The importance of quality of survival as an outcome measure for an integrated trauma system

Follow-up after major traumatic injury: a survey of services in Australian and New Zealand public hospitals

BACKGROUND

Increased survival from traumatic injury has led to a higher demand for follow-up care when patients are discharged from hospital. It is currently unclear how follow-up care following major trauma is provided to patients, and how, when, and to whom follow-up services are delivered. The aim of this study was to describe the current follow-up care provided to patients and their families who have experienced major traumatic injury in Australia and New Zealand (ANZ).

METHODS

Informed by Donabedian's 'Evaluating the Quality of Medical Care' model and the Institute of Medicine's Six Domains of Healthcare Quality, a cross-sectional online survey was developed in conjunction with trauma experts. Their responses informed the final survey which was distributed to key personnel in 71 hospitals in Australia and New Zealand that (i) delivered trauma care to patients, (ii) provided data to the Australasian Trauma Registry, or (iii) were a Trauma Centre.

RESULTS

Data were received from 38/71 (53.5%) hospitals. Most were Level 1 trauma centres (n = 23, 60.5%); 76% (n = 16) follow-up services were permanently funded. Follow-up services were led by a range of health professionals with over 60% (n = 19) identifying as trauma specialists. Patient inclusion criteria varied; only one service allowed self-referral (3.3%). Follow-up was within two weeks of acute care discharge in 53% (n = 16) of services. Care activities focused on physical health; psychosocial assessments were the least common. Most services provided care for adults and paediatric trauma (60.5%, n = 23); no service incorporated follow-up for family members. Evaluation of follow-up care was largely as part of a health service initiative; only three sites stated evaluation was specific to trauma follow-up.

CONCLUSION

Follow-up care is provided by trauma specialists and predominantly focuses on the physical health of the patients affected by major traumatic injury. Variations exist in terms of patient selection, reason for follow-up and care activities delivered with gaps in the provision of psychosocial and family health services identified. Currently, evaluation of trauma follow-up care is limited, indicating a need for further development to ensure that the care delivered is safe, effective and beneficial to patients, families and healthcare organisations.

Barriers and facilitators associated with the upscaling of the Transmural Trauma Care Model: a qualitative study

BACKGROUND

To assess the barriers and facilitators associated with upscaling the Transmural Trauma Care Model (TTCM), a multidisciplinary and patient-centred transmural rehabilitation care model.

METHODS

Semi-structured interviews were conducted with eight trauma surgeons, eight hospital-based physiotherapists, eight trauma patients, and eight primary care physiotherapists who were part of a trauma rehabilitation network. Audio recordings of the interviews were made and transcribed verbatim. Data were analysed using a framework method based on the "constellation approach". Identified barriers and facilitators were grouped into categories related to structure, culture, and practice.

RESULTS

Various barriers and facilitators to upscaling were identified. Under structure, barriers and facilitators belonged to one of five themes: "financial structure", "communication structure", "physical structures and resources", "rules and regulations", and "organisation of the network". Under culture, the five themes were "commitment", "job satisfaction", "acting as a team", "quality and efficiency of care", and "patients' experience". Under practice, the two themes were "practical issues at the outpatient clinic" and "knowledge gained".

CONCLUSION

The success of upscaling the TTCM differed across hospitals and settings. The most important prerequisites for successfully upscaling the TTCM were adequate financial support and presence of "key actors" within an organisation who felt a sense of urgency for change and/or expected the intervention to increase their job satisfaction.

TRIAL REGISTRATION

NL8163 The Netherlands National Trial Register, date of registration 16-11-2019.

Effects of the establishment of trauma centres on the mortality rate among seriously injured patients: a propensity score matching retrospective study

BACKGROUND

Little evidence suggests that trauma centres are associated with a lower risk of mortality in severely injured patients (Injury Severity Score (ISS) ≥16) with multiple injuries in China. The objective of this study was to determine the association between the establishment of trauma centres and mortality among severely injured patients with multiple injuries and to identify some risk factors associated with mortality.

METHODS

A retrospective single-centre study was performed including trauma patients admitted to the First Affiliated Hospital of Nanchang University (FAHNU) between January 2016 and December 2021. To determine whether the establishment of a trauma centre was an independent predictor of mortality, logistic regression analysis and propensity score matching (PSM) were performed.

RESULTS

Among 431 trauma patients, 172 were enrolled before the trauma centre was built, while 259 were included after the trauma centre was built. A higher frequency of older age and traffic accident injury was found in patients diagnosed after the trauma centre was built. The times for the completion of CT examinations, emergency operations and blood transfusions in the "after trauma centre" group were shorter than those in the "before trauma centre" group. However, the total expenditure of patients was increased. In the overall group, univariate and multivariate logistic regression analyses showed that a higher ISS was an independent predictor for worse mortality (OR = 17.859, 95% CI, 8.207-38.86, P < 0.001), while the establishment of a trauma centre was favourable for patient survival (OR = 0.492), which was also demonstrated by PSM. After determining the cut-off value of time for the completion of CT examination, emergency operation and blood transfusion, we found that the values were within the "golden one hour", and it was better for patients when the time was less than the cut-off value.

CONCLUSION

Our study showed that for severely injured patients, the establishment of a trauma centre was favourable for a lower mortality rate. Furthermore, the completion of a CT examination, emergency surgery and blood transfusion in a timely manner and a lower ISS were associated with a decreased mortality rate.

Influence of psychiatric co-morbidity on health-related quality of life among major trauma patients

PURPOSE

The purpose of this study was to compare 1-year post-discharge health-related quality of life (HRQL) between trauma patients with and without psychiatric co-comorbidity.

METHODS

A retrospective single-center cohort study identified all severely injured adult trauma patients admitted to a Level 1 trauma center between 2018 and 2019. Bivariate analysis compared patients with and without psychiatric co-morbidity, which was defined as prior diagnosis by a healthcare provider or acute psychiatric consultation for new or chronic mental illness. HRQL metrics included the EuroQol-5D-5L (EQ-5D) questionnaire, visual analogue scale (EQ-VAS), and overall index score. A multiple linear regression model was utilized to identify predictors of EQ-5D index scores.

RESULTS

Analysis of baseline characteristics revealed significantly greater rates of substance abuse, severe extremity injuries, inpatient morbidity, and hospital length-of-stay among patients with psychiatric illness. At 1-year follow-up, patients with psychiatric co-morbidity had lower median EQ-5D index scores compared to the control group (0.71, interquartile range [IQR] 0.32 vs. 0.79, IQR 0.22, p = 0.03). There were no differences between groups in individual EQ-5D dimensions, nor in EQ-VAS scores. Presence of psychiatric co-morbidity was not found to independently predict EQ-5D index scores in the linear regression model. Instead, Injury Severity Score (standardized regression coefficient [SRC] - 0.15, 95% confidence interval [CI] - 0.010 to - 0.001) and American Society of Anesthesiologists Physical Status score (SRC - 0.13, 95% CI - 0.08 to - 0.004) predicted poor HRQL 1-year after injury.

CONCLUSIONS

Psychiatric co-morbidity does not independently predict low HRQL 1 year after injury. Instead, lower HRQL scores among patients with psychiatric co-morbidity appear to be mediated by baseline health status and injury severity.

Scoping review of the literature to ascertain how follow-up care is provided to major trauma patients post discharge from acute care

OBJECTIVES

Survival following traumatic injury has increased, requiring ongoing patient follow-up. While longitudinal outcomes of trauma patients are reported, little is known about optimal delivery of follow-up service for this group. The aim of this scoping review was to identify and describe the structure, process and outcomes of postdischarge follow-up services for patients who sustained major trauma.

EVIDENCE REVIEW

This scoping review was conducted by searching CINAHL, MEDLINE and EMBASE databases. Articles were screened by three independent reviewers. The data of selected articles were organised in the categories of the Donabedian quality framework: structure, processes and outcomes.

RESULTS

Twenty-six articles were included after screening by title/abstract then full text against the inclusion/exclusion criteria; 92% (n=24) were from the USA.Follow-up services were provided by designated trauma centres and delivered by a mixture of health disciplines. Delivery of follow-up was multimodal (in person/telehealth). Protocols and guidelines helped to deliver follow-up care for non-physician led services.Ongoing health issues including missed injuries, pain and infection were identified. No standardised criteria were established to determine recipients, the timing or frequency of follow-up was identified. Patients who engaged with follow-up services were more likely to participate in other health services. Patients reported satisfaction with follow-up care.

CONCLUSION

There are wide variations in how follow-up services for major trauma patients are provided. Further evaluation should focus on patient, family and organisational outcomes. Identifying who is most likely to benefit, when and how follow-up care is delivered are important next steps in improving outcomes.

Follow-up of severely injured patients can be embedded in routine hospital care: results from a feasibility study

OBJECTIVE

Understanding the longitudinal patient experience outcomes following major trauma can promote successful recovery. A novel, hospital-led telephone follow-up program was implemented by a multi-disciplinary clinical trauma service team at a Level I trauma center. This process evaluation examined what factors promoted or impeded the program's implementation.

METHODS

A prospective convergent mixed methods process evaluation design was used. Quantitative data included patient and injury demographics and program feasibility data such number of telephone calls attempted/completed and call duration. Qualitative data consisted of semi-structured interviews with program participants (staff, patients, caregivers) who had participated in the program. Descriptive statistics and thematic analysis were applied to quantitative and qualitative data respectively. Data were collected concurrently and merged in the results to understand and describe the implementation and sustainability of the program.

RESULTS

274 major trauma patients (ISS ≥ 12) were eligible for follow-up. A response rate of over 75% was achieved, with nurses responsible for most of the calls. Limited time and competing clinical demands were identified as barriers to the timely completion of the calls.

Participants valued the pre-existing trauma service/patient relationship, and this facilitated program implementation. Clinicians were motivated to evaluate their patient's recovery, whilst patients felt 'cared for' and 'not forgotten' post-hospital discharge. Teamwork and leadership were highly valued by the clinical staff throughout the implementation period as ongoing source of motivation and support.

Staff spontaneously developed the program to incorporate clinical follow up processes by providing guidance, advice and referrals to patients who indicated ongoing issues such as pain or emotional problems.

CONCLUSION

Telephone follow-up within a clinical trauma service team is feasible, accepted by staff and valued by patients and families. Despite time constraints, the successful implementation of this program is reliant on existing clinical/patient relationships, staff teamwork and leadership support.

Important Issues to Severe Trauma Survivors: A Qualitative Study

OBJECTIVE

Identify issues that are important to severe trauma survivors up to 3 years after the trauma.

BACKGROUND

Severe trauma is the first cause of disability-adjusted life years worldwide, yet most attention has focused on acute care and the impact on long-term health is poorly evaluated.

METHOD

We conducted a large-scale qualitative study based on semi-structured phone interviews. Qualitative research methods involve the systematic collection, organization, and interpretation of conversations or textual data with patients to explore the meaning of a phenomenon experienced by individuals themselves. We randomly selected severe trauma survivors (abbreviated injury score ≥3 in at least 1 body region) who were receiving care in 6 urban academic level-I trauma centers in France between March 2015 and March 2018. We conducted double independent thematic analysis. Issues reported by patients were grouped into overarching domains by a panel of 5 experts in trauma care. Point of data saturation was estimated with a mathematical model.

RESULTS

We included 340 participants from 3 months to 3 years after the trauma [median age: 41 years (Q1-Q3 24-54), median injury severity score: 17 (Q1-Q3 11-22)]. We identified 97 common issues that we grouped into 5 overarching domains: body and neurological issues (29 issues elicited by 277 participants), biographical disruption (23 issues, 210 participants), psychological and personality issues (21 issues, 147 participants), burden of treatment (14 issues, 145 participants), and altered relationships (10 issues, 87 participants). Time elapsed because the trauma, injury location, or in-hospital trauma severity did not affect the distribution of these domains across participants' answers.

CONCLUSIONS

This qualitative study explored trauma survivors' experiences of the long-term effect of their injury and allowed for identifying a set of issues that they consider important, including dimensions that seem overlooked in trauma research. Our findings confirm that trauma is a chronic medical condition that demands new approaches to post-discharge and long-term care.

Assessment of patient-reported outcomes after polytrauma - instruments and methods: a systematic review

OBJECTIVES

We (1) collected instruments that assess health-related quality of life (HRQoL), activities of daily living (ADL) and social participation during follow-up after polytrauma, (2) described their use and (3) investigated other relevant patient-reported outcomes (PROs) assessed in the studies.

DESIGN

Systematic Review using the Preferred Reporting Items for Systematic Review and Meta-Analysis guideline.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL, as well as the trials registers ClinicalTrials.gov and WHO ICTRP were searched from January 2005 to April 2018.

ELIGIBILITY CRITERIA

All original empirical research published in English or German including PROs of patients aged 18-75 years with an Injury Severity Score≥16 and/or an Abbreviated Injury Scale≥3. Studies with defined injuries or diseases (e.g. low-energy injuries) and some text types (e.g. grey literature and books) were excluded. Systematic reviews and meta-analyses were excluded, but references screened for appropriate studies.

DATA EXTRACTION AND SYNTHESIS

Data extraction, narrative content analysis and a critical appraisal (e.g. UK National Institute for Health and Care Excellence) were performed by two reviewers independently.

RESULTS

The search yielded 3496 hits; 54 publications were included. Predominantly, HRQoL was assessed, with Short Form-36 Health Survey applied most frequently. ADL and (social) participation were rarely assessed. The methods most used were postal surveys and single assessments of PROs, with a follow-up period of one to one and a half years. Other relevant PRO areas reported were function, mental disorders and pain.

CONCLUSIONS

There is a large variation in the assessment of PROs after polytrauma, impairing comparability of outcomes. First efforts to standardise the collection of PROs have been initiated, but require further harmonisation between central players. Additional knowledge on rarely reported PRO areas (e.g. (social) participation, social networks) may lead to their consideration in health services provision.

PROSPERO REGISTRATION NUMBER

CRD42017060825.

The effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis

BACKGROUND

Traumatic injury remains the leading cause of death, with more than five million deaths every year. Little is known about the comparative effectiveness in reducing mortality of trauma care systems at different stages of development. The objective of this study was to review the literature and examine differences in mortality associated with different stages of trauma system development.

METHOD

A systematic review of peer-reviewed population-based studies retrieved from MEDLINE, EMBASE, and CINAHL. Additional studies were identified from references of articles, through database searching, and author lists. Articles written in English and published between 2000 and 2020 were included. Selection of studies, data extraction, and quality assessment of the included studies were performed by two independent reviewers. The results were reported as odds ratio (OR) with 95 % confidence intervals (CI).

RESULTS

A total of 52 studies with a combined 1,106,431 traumatic injury patients were included for quantitative analysis. The overall mortality rate was 6.77% (n = 74,930). When patients were treated in a non-trauma centre compared to a trauma centre, the pooled statistical odds of mortality were reduced (OR 0.74 [95% CI 0.69-0.79]; p < 0.001). When patients were treated in a non-trauma system compared to a trauma system the odds of mortality rates increased (OR 1.17 [95% CI 1.10-1.24]; p < 0.001). When patients were treated in a post-implementation/initial system compared to a mature system, odds of mortality were significantly higher (OR 1.46 [95% CI 1.37-1.55]; p < 0.001).

CONCLUSION

The present study highlights that the survival of traumatic injured patients varies according to the stage of trauma system development in which the patient was treated. The analysis indicates a significant reduction in mortality following the introduction of the trauma system which is further enhanced as the system matures. These results provide evidence to support efforts to, firstly, implement trauma systems in countries currently without and, secondly, to enhance existing systems by investing in system development.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019142842 .

Assessing unmet rehabilitation needs and the feasibility of a telehealth rehabilitation consultation service for road trauma survivors recently discharged from hospital

PURPOSE

Persistent activity limitations are common among road trauma survivors, yet access to rehabilitation in hospital and in the community remains variable. This study aimed to identify unmet rehabilitation needs following road trauma and assess the feasibility of a novel rehabilitation consultation service delivered via telehealth following hospitalization.

METHODS

A pilot cohort study was conducted with survivors of road trauma who were hospitalized but did not receive formal inpatient rehabilitation. All participants received a multidisciplinary rehabilitation consultation via telehealth 1-3 weeks post-discharge, to assess rehabilitation needs and initiate treatment referrals as required. Functional and qualitative outcomes were assessed at baseline (1-7 days); one month and three months post-discharge.

RESULTS

38 participants were enrolled. All (100%) reported functional limitations at baseline; 86.5% were found to have unmet rehabilitation needs, and 75.7% were recommended rehabilitation interventions. Functional ability improved over time, but more than half the cohort continued to report activity limitations (67.6%), pain (64.7%) and/or altered mood (41.2%) for up to three months. Participants found the telehealth service to be acceptable, convenient, and helpful for recovery.

CONCLUSIONS

A high proportion of mild-moderate trauma survivors report unmet rehabilitation needs following hospital discharge. Telehealth appears to be a feasible, convenient and acceptable mode of assessing these needs.Implications for rehabilitationSurvivors of road-related injuries often experience ongoing impairments and activity limitations.Among those who don't receive rehabilitation in hospital, we found a high proportion (86.5%) had unmet rehabilitation needs after discharge.A telehealth rehabilitation service was feasible to deliver and could successfully identify unmet rehabilitation needs.The piloted telehealth intervention was viewed as acceptable, convenient and beneficial by patients.

Mortality and return to work in patients transported by emergency ambulance after involvement in a traffic accident

Introduction/background

Traffic accidents constitute a common reason for injury. Little is known about long-term outcomes for patients following a traffic accident. Therefore, in this present paper, we examine 1-day, 30-day and 1-year mortality, and return to work (RTW) during a 1-year period.

Methods

Patients (between 18 and 65 years of age) who had an ambulance dispatched to them following a traffic accident and who were employed prior to the accident were identified from the Electronic Prehospital Emergency Patient (amPHI™) database in the North Denmark Region (catchment population ≈600,000) during 2006–2014. Outcomes of 1- and 30- and 365-day mortality and 1-year return to work (RTW), with mortality as competing risk. We stratified by intensive care unit (ICU) admission; and the anatomical region of injury (head/neck, thorax, abdomen, extremities and multiple injuries) is reported.

Results

Of 6072 patients in our study population, 59 (1%) died within 1 day and 76 (1.3%) within 30 days; 88 (1.5%) were dead within a year.

Thirty-day mortality was 1.7% for the 290 patients admitted to the ICU, and 1.2% for the remaining 5782 patients.

Within the study population, RTW rate was 92.7% (N = 5984). RTW was 84.8% among 290 ICU-admitted patients versus 93.1% for the remaining 5782 patients.

RTW rate was 94.6% for the 1793 patients discharged with a diagnosis of head/neck injury. Of 671 patients with a discharge diagnosis for the thoracic region, 92.6% returned to work. Of 402 patients with abdominal injury diagnoses, 90.8% returned to work. Of 1603 patients discharged with a diagnosis of extremity injury, the RTW rate was 93.6%. Of 192 patients with a discharge diagnosis of injury in multiple regions, 91.7% returned to work.

Conclusion

Overall, mortality rates were low and RTW rates high in patients who had an ambulance dispatched due to a traffic accident. Those admitted to the ICU had the lowest RTW rate, yet still around 80% returned to work.

Predicting factors for major trauma patient mortality analyzed from trauma registry system

OBJECTIVE

We investigated the predictors of mortality in major trauma patients using a trauma registry system database.

METHODS

Data were obtained from the trauma registry of a level I trauma center for all patients aged ≥18 years admitted to an intensive care unit (ICU) between January 1, 2006 and December 31, 2013. Models were adjusted for patient demographics, injury mechanism, preexisting comorbidity, Glasgow coma scale (GCS), injury severity score (ISS), emergency department (ED) and ICU procedures, surgical procedures, and complications. Multivariate logistic regression analysis was used to determine predictors of mortality and odds ratios of its associated factors.

RESULTS

In total, 1561 patients met the inclusion criteria. The overall mortality rate was 13.4%. After controlling for all variables in a logistic regression model, the factors associated with increased mortality risk (P < 0.05) were age ≥ 45 years; ISS > 24; GCS score < 8 and 8-12; fall accident; preexisting comorbidity of renal insufficiency; ED cardiopulmonary resuscitation (CPR) procedures; ICU blood transfusion; and cardiovascular, respiratory, digestive system and infection complications.

CONCLUSION

Our data showed some predictors of patient mortality after major trauma, most of which were determined during the trauma event. Only those treatment complications may be improved when performing the treatment procedures.

Does the EQ-5D-5L benefit from extension with a cognitive domain: Testing a multi-criteria psychometric strategy in trauma patients

Purpose

This study investigated the psychometric yield of extension of the EQ-5D-5L with a cognitive domain (EQ-5D+C) in a mixed cohort of trauma patients with repeated data.

Methods

A stratified sample of patients that presented at the emergency department filled out a follow-up survey 6 and 12 months after trauma. The surveys included the EQ-5D-5L+C, EQ-VAS, and the impact of events scale-revised (IES-R), a validated post-traumatic stress disorder (PTSD) self-assessment scale. Generally, results of the EQ-5D and EQ-5D+C were compared. Psychometrics included the following: distributional features (ceiling/floor effects), discriminatory performance, convergent validity with the EQ-VAS as reference, and responsiveness to change. Psychometric properties were compared between predefined subgroups based on conditions with cognitive impact (Traumatic Brain Injury (TBI)/PTSD).

Results

In total, 1799 trauma patients responded 6 and 12 months after trauma, including 107 respondents with PTSD, and 273 with TBI. Six months post-trauma, ceiling of the EQ-5D (26.3%) was reduced with 2.2% with the additional cognitive domain. Using EQ-VAS as reference, convergent validity increased slightly with the addition of the cognitive domain: correlation increasing from 0.651 to 0.664. Cognitive level was found to slightly improve over time in TBI (delta: 0.04) and PTSD patients (delta: 0.05), while (almost) no change was found in patients without TBI and PTSD.

Conclusion

Adding a cognitive domain to the EQ-5D-5L slightly improved measurement properties and better captured change in health status for trauma patients with TBI and PTSD. Inclusion of the cognitive domain in the EQ-5D-5L when measuring in populations with cognitive problems should be considered.

A Call to Follow-Up: Results Regarding Trauma Clinic Follow-Up Patterns

The objective of this study was to assess the current practice pattern regarding posthospitalization follow-up of trauma patients among the members of the Eastern Association for the Surgery of Trauma (EAST). An anonymous online multiple-choice survey of EAST members in 2016 was conducted. Ten questions relating to the follow-up care of injured patients were presented to the Active, Senior, and Associate members of EAST. Data were screened for quantitative concerns prior to analysis. Of the 1,610 members surveyed, 289 responded (18%). Approximately 52% of respondents stated that their institution has a dedicated trauma follow-up clinic where most injured patients are seen after discharge. Less than 20% reported that nontrauma multidisciplinary providers are present in clinics. Most (89.5%) reported that follow-up is a single visit, unless a patient has long-standing issues. Only 3 respondents stated that patients are regularly seen 3+ months out from injury, and a significant minority (17.7%) acknowledged no set follow-up timeline. Only 3.6% of participants indicated that they have a psychologist embedded in the trauma team, and 11.5% reported that no system is currently in place to manage mental health. Despite more than 20 years of literature highlighting the long-term physical and mental health sequelae after trauma, these survey results demonstrate that there is a lack of standardized and multidisciplinary follow-up. Given the improvement in outcomes with the identification and treatment of these sequelae, greater attention should be paid to functional recovery, social and psychological well-being, and chronic pain.

Patterns and Predictors of Return to Work After Major Trauma: A Prospective, Population-based Registry Study

OBJECTIVE

To characterize patterns of engagement in work during the 4-year period after major traumatic injury, and to identify factors associated with those patterns.

BACKGROUND

Employment is an important marker of functional recovery from injury. There are few population-based studies of long-term employment outcomes, and limited data on the patterns of return to work (RTW) after injury.

METHODS

A population-based, prospective cohort study using the Victorian State Trauma Registry. A total of 1086 working age individuals, in paid employment or full-time education before injury, were followed-up through telephone interview at 6, 12, 24, 36, and 48 months post-injury. Responses to RTW questions were used to define 4 discrete patterns: early and sustained; delayed; failed; no RTW. Predictors of RTW patterns were assessed using multivariate multinomial logistic regression.

RESULTS

Slightly more than half of respondents (51.6%) recorded early sustained RTW. A further 15.5% had delayed and 13.3% failed RTW. One in 5 (19.7%) did not RTW. Compared with early sustained RTW, predictors of delayed and no RTW included being in a manual occupation and injury in a motor vehicle accident. Older age and receiving compensation predicted both failed and no RTW patterns. Preinjury disability was an additional predictor of failed RTW. Presence of comorbidity was an additional predictor of no RTW.

CONCLUSIONS

A range of personal, occupational, injury, health, and compensation system factors influence RTW patterns after serious injury. Early identification of people at risk for delayed, failed, or no RTW is needed so that targeted interventions can be delivered.

Routine incorporation of longer-term patient-reported outcomes into a Dutch trauma registry

Purpose

Routine collection of post-discharge patient-reported outcomes within trauma registries can be used to benchmark quality of trauma care. This process is dependent on geographic and cultural context, but results are lacking regarding the European experience. We aimed to investigate the feasibility of routine inclusion of longer-term patient-reported health-related quality of life (HRQoL) in a Dutch National Trauma Database (DNTD) and to characterize these outcomes in a prospective cohort study.

Methods

All adult patients (≥ 18 years) who presented for traumatic injury in 2015–2016 and met the inclusion criteria of the DNTD were included. Inclusion criteria of the DNTD are presence of traumatic injury, hospital presentation within 48 h from trauma and hospital admission for treatment of traumatic injury or immediate mortality from traumatic injury after presentation. Exclusion criteria were death, mental impairment, insufficient command of Dutch language and residency outside the Netherlands. Primary outcomes were process-related measures of feasibility (response rate, response methods and reasons for non-response). Secondary outcomes were HRQoL measures [EuroQOL 5-Dimensions 3-Level (EQ-5D-3L) with added cognitive dimension and Visual Analogue Scale (EQ-VAS)].

Results

2025 unique patients met the initial inclusion criteria, with 1753 patients eligible for follow-up. Of these, 1315 patients participated (response rate 75%). The majority of questionnaires, 990 (75%), were completed on paper, with an additional 325 (25%) through telephone interviews. Primary reason for non-response was lack of contact information (245/438 non-responders; 56%). Median EQ-5D score was 0.81 (IQR 0.68–1.00) (mean 0.74; SD 0.31) and median EQ-VAS score was 78 (IQR 65–90). Compared to a Dutch reference population (mean EQ-5D = 0.87), EQ-5D scores were significantly lower (p < 0.001).

Conclusions

Routine collection of HRQoL is feasible within European health systems, like in the Netherlands. Further integration of these measures into trauma registries may aid worldwide benchmarking of trauma care quality.

Health-related quality of life in injury patients: the added value of extending the EQ-5D-3L with a cognitive dimension

Introduction

The EQ-5D is frequently used to understand the development of health-related quality of life (HRQL) following injury. However, the lack of a cognition dimension is generally felt as disadvantageous as many injuries involve cognitive effects. We aimed to assess the added value of a cognitive dimension in a cohort of injury patients.

Methods

We analyzed EQ-5D-3L extended with cognition (EQ-5D + C) dimension responses of 5346 adult injury patients. We studied dimension dependency, assessed the additional effect of the cognitive dimension on the EQ-VAS, and, using the EQ-VAS as a dependent variable, determined the impact of EQ-5D and EQ-5D + C attributes in multivariate regression analyses.

Results

Extreme cognitive problems combined with no problems on other dimensions are uncommon, whereas severe problems on other dimensions frequently occur without cognitive problems. The EQ-VAS significantly decreased when cognitive problems emerged. Univariate regression analyses indicated that all EQ-5D + C dimensions were significantly associated with the EQ-VAS. Exploratory analyses showed that using any set of five of the six EQ-5D + C dimensions resulted in almost identical explained variance, and adding the remaining 6th dimension resulted in a similar additional impact.

Conclusions

The addition of the cognition dimension increased the explanatory power of the EQ-5D-3L. Although the increase in explanatory power was relatively small after the cognition dimension was added, the decrease of HRQoL (measured with the EQ-VAS) resulting from cognitive problems was comparable to the decreases resulting from other EQ-5D dimensions.

Patient-centred outcomes for prehospital trauma trials: A systematic review and patient involvement exercise

Introduction

Outcome measures are used in clinical trials to determine efficacy of interventions. We aimed to determine which outcome measures in prehospital major trauma trials have been reported in the literature, and which of these are most patient-centred.

Methods

A systematic review identified outcomes reported in prehospital clinical trials of major trauma patients. A search was undertaken using Medline, Embase, clinicaltrials.gov, Web of Science and Google Scholar. Data were summarised by dividing outcomes into common themes which were presented to a Patient and Public Involvement group consisting of trauma survivors and their relatives. This group ranked the categories of outcomes in order of most importance, and agreed consensus statements regarding these outcome measures.

Results

There were 27 eligible studies, including 9,537 patients. Outcome measures were divided into nine categories: quality of life; length of stay; mortality/survival; physiological parameters; fluid/blood product requirements; complications; health economics; safety and feasibility; and intervention success. Of these, mortality/survival was the most commonly reported category, but over multiple timescales. The Patient and Public Involvement group agreed that the most important category was quality of life, and that mortality/survival should only be reported if concurrently reported with longer term quality of life. Length of stay and health economics were not considered important.

Conclusions

Outcome measures in prehospital clinical trials in major trauma have been heterogeneous, inconsistent, and not necessarily patient-centred. Trauma survivors considered quality of life and mortality most important when combined. Consensus is required for consistent, patient-centred, outcome measures in order to investigate interventions of meaningful impact to patients.

Long-term health status and trajectories of seriously injured patients: A population-based longitudinal study

BACKGROUND

Improved understanding of the quality of survival of patients is crucial in evaluating trauma care, understanding recovery patterns and timeframes, and informing healthcare, social, and disability service provision. We aimed to describe the longer-term health status of seriously injured patients, identify predictors of outcome, and establish recovery trajectories by population characteristics.

METHODS AND FINDINGS

A population-based, prospective cohort study using the Victorian State Trauma Registry (VSTR) was undertaken. We followed up 2,757 adult patients, injured between July 2011 and June 2012, through deaths registry linkage and telephone interview at 6-, 12-, 24-, and 36-months postinjury. The 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3L) was collected, and mixed-effects regression modelling was used to identify predictors of outcome, and recovery trajectories, for the EQ-5D-3L items and summary score. Mean (SD) age of participants was 50.8 (21.6) years, and 72% were male. Twelve percent (n = 333) died during their hospital stay, 8.1% (n = 222) of patients died postdischarge, and 155 (7.0%) were known to have survived to 36-months postinjury but were lost to follow-up at all time points. The prevalence of reporting problems at 36-months postinjury was 37% for mobility, 21% for self-care, 47% for usual activities, 50% for pain/discomfort, and 41% for anxiety/depression. Continued improvement to 36-months postinjury was only present for the usual activities item; the adjusted relative risk (ARR) of reporting problems decreased from 6 to 12 (ARR 0.87, 95% CI: 0.83-0.90), 12 to 24 (ARR 0.94, 95% CI: 0.90-0.98), and 24 to 36 months (ARR 0.95, 95% CI: 0.95-0.99). The risk of reporting problems with pain or discomfort increased from 24- to 36-months postinjury (ARR 1.06, 95% CI: 1.01, 1.12). While loss to follow-up was low, there was responder bias with patients injured in intentional events, younger, and less seriously injured patients less likely to participate; therefore, these patient subgroups were underrepresented in the study findings.

CONCLUSIONS

The prevalence of ongoing problems at 3-years postinjury is high, confirming that serious injury is frequently a chronic disorder. These findings have implications for trauma system design. Investment in interventions to reduce the longer-term impact of injuries is needed, and greater investment in primary prevention is needed.

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.

Association between trauma and socioeconomic deprivation: a registry-based, Scotland-wide retrospective cohort study of 9,238 patients

Background

Trauma remains a leading cause of morbidity and mortality in the UK and throughout the world. Socioeconomic deprivation has been linked with many types of ill-health and previous studies have shown an association with injury in other parts of the world. The aim of this study was to investigate the association between socioeconomic deprivation and trauma incidence and case-fatality in Scotland.

Methods

The study included nine thousand two hundred and thirty eight patients attending Emergency Departments following trauma across Scotland in 2011-12. A retrospective cohort study was conducted using secondary data extracted from the national trauma registry. Postcode of residence was used to generate deciles using the Scottish Index of Multiple Deprivation. The incidence rate ratio (IRR) was calculated to allow comparison of incidence of trauma across SIMD deciles. For mortality, observed: expected ratios were obtained using observed mortality in the cohort and expected deaths using probability of survival based on Trauma and Injury Severity Score (TRISS) method.

Results

Compared with the most deprived decile, the least deprived had an incidence rate ratio (IRR) for all trauma of 0.43 (95 % CI 0.32–0.58, p < 0.001). The association was stronger for penetrating trauma (IRR 0.07, 95 % CI .01–0.56, p = 0.011). There was a significant interaction between age, gender and SIMD. For case fatality, multivariate logistic regression showed that, severity of trauma (ISS > 15) OR 18.11 (95 % CI 13.91 to 23.58) and type of injury (Penetrating versus blunt injury) OR 2.07 (95 % CI 1.15 to 3.72) remain as independent predictors of case fatality in this dataset.

Discussion

Our data shows a higher incidence of trauma amongst a socioeconomically deprived population, in keeping with other areas of the world. In our dataset, outcome, as measured by in-hospital mortality, does not appear to be associated with socioeconomic deprivation.

Conclusion

In Scotland, populations living in socioeconomically deprived areas have a higher incidence of trauma, especially penetrating trauma, requiring hospital attendance. Case fatality is associated with more severe trauma and penetrating trauma, but not socioeconomic deprivation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0275-7) contains supplementary material, which is available to authorized users.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review

BACKGROUND

Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear.

AIMS

This research aims to identify the impact of trauma systems on the health outcomes of children following severe injury.

METHODS

Integrative review with data sourced from Medline, Embase, CINAHL, Scopus and hand searched references. Abstracts were screened for inclusion/exclusion criteria with fifty nine articles appraised for quality, analysed and synthesised into 3 main categories.

RESULTS

The key findings from this review include: (1) a lack of consistency of prehospital and inhospital triage criteria for severely injured children leading to missed injuries, secondary transfer and poor utilisation of finite resources; (2) severely injured children treated at paediatric trauma centres had improved outcomes when compared to those treated at adult trauma centres, particularly younger children; (3) major causes of delays to secondary transfer are unnecessary imaging and failure to recognise the need for transfer; (4) a lack of functional or long term outcomes measurements identified in the literature.

CONCLUSIONS

Research designed to identify the best processes of care and describe the impacts of trauma systems on the long term health outcomes of severely injured children is required. Ideally all phases of care including prehospital, paediatric triage trauma criteria, hospital type and interfacility transfer should be included, focusing on timeliness and appropriateness of care. Outcome measures should include long term functional outcomes in addition to mortality.

Defining major trauma using the 2008 Abbreviated Injury Scale

BACKGROUND

The Injury Severity Score (ISS) is the most ubiquitous summary score derived from Abbreviated Injury Scale (AIS) data. It is frequently used to classify patients as 'major trauma' using a threshold of ISS >15. However, it is not known whether this is still appropriate, given the changes which have been made to the AIS codeset since this threshold was first used. This study aimed to identify appropriate ISS and New Injury Severity Score (NISS) thresholds for use with the 2008 AIS (AIS08) which predict mortality and in-hospital resource use comparably to ISS >15 using AIS98.

METHODS

Data from 37,760 patients in a state trauma registry were retrieved and reviewed. AIS data coded using the 1998 AIS (AIS98) were mapped to AIS08. ISS and NISS were calculated, and their effects on patient classification compared. The ability of selected ISS and NISS thresholds to predict mortality or high-level in-hospital resource use (the need for ICU or urgent surgery) was assessed.

RESULTS

An ISS >12 using AIS08 was similar to an ISS >15 using AIS98 in terms of both the number of patients classified major trauma, and overall major trauma mortality. A 10% mortality level was only seen for ISS 25 or greater. A NISS >15 performed similarly to both of these ISS thresholds. However, the AIS08-based ISS >12 threshold correctly classified significantly more patients than a NISS >15 threshold for all three severity measures assessed.

CONCLUSIONS

When coding injuries using AIS08, an ISS >12 appears to function similarly to an ISS >15 in AIS98 for the purposes of identifying a population with an elevated risk of death after injury. Where mortality is a primary outcome of trauma monitoring, an ISS >12 threshold could be adopted to identify major trauma patients.

LEVEL OF EVIDENCE

Level II evidence--diagnostic tests and criteria.

Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system

BACKGROUND

According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains.

METHODS

Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients.

RESULTS

Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS).

CONCLUSION

Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes.

LEVEL OF EVIDENCE

Prognostic study, level III.

Health status and return to work in trauma patients at 3 and 6 months post-discharge: an Australian major trauma centre study

INTRODUCTION

The aim of this study was to describe post-discharge outcomes, and determine predictors of 3 and 6 months health status outcomes in a population of trauma patients at an inner city major trauma centre.

METHODS

This was a prospective cohort study of adult trauma patients admitted to this hospital with 3 and 6 months post-discharge outcomes assessment. Outcome measures were the Physical Component Scores (PCS) and Mental Component Scores (MCS) of the Short Form 12, EQ-5D, and return to work (in any capacity) if working prior to injury. Repeated measures mixed models and generalised estimating equation models were used to determine predictors of outcomes at 3 and 6 months.

RESULTS

One hundred and seventy-nine patients were followed up. Patients with lower limb injuries reported lower mean PCS scores between 3 and 6 months (coefficient -4.21, 95 % CI -7.58, -0.85) than those without lower limb injuries. Patients involved in pedestrian incidents or assaults and those with pre-existing mental health diagnoses reported lower mean MCS scores. In adjusted models upper limb injuries were associated with reduced odds of return to work at 3 and 6 months (OR 0.20, 95 % CI 0.07, 0.57) compared to those without upper limb injuries.

DISCUSSION

Predictors of poorer physical health status were lower limb injuries and predictors of mental health were related to the mechanism of injury and past mental health. Increasing injury severity score and upper limb injuries were the only predictors of reduced return to work. The results provide insights into the feasibility of routine post-discharge follow-up at a trauma service level.

Quality of life after mild to moderate trauma

INTRODUCTION

To evaluate potential reduction in health-related quality of life (HRQOL) after a mild to moderate trauma.

MATERIALS AND METHODS

Follow-up study of a cohort of 153 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to February 2012. After 6 months from the event, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted. Patients reported their HRQOL both at present and before trauma. Scores ≥ 50 represent no disability; 40-49, mild disability; 30-39, moderate disability; and below 30, severe disability.

RESULTS

Before the event 143 (93%) subjects reported a normal PCS and MCS. After the events, a significantly lower proportion of patients maintained a normal PCS and MCS values (52 and 68%, all p<0.01). One, two, three and four PCS items worsened in 14%, 15%, 18% and 38% of the study population, while one, two, three or four MCS dimensions worsened in 12%, 19%, 19% and 24%. We identified 109 subjects (N+), which showed normal PCS and MCS values before trauma, in the absence of any pre-existing medical condition. After the event, we observed a significant PCS (before: 54, standard deviation, SD 6; after 43, SD 11, p<0.0001) and MCS (before: 55, SD 7; after 47, SD 11, p<0.0001) worsening among N+ subjects. Distribution across the four disability categories was 52, 24, 17 and 6% for MCS score and 38, 25, 27 and 11% for PCS score: overall 8 (7%) patients reported a moderate disability and 5 (5%) reported a severe disability in both dimensions. Compared with subjects with preserved values, patients with an abnormal (<39) HRQOL were older, showed a higher prevalence of female gender and pre-existing medical conditions and a worst Sequential Organ Failure Assessment score. An advanced age (OR 1.033, 95% CI 1.010-1.057, p=0.005) and a higher SOFA T1 score (OR 1.500, 95% CI 1.027-2.190, p=0.036) were independently associated with a worsening PCS.

CONCLUSIONS

After a mild trauma, we evidenced a relevant reduction in HRQOL; an advanced age and a higher degree of organ dysfunction were independently associated with HRQOL deterioration.

Comparison of long-term outcomes following traumatic injury: what is the unique experience for those with brain injury compared with orthopaedic injury?

OBJECTIVE

Whilst it has been well-demonstrated that traumatic brain injury (TBI) results in long-term cognitive, behavioural and emotional difficulties, less is understood about how these outcomes differ from those following traumatic orthopaedic injury (TOI). The aim of this study was to compare self-reported outcomes at 5-10 years post-injury for those with TBI, TOI, and uninjured controls. It was hypothesised that participants with TBI would have greater cognitive difficulties; participants with TOI and TBI would have similar functional and physical outcomes, both being poorer than controls; and participants with TBI would have poorer psychosocial outcomes than those with TOI.

PARTICIPANTS AND METHODS

Eighty-eight individuals with complicated mild to severe TBI and 96 with TOI recruited during inpatient rehabilitation were followed up 5-10 years post-injury, together with 48 controls followed over a similar period. Self-report measures of global functioning (GOS-E), quality of life (SF-36), psychological wellbeing (SCL-90-R, HADS, PCL-S), psychosocial difficulties (SIP), cognitive difficulties (SF-36 COG), pain (BPI), and fatigue (FSS) were administered.

RESULTS

Outcomes for individuals with TBI and TOI differed significantly from controls, with poorer global functioning, and greater psychological distress and interference from pain. Only participants with TBI reported greater cognitive difficulties and anxiety than controls, and were less likely to be employed or in a relationship. Participants with TBI reported greater anxiety, PTSD, psychological distress and psychosocial difficulties than those with TOI.

CONCLUSIONS

Both TOI and TBI cause long-term disability, interference from pain, and psychological distress. However, cognitive impairments, unemployment, lack of long-term relationships, anxiety and PTSD are more substantial long-term problems following TBI. Findings from this study have implications for managing risks associated with these injury groups and tailoring rehabilitation to improve long-term outcomes.

Health outcome after major trauma: what are we measuring?

Importance

Trauma is a global disease and is among the leading causes of disability in the world. The importance of outcome beyond trauma survival has been recognised over the last decade. Despite this there is no internationally agreed approach for assessment of health outcome and rehabilitation of trauma patients.

Objective

To systematically examine to what extent outcomes measures evaluate health outcomes in patients with major trauma.

Data Sources

MEDLINE, EMBASE, and CINAHL (from 2006–2012) were searched for studies evaluating health outcome after traumatic injuries.

Study selection and data extraction

Studies of adult patients with injuries involving at least two body areas or organ systems were included. Information on study design, outcome measures used, sample size and outcomes were extracted. The World Health Organisation International Classification of Function, Disability and Health (ICF) were used to evaluate to what extent outcome measures captured health impacts.

Results

34 studies from 755 studies were included in the review. 38 outcome measures were identified. 21 outcome measures were used only once and only five were used in three or more studies. Only 6% of all possible health impacts were captured. Concepts related to activity and participation were the most represented but still only captured 12% of all possible concepts in this domain. Measures performed very poorly in capturing concepts related to body function (5%), functional activities (11%) and environmental factors (2%).

Conclusion

Outcome measures used in major trauma capture only a small proportion of health impacts. There is no inclusive classification for measuring disability or health outcome following trauma. The ICF may provide a useful framework for the development of a comprehensive health outcome measure for trauma care.

Predictors of transfer to rehabilitation for trauma patients admitted to a level 1 trauma centre--a model derivation and internal validation study

OBJECTIVE

Determine the predictors of transfer to rehabilitation in a cohort of trauma patients and derive a risk score based clinical prediction tool to identify such patients during the acute phase of injury management.

METHODS

Trauma registry data at a single level one trauma centre were obtained for all patients aged between 15 and 65 years admitted due to injury between 2007 and 2011. Multivariable logistic regression with stepwise selection was performed to derive a prediction model for transfer to rehabilitation. The model was tested on a validation dataset using receiver operator characteristic analyses and bootstrap cross validation on the entire dataset. A clinical prediction risk score was developed based on the final model.

RESULTS

There were 4900 patients included in the study. Variables found to be the strongest predictors of rehabilitation after logistic regression with stepwise selection were pelvic injuries (OR 12.6 95% CI 6.2, 25.2 p<0.001), need for intensive care unit admission (OR 7.2 95% CI 4.2, 12.3 p<0.001) and neurosurgical operation (OR 10.5 95% CI 4.7, 23.1 p<0.001). After bootstrap cross validation the mean AUC was 0.86 (95% CI 0.84, 0.89). The model had a sensitivity of 89% and specificity of 64%.

CONCLUSION

Intensive unit admission, neurosurgical operation, pelvic injuries and other lower limb injuries were the most important predictors of the need for rehabilitation after trauma. The prediction model has good overall sensitivity, discrimination and could be further validated for use in clinical practice.

The concurrent validity and responsiveness of the high-level mobility assessment tool for mobility limitations in people with multitrauma orthopedic injuries

OBJECTIVE

To investigate the concurrent validity, responsiveness, and ceiling effect of the revised High-Level Mobility Assessment Tool (HiMAT) in persons after orthopedic multitrauma.

DESIGN

Cross-sectional sample of convenience.

SETTING

A large tertiary rehabilitation hospital.

PARTICIPANTS

Forty-three participants with orthopedic multitrauma lower limb injuries that resulted from motor vehicle accidents.

METHODS

This study compared the concurrent validity, responsiveness, and ceiling effects of the revised HiMAT, motor subsection of the Functional Independence Measure (FIM) instrument. Performances for all participants were concurrently scored on the motor FIM, revised HiMAT, and the Lower Extremity Functional Scale (LEFS) at initial testing, and 6 and 12 weeks after the decision to fully bear weight.

MAIN OUTCOME MEASUREMENTS

Revised HiMAT, motor FIM, and LEFS.

RESULTS

The correlation between the revised HiMAT and the motor FIM was moderate (r = 0.49; P <.001) and partly induced by a ceiling effect in the motor FIM. After 12 weeks of full weight bearing, 51.2% of participants achieved the maximum score on the motor FIM. The correlation between the revised HiMAT and LEFS was weak (r = 0.39; P = .012), which indicated a weak relationship between self-reported mobility problems and actual performance. The revised HiMAT was more responsive than the motor FIM and the LEFS, based on the proportion of persons who exceeded the minimal detectable change score over a period of 6 and 12 weeks.

CONCLUSION

The revised HiMAT is more responsive to change than the LEFS and motor FIM, and less susceptible to a ceiling effect than the motor FIM for persons with orthopedic multitrauma. It has poor-to-moderate concurrent validity with the LEFS and motor FIM, which suggests that it may be measuring a different aspect of mobility.

Developing process guidelines for trauma care in the Netherlands for severely injured patients: results from a Delphi study

BACKGROUND

In organised trauma systems the process of care is the key to quality. Nevertheless, the optimal process of trauma care remains unclear due to lack of or inconclusive evidence. Because monitoring and improving the performance of a trauma system is complex, this study aimed to develop consensus-based process guidelines for trauma care in the Netherlands for severely injured patients.

METHODS

A five-round Delphi study was conducted with 141 participants that represent all professions involved in trauma care. Sensitivity analyses were carried out to evaluate whether consensus extended across all professions and to detect possible bias.

RESULTS

Consensus was reached on 21 guidelines within 4 categories: timeliness, actions, competent teams and interdisciplinary process. Timeliness guidelines set specific critical limits and definitions for 10 time intervals in the time period from an emergency call until the patient leaves the trauma room. Action guidelines reflect aspects of appropriate care and strongly rely on the international Advanced Trauma Life Support principles. Competence guidelines include flow charts to assess the competence of prehospital and emergency department teams. Essential to competent teams are education and experience of all team members. The interdisciplinary process guideline focuses on cooperation, communication and feedback within and between all professions involved. Consensus was extended across all professions and no bias was detected.

CONCLUSIONS

In this Delphi study, a large expert panel agreed on a set of guidelines describing the optimal process of care for severely injured trauma patients in the Netherlands. In addition to time intervals and appropriate actions, these guidelines emphasise the importance of team competence and interdisciplinary processes in trauma care. The guidelines can be seen as a description of a best practice and a new field standard in the Netherlands. The next step is to implement the guidelines and monitor the performance of the Dutch trauma system based on the guidelines.

[Risk factors for the deterioration of quality of life in critical trauma patients. Assessment at 6 and 12 months after discharge from the intensive care unit]

OBJECTIVE

To evaluate factors influencing the deterioration of health-related quality of life (HRQoL) in trauma patients admitted to an ICU.

DESIGN

A prospective observational study was carried out.

SETTING

The combined medical/surgical ICU in a university secondary hospital with 24-hour neurosurgery service.

PATIENTS

Trauma patients admitted to the ICU during a two-year period. HRQoL assessment prior to admission to the ICU, and at 6 and 12 months after discharge.

MAIN VARIABLES

Demographic variables, type and severity of injury (AIS), severity (APACHE II, ISS, TRISS), length of stay, procedures, mortality and HRQoL according to the SF-36 and EQ-5D.

RESULTS

We completed the monitoring of 110 patients that showed significant impairment of their HRQoL in all the dimensions assessed. According to the SF-36, physical role was more deteriorated at 12 months, but the mental component decreased more than the physical component after 6 months. The VAS scale of the EQ-5D decreased to 55 at 6 months (19) and increased to 66 at 12 months (17). In the multiple logistic regression analysis, the variables associated with poorer HRQoL were age > 45 years, TRISS > 10, previous porer quality of life, and serious injuries in the extremities.

CONCLUSIONS

Patients showed marked deterioration of their HRQoL at 6 months, followed by overall improvement at 12 months, though without reaching their previous state. The factors that determine poorer quality of life include age, severity, previous HRQoL, and severe injuries in the extremities.

Measuring acute rehabilitation needs in trauma: preliminary evaluation of the Rehabilitation Complexity Scale

BACKGROUND

Injury severity, disability and care dependency are frequently used as surrogate measures for rehabilitation requirements following trauma. The true rehabilitation needs of patients may be different but there are no validated tools for the measurement of rehabilitation complexity in acute trauma care. The aim of the study was to evaluate the potential utility of the Rehabilitation Complexity Scale (RCS) version 2 in measuring acute rehabilitation needs in trauma patients.

METHODS

A prospective observation study of 103 patients with traumatic injuries in a Major Trauma Centre. Rehabilitation complexity was measured using the RCS and disability was measured using the Barthel Index. Demographic information and injury characteristics were obtained from the trauma database.

RESULTS

The RCS was closely correlated with injury severity (r=0.69, p<0.001) and the Barthel Index (r=0.91, p<0.001). However the Barthel was poor at discriminating between patients rehabilitation needs, especially for patients with higher injury severities. Of 58 patients classified as 'very dependent' by the Barthel, 21 (36%) had low or moderate rehabilitation complexity. The RCS correlated with acute hospital length of stay (r=0.64, p=<0.001) and patients with a low RCS were more likely to be discharged home. The Barthel which had a flooring effect (56% of patients classified as very dependent were discharged home) and lacked discrimination despite close statistical correlation.

CONCLUSION

The RCS outperformed the ISS and the Barthel in its ability to identify rehabilitation requirements in relation to injury severity, rehabilitation complexity, length of stay and discharge destination. The RCS is potentially a feasible and useful tool for the assessment of rehabilitation complexity in acute trauma care by providing specific measurement of patients' rehabilitation requirements. A larger longitudinal study is needed to evaluate the RCS in the assessment of patient need, service provision and trauma system performance.

Validity of outcome measures used to assess one and six month outcomes in orthopaedic trauma patients

INTRODUCTION

To evaluate the validity of the 12-item Short Form Health Survey (SF-12), Sickness Impact Profile (SIP) and the Short Musculoskeletal Functional Assessment Questionnaire (SMFA) for use in an orthopaedic trauma population.

MATERIALS AND METHODS

A prospective validation trial was completed at a Level 1 adult trauma centre in Melbourne, Australia. One hundred and fifty four patients with orthopaedic trauma managed or followed-up by an orthopaedic unit were prospectively recruited. Patients with pathological fractures related to metastatic disease and/or an isolated orthopaedic injury, a documented history of mental illness or dementia or those for whom follow-up was likely to be difficult were excluded. The SF-12, SIP and SMFA were administered by a trained interviewer at one and six months. Each questionnaire was scored for the physical and mental components and then compared for content and construct validity at each time point.

RESULTS

Complete data were collected for 134 patients at one and six months. The one and six month component scores correlated strongly between the SF-12 physical, SIP physical (r=0.513-0.669) and SMFA dysfunction (r=0.529-0.778); the SF-12 mental, SIP mental (r=0.643-0.719) and SMFA bother (r=0.564-0.602) components. The strength of association was greater for the six month time point compared to the one month measure. The SF-12 demonstrated no ceiling or floor effects, and provided a lower time burden on participants and researchers when compared to the SIP and SMFA.

CONCLUSIONS

For large population-based surveillance research into orthopaedic injury the SF-12 provides a valid and versatile tool.

Long-term survival and health-related quality of life 6 to 9 years after trauma

BACKGROUND

Trauma systems have improved short-term survival of the severely injured but knowledge on long-term outcome is limited. This study aimed to assess outcome 6 years to 9 years after moderate to severe injury in terms of survival, Health-Related Quality of Life (HRQOL) and employment status.

METHODS

Patients admitted to Aarhus Level I Trauma Center in 1998 to 2000, aged 15 years or more, with an Injury Severity Score (ISS) ≥9 were included. Patients were divided into three groups based on ISS (ISS, 9-15; ISS, 16-24; ISS >24). Survival status was obtained from the Danish Central Person Registry. HRQOL was measured with the Short Form 36 (SF-36) questionnaire, which was mailed to survivors 6 years to 9 years after admission and compared with a matched control group.

RESULTS

Three hundred twenty-two patients were included. Seventy-one percentage were men, median age was 34 years (range, 15-89 years), median ISS was 17 (range, 9-75). In-hospital survival was 85%. After a median of 7.3 years, overall survival was 78%. After hospital discharge, no difference in survival was found between the three patient groups.Sixty-nine percentage of the contacted patients completed the SF-36. Mean SF-36 scores were significantly lower in the patient group than in the control group in all eight SF-36 domains (p < 0.001). Return to employment or education was 52%, whereas 20% of the patients reported to be on early retirement.

CONCLUSION

Six years to nine years after traumatic injury, 78% of the patients were alive. HRQOL was significantly lower for injured patients than a matched control group. Twenty percentage of the patients retired early.

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.

Functional outcome and quality of life in victims of terrorist explosions as compared to conventional trauma

BACKGROUND

Following trauma, the number of preventable deaths is low. Outcome should also be measured in terms of quality of life (QoL). Studies analyzing QoL in trauma patients have been published, but little is known about the long term QoL of victims of terrorist attacks.

METHODS

This is a case-control study of casualties of the March 11, 2004 attacks in Madrid. Patients treated for other trauma with similar age and Injury Severity Score (ISS), served as controls. Patients were assessed using the POLO-Chart (VAS, SF-36 and TOP).

RESULTS

Fifty-eight patients were included, 32 casualties admitted following the March 11, 2004 attacks and 26 controls. Both groups were comparable in age (average = 37), ISS (average = 23) and time from trauma (average = 1,770 days). Subjects demonstrated lower scores for the VAS, and the SF-36 clusters social functioning, role emotional and mental health. There was a tendency towards higher prevalence of symptoms associated to posttraumatic stress disorder (PTSD) in subjects (p = 0.056). Subjects suffered from higher residual pain in the head region (p = 0.032). Strong association was found between the presence of symptoms associated to depression, anxiety and PTSD and worse QoL (p < 0.001).

CONCLUSION

Subjects present more emotional distortions, residual pain in the head region and a tendency towards a worsened perception of their own health and wellness. They also present symptoms associated to PTSD more frequently. The presence of symptoms associated to PTSD, depression or anxiety was an independent variable related to lower QoL in both groups.

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.

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.

Follow-up disparities after trauma: a real problem for outcomes research

INTRODUCTION

The objectives of this study were to (1) determine risk factors associated with failure to follow-up (FTF) after traumatic injury and (2) in those patients who do follow up, to determine if information within the electronic medical record (EMR) is an adequate data-collection tool for outcomes research.

METHODS

A 6-year retrospective analysis was conducted on all admitted trauma patients using data from the trauma registry, National Death Index, 2000 Census Data, and the EMR. Bivariate and logistic regression analyses identified risk factors for FTF. A subgroup analysis evaluated the utility of using the EMR to determine basic functional outcomes (Glasgow outcome scale, diet, ambulation, and employment status).

RESULTS

A total of 14,784 patients were discharged, and 61% had follow-up appointments. Lower income, higher poverty rates, and lower education were significantly (P<.05) associated with FTF. Logistic regression analysis (excluding census data) identified that older age, lower Injury Severity Score, less severe head injury, nonwhite race, blunt injury, death after discharge, zip code within 25 miles, and patients discharged to home independently predicted FTF after traumatic injury. A subgroup analysis of the EMR showed the inability to reliably determine functional outcomes.

CONCLUSIONS

There are several disparities related to follow-up after trauma. Furthermore, charting deficiencies, even with an EMR, highlight the weaknesses of data available for trauma outcomes research. Trauma process improvement programs could target patients at risk for not following up and use a structured electronic outpatient note.