion of this agent. No vasoactive side effects were associated with the treatment, possibly due to the slow infusion, and the patient survived.

A comparison of major trauma patients transported to trauma centres vs. non-trauma centres in metropolitan Perth

INTRODUCTION

Some major trauma patients in metropolitan Perth (area 5000 km(2)) are initially transported to a secondary hospital (non-trauma centre), rather than directly to a tertiary hospital (trauma centre). They are subsequently transferred to a tertiary hospital. We compared outcomes from these different systems of care.

METHODS

Major trauma (Injury Severity Score, ISS>15) data from the Trauma Registries, 1 July 1997-30 June 2006. Two groups were studied: group 1 (metropolitan major trauma transported directly to a tertiary hospital) and group 2 (metropolitan major trauma transported initially to a secondary hospital and then to a tertiary hospital). The primary endpoint was death.

RESULTS

Group 1 (n = 2005) and group 2 (n = 1078) mean age (43.9 ± 24.3 yrs vs. 39.1 ± 24.3 yrs, p < 0.0001) both with a median ISS = 24 (p = 0.084). Group 2 had significantly more head/neck injuries (p < 0.0001) and significantly less thoracic, abdominal and pelvis/extremities injuries (p < 0.0001). There were also a significantly greater total number of regions injured in group 1 vs. group 2 (p < 0.0001). Mean times to definitive care were 59 min vs. 4.5h, respectively (p < 0.0001). After adjusting for age, ISS, RTS, total regions injured and time, the OR for death in group 2 was 0.99 (95% CI 0.58-1.68).

CONCLUSION

There is an equivalent risk of major trauma death in these two systems of care. In our metropolitan area, we were unable to demonstrate a mortality benefit associated with time.

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.

The Victorian major trauma transfer study

AIMS

To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events.

METHODS

This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form.

RESULTS

A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001).

CONCLUSION

Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia

OBJECTIVE

To examine the response of the Victorian State Trauma System to the February 2009 bushfires.

DESIGN AND SETTING

A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state's adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires.

RESULTS

There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity.

CONCLUSIONS

Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.

Occipital condyle fractures: incidence and clinical follow-up at a level 1 trauma centre

The purpose of the study was to investigate the incidence, management, and outcomes of occipital condyle fractures at a level 1 trauma center. Blunt trauma patients with occipital condyle fracture admitted to a level 1 trauma center over a 3-year period were identified. Prospective clinical and functional follow-up was undertaken, including further radiographic imaging. The incidence of occipital condyle fracture in patients presenting to our level 1 trauma center was 1.7/1,000 per year. Twenty-four patients were followed up at a mean of 27 months post-injury. There was one case of isolated occipital condyle fracture; all other patients had sustained additional orthopedic, cervical spine, and/or head injury. Seven (29%) patients sustained unilateral Type III avulsion fractures, none of which were isolated injuries. Traumatic brain injury was detected in 46% of study patients, and 42% had cervical spine injury. External halothoracic immobilization was used in 33% of cases. Fracture union with anatomical alignment occurred in 21 patients (88%). No patient had cranial nerve deficit at admission or follow-up. Three patients (12.5%) had moderate to severe neck pain/disability at follow-up, all of whom had sustained multiple injuries. Occipital condyle fractures most frequently occur in conjunction with additional injuries, particularly head and cervical spine injuries. Most cases can be managed successfully nonoperatively. Functional outcome is generally determined by pain and disability related to other injuries, rather than occipital fracture configuration.

The challenges of developing a trauma system for Indigenous people

Trauma systems have been shown to provide the best trauma care for injured patients. A trauma system developed for Indigenous people should take into account many factors including geographical remoteness and cultural diversity. Indigenous people suffer from a significant intentional and non-intentional burden of injury, often greater than non-Indigenous populations, and a public health approach in dealing with trauma can be adopted. This includes transport issues, prevention and control of intentional violence, cultural sensitization of health providers, community emergency responses, community rehabilitation and improving resilience. The ultimate aim is to decrease the trauma burden through a trauma system with which indigenous people can fully identify.

A statewide system of trauma care in Victoria: effect on patient survival

OBJECTIVE

To determine whether the statewide system of trauma care introduced in 2000 has resulted in improved survival for all major trauma patients in Victoria.

DESIGN, SETTING AND PARTICIPANTS

Population-based cohort study using data from the Victorian State Trauma Registry (VSTR), a registry of all hospitalised major trauma patients in Victoria. The study included major trauma patients with an Injury Severity Score > 15 captured by the VSTR between July 2001 and June 2006.

MAIN OUTCOME MEASURE

In-hospital mortality.

RESULTS

The number of major trauma cases captured by the registry rose from 1153 in 2001-02 to 1737 in 2005-06. Adjusting for key predictors of mortality, there was a significant overall reduction between 2001-02 and 2005-06 in the risk of death for patients treated in the trauma system (adjusted odds ratio [AOR], 0.62 [95% CI, 0.48-0.80]). The reduced risk of death was also significant when road trauma cases (AOR, 0.56 [95% CI, 0.39-0.80]) and serious head injury cases (AOR, 0.62 [95% CI, 0.46-0.83]) were analysed separately. The proportion of road trauma patients definitively treated at one of the three major trauma service (MTS) hospitals in Victoria rose by 7% over the 5-year period. Direct transfers from the scene of injury to MTS hospitals rose by 8% for all cases and 13% for road trauma cases over the same period.

CONCLUSIONS

Introduction of a statewide trauma system was associated with a significant reduction in risk-adjusted mortality. Such inclusive systems of trauma care should be regarded as a minimum standard for health jurisdictions.

Survival following resuscitative thoracotomy for combined left ventricle and left atrium ruptures secondary to blunt trauma

Improvements in pre-hospital care and the development of integrated Trauma Systems have streamlined access for the severely injured to sophisticated, specialist Trauma Centre reception and resuscitation. We describe the initial care of a survivor of combined ruptures of the left ventricle and left atrium secondary to blunt injury. This case emphasises the contribution of such a Trauma System in achieving a favourable outcome for a severely injured trauma patient with injuries previously considered non-survivable.

Monitoring the "tip of the iceberg'': ambulance records as a source of injury surveillance

AIMS

The aim of this study was to describe the epidemiology of moderate and severe injury morbidity in a defined population on the basis of ambulance records, and to validate ambulance records as a potential source of surveillance.

METHODS

A geographical target area was defined; the county of Värmland, Sweden. All ambulance attendances and hospitalizations for unintentional and intentional injury in 2002 were selected, analysed, and compared.

RESULTS

Ambulance data comprised 3,964 injury cases (14.5/1,000). Most injuries for which ambulance attention was sought occurred in road traffic areas (27%), followed by residential areas (20%), school and institutional areas (14%), and sports areas (8%). An ecological comparison between ambulance-based data and hospitalizations showed that ambulance services captured approximately the same amount of injury cases (3,235 ambulance reports, as compared to 3,456 hospital discharges) with a similar profile.

CONCLUSIONS

This study provides epidemiological support for ambulance services as a potential source of regular surveillance data on moderate and severe injuries. However, at a population level, our results indicate that ambulance data tend to overestimate some injury categories, and underestimate others, as compared to hospital data. The significance of these differences for preventive work, as well as other practical aspects of the feasibility of regular injury surveillance, will be analysed and discussed on the basis of general criteria for evaluation of surveillance systems in a forthcoming paper.

Could bystander first-aid prevent trauma deaths at the scene of injury?

OBJECTIVE

To identify potentially preventable prehospital deaths following traumatic cardiac arrest.

METHODS

Deaths following prehospital traumatic cardiac arrest during 2003 were reviewed in the state of Victoria, Australia. Possible survival with optimal bystander first-aid and shorter ambulance response times were identified. Injury Severity Scores (ISS) were calculated. Victims with an ISS <50 and signs of life were reviewed for potentially preventable factors contributing to death including signs of airway obstruction, excessive bleeding and/or delayed ambulance response times.

RESULTS

We reviewed 112 cases that had full ambulance care records, hospital records and autopsy details in Victoria 2003. Most deaths involved road trauma and 55 victims had an ISS <50. Twelve patients received first-aid from bystanders. Ambulance response times >10 min might have contributed to five deaths with an ISS <25.

CONCLUSION

Five (4.5%) potentially preventable prehospital trauma deaths were identified. Three deaths potentially involved airway obstruction and two involved excessive bleeding. There is a case for increased awareness of the need for bystander first-aid at scene following major trauma.