Quality of life two years after severe trauma: a single-centre evaluation

[What is the Impact of Early Rehabilitation and Rehabilitation Management on Outcome after Polytrauma?]

Patients with polytrauma and other severe musculoskeletal injuries often suffer from permanently impaired functionality and quality of life. This results in long-term damage with high costs for the social system. A narrative review will show the impact of targeted coordination in the rehabilitation process from early rehabilitation to long-term case management on patients with severe musculoskeletal injuries. A systematic database search of MEDLINE and the Cochrane Library identified studies of multiple injuries that compared the outcome of early rehabilitation and rehabilitation management with other types of care. Studies of predominantly neurologic injury types, soldiers, and mild injury types with an ISS less than 9 or AIS less than 3 were excluded. Four studies were included and analyzed. They looked at functionality, quality of life, psychological impairment, and costs. While treatment and total costs were higher for early rehabilitation and rehabilitation management, no better results for improved function, psychological condition and quality of life could be demonstrated in the group comparison. An effect estimate is possible due to small group differences and the small number of individual studies included. There are insufficient studies to draw conclusions about the effectiveness of the early interventions. Future studies are needed that take into greater account structures of standard care and national differences in social security systems, as well as the chosen rehabilitation management interventions.

Implementation of health-related quality of life in the German TraumaRegister DGU® - first results of a pilot study

BACKGROUND

Approximately 30,000 people are affected by severe injuries in Germany each year. Continuous progress in prehospital and hospital care has significantly reduced the mortality of polytrauma patients. With increasing survival rates, the functional outcome, health-related quality (hrQoL) of life and ability to work are now gaining importance. Aim of the study is, the presentation of the response behavior of seriously injured patients on the one hand and the examination of the factors influencing the quality of life and ability to work 12 months after major trauma on the other hand. Building on these initial results, a standard outcome tool shall be integrated in the established TraumaRegister DGU® in the future.

METHODS

In 2018, patients [Injury Severity Score (ISS) ≥ 16; age:18-75 years] underwent multicenter one-year posttraumatic follow-up in six study hospitals. In addition to assessing hrQoL by using the Short-Form Health Survey (SF-12), five additional questions (treatment satisfaction; ability to work; trauma-related medical treatment; relevant physical disability, hrQoL as compared with the prior to injury status) were applied.

RESULTS

Of the 1,162 patients contacted, 594 responded and were included in the analysis. The post-injury hrQoL does not show statistically significant differences between the sexes. Regarding age, however, the younger the patient at injury, the better the SF-12 physical sum score. Furthermore, the physically perceived quality of life decreases statistically significantly in relation to the severity of the trauma as measured by the ISS, whereas the mentally perceived quality of life shows no differences in terms of injury severity. A large proportion of severely injured patients were very satisfied (42.2%) or satisfied (39.9%) with the treatment outcome. It should be emphasized that patients with a high injury severity (ISS > 50) were on average more often very satisfied with the treatment outcome (46.7%). A total of 429 patients provided information on their ability to work 12 months post-injury. Here, 194 (45.2%) patients had a full employment, and 58 (13.5%) patients were had a restricted employment.

CONCLUSION

The present results show the importance of a structured assessment of the postinjury hrQoL and the ability to work after polytrauma. Further studies on the detection of influenceable risk factors on hrQoL and ability to work in the intersectoral course of treatment should follow to enable the best possible outcome of polytrauma survivors.

Long-term functional outcomes in polytrauma: a fundamentally new approach is needed in prediction

PURPOSE

Modern trauma care has reduced mortality but poor long-term outcomes with low follow-up rates are common with limited recommendations for improvements. The aim of this study was to describe the impact of severe injury on the health-related quality of life, specifically characterise the non-responder population and to identify modifiable predictors of poorer outcomes.

METHODS

Five-year (2012-2016) prospective cohort study was performed at a level 1 trauma centre. Baseline Short-Form Health Survey (SF36) was collected at admission, and at 6 and 12 months postinjury together with demographics, injury mechanism and severity, psychosocial wellbeing, and return to work capacity.

RESULTS

Of the 306 consecutive patients [age 52 ± 17 years, male 72%, ISS 21 (17, 29), mortality 5%], 195 (64%) completed questionnaires at baseline, and at 12 months. Preinjury physical health scores were above the general population (53.1 vs. 50.3, p < 0.001) and mental health component was consistent with the population norms (51.7 vs. 52.9, p = 0.065). One year following injury, both physical health (13.2, 95% CI 14.8, 11.6) and mental health scores (6.0, 95% CI 8.1, 3.8) were significantly below age- and sex-adjusted preinjury baselines. Non-responders had similar ISS but with a lower admission GCS, and were more likely to be younger, and without comorbidities, employment, or university education.

CONCLUSION

Contrary to their better than population norm preinjury health status, polytrauma patients remain functionally impaired at least 1 year after injury. The identified high risk for non-responding group needs more focused efforts for follow-up. A fundamentally different approach is required in polytrauma research which identify modifiable predictors of poor long-term outcomes.

A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory

OBJECTIVES

To explore trauma patients' experiences of the long-term recovery pathway during 18 months following hospital discharge.

DESIGN

Longitudinal qualitative study.

SETTING AND PARTICIPANTS

Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge.

METHOD

The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically.

RESULTS

Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress.

CONCLUSIONS AND IMPLICATIONS

The patients' experiences from this study establish knowledge of several challenges in the trauma population's recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients' health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.

Descriptive Analysis of Trauma Admission Trends before and during the COVID-19 Pandemic

INTRODUCTION

Traumatic injuries are a significant global health concern, with profound medical and socioeconomic impacts. This study explores the patterns of trauma-related hospitalizations in the Lublin Province of Poland, with a particular focus on the periods before and during the COVID-19 pandemic.

AIM OF THE STUDY

The primary aim of this research was to assess the trends in trauma admissions, the average length of hospital stays, and mortality rates associated with different types of injuries, comparing urban and rural settings over two distinct time periods: 2018-2019 and 2020-2021.

METHODS

This descriptive study analyzed trauma admission data from 35 hospitals in the Lublin Province, as recorded in the National General Hospital Morbidity Study (NGHMS). Patients were classified based on the International Classification of Diseases Revision 10 (ICD-10) codes. The data were compared for two periods: an 11-week span during the initial COVID-19 lockdown in 2020 and the equivalent period in 2019.

RESULTS

The study found a decrease in overall trauma admissions during the pandemic years (11,394 in 2020-2021 compared to 17,773 in 2018-2019). Notably, the average length of hospitalization increased during the pandemic, especially in rural areas (from 3.5 days in 2018-2019 to 5.5 days in 2020-2021 for head injuries). Male patients predominantly suffered from trauma, with a notable rise in female admissions for abdominal injuries during the pandemic. The maximal hospitalization days were higher in rural areas for head and neck injuries during the pandemic.

CONCLUSIONS

The study highlights significant disparities in trauma care between urban and rural areas and between the pre-pandemic and pandemic periods. It underscores the need for healthcare systems to adapt to changing circumstances, particularly in rural settings, and calls for targeted strategies to address the specific challenges faced in trauma care during public health crises.

Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial

INTRODUCTION

Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL).

METHODS

The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference.

RESULTS

Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively.

CONCLUSIONS

Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.

A prospective assessment of resilience in trauma patients using the Connor-Davidson Resilience Scale

BACKGROUND

Resilience, or the ability to adapt to difficult or challenging life experiences, may be an important mediator in trauma recovery. The primary aim of this study was to describe resilience levels for trauma patients using the validated Connor-Davidson Resilience Scale.

METHODS

Adult trauma patients admitted to a Level 1 trauma center (June 2022-August 2022) were surveyed at the time of admission and by phone between 2 weeks and 1 month after the original survey to obtain follow-up scores. We utilized the validated Connor-Davidson Resilience Scale score, a 25-question survey with 5 subfactors (Tenacity, Positive Outlook, Social Support, Problem Solving, and Meaning and Purpose). Each question was scored from 0 to 4 (maximum score 100, representing the highest resilience). Patient factors were collected from the electronic medical record and trauma health registry. Wilcoxon signed-rank test and multivariable linear regression were used to understand associations with Connor-Davidson Resilience Scale scores.

RESULTS

We enrolled 98 patients. The median age was 50 years (interquartile range 32-67), and 74% were male sex. The baseline median Connor-Davidson Resilience Scale score on admission was 88 (interquartile range 81-94). Follow-up surveys (N = 64) showed a median score of 89.5 (80-90.5) (P = non-significant). No demographic variable was significantly associated with increasing baseline Connor-Davidson Resilience Scale score. Increased length of stay (β = 1.03), insurance (β = -7.50), and unknown race (β = 23.69) were correlated with follow-up Connor-Davidson Resilience Scale scores. The subfactor "Meaning and Purpose" decreased at follow-up but was not statistically significant (P = .05).

CONCLUSION

Validated tools that can accurately distinguish variability in resilience scores are needed for the trauma patient population to understand its relationship with long-term patient health outcomes.

Pre-Trauma Pain Is the Strongest Predictor of Persistent Enhanced Pain Patterns after Severe Trauma: Results of a Single-Centre Retrospective Study

Background and Objectives: Traumatic injuries are a significant public health issue worldwide, with persistent enhanced pain being a common complication following severe trauma. Persistent and chronic pain can have a profound impact on patients' quality of life, affecting physical, emotional, and social functioning. This study aimed to investigate the pain patterns of trauma patients before and after severe trauma, and identify the predictors of persisting pain after injury. Materials and Methods: A total of 596 patients of a level-one trauma centre with severe trauma were included in this study. The Trauma Outcome Profile Scale was used to assess pain severity before and after trauma, and a logistic regression analysis was performed to determine the most significant predictors of relevant pain after severe trauma. Results: The mean age of the included patients was 48.2 years, and 72% were males. The most frequent cause of injury was traffic accidents, and the mean Injury Severity Score was 17.6. Nearly half of the patients experienced reduced pain-related quality of life after trauma, with persisting pain predominantly occurring in the neck, spine, shoulder, pelvis, hip, knee, and feet. Even minor injuries led to increased pain scores. Preexisting pain before injury (OR: 5.43; CI: 2.60-11.34), older age (OR: 2.09, CI: 1.22-3.27), female gender (OR: 1.08, CI: 0.73-1.59), and high injury severity (OR: 1.80, CI: 1.20-2.69) were identified as significant predictors of enhanced pain. Conclusions: These findings highlight the importance of considering pre-existing pain, body area, and injury severity in assessing the risk of persistent pain in trauma patients.

Adherence to Guidelines for Acute Rehabilitation in the Norwegian Trauma Plan

OBJECTIVE

To evaluate adherence to 3 central operational recommendations for acute rehabilitation in the Norwegian trauma plan.

METHODS

A prospective multi-centre study of 538 adults with moderate and severe trauma with New Injury Severity Score > 9.

RESULTS

Adherence to the first recommendation, assessment by a physical medicine and rehabilitation physician within 72 h following admission to the intensive care unit (ICU) at the trauma centre, was documented for 18% of patients. Adherence to the second recommendation, early rehabilitation in the intensive care unit, was documented for 72% of those with severe trauma and ≥ 2 days ICU stay. Predictors for early rehabilitation were ICU length of stay and spinal cord injury. Adherence to the third recommendation, direct transfer of patients from acute ward to a specialized rehabilitation unit, was documented in 22% of patients, and occurred more often in those with severe trauma (26%), spinal cord injury (54%) and traumatic brain injury (39%). Being employed, having head or spinal chord injury and longer ICU stay were predictors for direct transfer to a specialized rehabilitation unit.

CONCLUSION

Adherence to acute rehabilitation guidelines after trauma is poor. This applies to documented early assessment by a physical medicine and rehabilitation physician, and direct transfer from acute care to rehabilitation after head and extremity injuries. These findings indicate a need for more systematic integration of rehabilitation in the acute treatment phase after trauma.

Factors associated with discharge destination from acute care after moderate-to-severe traumatic injuries in Norway: a prospective population-based study

BACKGROUND

Previous studies have demonstrated that the trauma population has needs for rehabilitation services that are best provided in a continuous and coordinated way. The discharge destination after acute care is the second step to ensuring quality of care. There is a lack of knowledge regarding the factors associated with the discharge destination for the overall trauma population. This paper aims to identify sociodemographic, geographical, and injury-related factors associated with discharge destination following acute care at trauma centers for patients with moderate-to-severe traumatic injuries.

METHODS

A multicenter, population-based, prospective study was conducted with patients of all ages with traumatic injury [New Injury Severity Score (NISS) > 9] admitted within 72 h after the injury to regional trauma centers in southeastern and northern Norway over a 1-year period (2020).

RESULTS

In total, 601 patients were included; a majority (76%) sustained severe injuries, and 22% were discharged directly to specialized rehabilitation. Children were primarily discharged home, and most of the patients ≥ 65 years to their local hospital. Depending on the centrality of their residence [Norwegian Centrality Index (NCI) 1-6, where 1 is most central], we found that patients residing in NCI 3-4 and 5-6 areas sustained more severe injuries than patients residing in NCI 1-2 areas. An increase in the NISS, number of injuries, or a spinal injury with an Abbreviated Injury Scale (AIS) ≥ 3 was associated with discharge to local hospitals and specialized rehabilitation than to home. Patients with an AIS ≥ 3 head injury (RRR 6.1, 95% Confidence interval 2.80-13.38) were significantly more likely to be discharged to specialized rehabilitation than patients with a less severe head injury. Age < 18 years was negatively associated with discharge to a local hospital, while NCI 3-4, preinjury comorbidity, and increased severity of injuries in the lower extremities were positively associated.

CONCLUSIONS

Two-thirds of the patients sustained severe traumatic injury, and 22% were discharged directly to specialized rehabilitation. Age, centrality of the residence, preinjury comorbidity, injury severity, length of hospital stay, and the number and specific types of injuries were factors that had the greatest influence on discharge destination.

Long-term health-related quality of life after trauma with and without traumatic brain injury: a prospective cohort study

To purpose was to assess and compare the health-related quality of life (HRQoL) and risk of depression two years after trauma, between patients with and without traumatic brain injury (TBI) in a mixed Swedish trauma cohort. In this prospective cohort study, TBI and non-TBI trauma patients included in the Swedish Trauma registry 2019 at a level II trauma center in Stockholm, Sweden, were contacted two years after admission. HRQoL was assessed with RAND-36 and EQ-5D-3L, and depression with Montgomery Åsberg depression Rating Scale self-report (MADRS-S). Abbreviated Injury Score (AIS) head was used to grade TBI severity, and American Society of Anesthesiologists (ASA) score was used to assess comorbidities. Data were compared using Chi-squared test, Mann Whitney U test and ordered logistic regression, and Bonferroni correction was applied. A total of 170 of 737 eligible patients were included. TBI was associated with higher scores in 5/8 domains of RAND-36 and 3/5 domains of EQ-5D (p < 0.05). No significant difference in MADRS-S. An AIS (head) of three or higher was associated with lower scores in five domains of RAND-36 and two domains of EQ-5D but not for MADRS-S. An ASA-score of three was associated with lower scores in all domains of both RAND-36 (p < 0.05, except mental health) and EQ-5D (p < 0.001, except anxiety/depression), but not for MADRS-S. In conclusion, patients without TBI reported a lower HRQoL than TBI patients two years after trauma. TBI severity assessed according to AIS (head) was associated with HRQoL, and ASA-score was found to be a predictor of HRQoL, emphasizing the importance of considering pre-injury health status when assessing outcomes in TBI patients.

Completeness and Mismatch of Patient-Important Outcomes After Trauma

To assess the completeness of the collection of patient-important outcomes and the mismatch between outcomes measured in research and patients' important issues after trauma.

Summary Background Data

To date, severe trauma has mainly been assessed using in-hospital mortality. Yet, with 80 to 90% survivors discharged from hospital, it is critical to assess the collection of patient important long-term outcomes of trauma.

Methods

Mixed methods study combining a systematic review of outcomes and their comparison with domains elicited by patients during a qualitative study. We searched Medline, EMBASE and clinicaltrials.gov from January 1, 2014 to September 30, 2019 and extracted all outcomes from reports including severe trauma. We compared these outcomes with 97 domains that matter to trauma survivors identified in a previous qualitative study. We defined as patient-important outcome as the 10 most frequently elicited domains in the qualitative study. We assessed the number of domains captured in each report to illustrate the completeness of the collection of patient-important outcomes. We also assessed the mismatch between outcomes collected and what matters to patients.

Findings

Among the 116 reports included in the systematic review, we identified 403 outcomes collected with 154 unique measurements tools. Beside mortality, measurement tools most frequently used were the Glasgow Outcome Scale (31.0%, n=36), questions on patients' return to work (20,7%, n=24) and the EQ-5D (19.0%, n=22). The comparison between the outcomes identified in the systematic review and the domains from the qualitative study found that 10.3% (n=12) reports did not collect any patient-important domains and one collected all 10 patient-important domains. By examining each of the 10 patient-important domains, none was collected in more than 72% of reports and only five were among the ten most frequently measured domains in studies.

Conclusion

The completeness of the collection of the long-term patient-important outcomes after trauma can be improved. There was a mismatch between the domains used in the literature and those considered important by patients during a qualitative study.

Health-related quality of life after severe trauma and available PROMS: an updated review (part I)

Introduction

Throughout the years, a decreasing trend in mortality rate has been demonstrated in patients suffering severe trauma. This increases the relevance of documentation of other outcomes for this population, including patient-reported outcome measures (PROMs), such as health-related quality of life (HRQoL). The aim of this review was to summarize the results of the studies that have been conducted regarding HRQoL in severely injured patients (as defined by the articles’ authors). Also, we present the instruments that are used most frequently to assess HRQoL in patients suffering severe trauma.

Methods

A literature search was conducted in the Cochrane Library, EMBASE, PubMed, and Web of Science for articles published from inception until the 1st of January 2022. Reference lists of included articles were reviewed as well. Studies were considered eligible when a population of patients with major, multiple or severe injury and/or polytrauma was included, well-defined by means of an ISS-threshold, and the outcome of interest was described in terms of (HR)QoL. A narrative design was chosen for this review.

Results

The search strategy identified 1583 articles, which were reduced to 113 after application of the eligibility criteria. In total, nineteen instruments were used to assess HRQoL. The SF-36 was used most frequently, followed by the EQ-5D and SF-12. HRQoL in patients with severe trauma was often compared to normative population norms or pre-injury status, and was found to be reduced in both cases, regardless of the tool used to assess this outcome. Some studies demonstrated higher scoring of the patients over time, suggesting improved HRQoL after considerable time after severe trauma.

Conclusion

HRQoL in severely injured patients is overall reduced, regardless of the instrument used to assess it. The instruments that were used most frequently to assess HRQoL were the SF-36 and EQ-5D. Future research is needed to shed light on the consequences of the reduced HRQoL in this population. We recommend routine assessment and documentation of HRQoL in severely injured patients.

Repeat assault injuries: A scoping review of the incidence and associated risk factors

OBJECTIVE

Individuals who experience assault are at high risk of being re-assaulted. Our objective was to identify reported incidences of re-assault and associated risk factors to better inform prevention strategies.

METHODS

We conducted a scoping review and searched databases (MEDLINE, PsychINFO, CINAHL, Cochrane Reviews, and Scopus) and grey literature. We performed abstract and full-text screening, and abstracted incidence of re-assault and information related to age, sex, socioeconomic status, mental illness, and incarceration.

RESULTS

We included 32 articles. Studies varied based on setting where index assaults were captured (n=18 inpatient only, n=13 emergency department or inpatient, n=1 other). Reported incidences ranged from 0.8% over one month to 62% through the lifetime. Important risk factors identified include young age, low socioeconomic status, racialized groups, history of mental illness or substance use disorder, and history of incarceration.

CONCLUSIONS

Rates of re-assault are high and early intervention is necessary for prevention. We identified notable risk factors that require further in-depth analysis, including sex, gender and age-stratified analyses.

POLICY IMPLICATIONS

Key risk factors identified should inform timely and targeted intervention strategies for prevention.

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.

Measuring functional outcomes in major trauma: can we do better?

PURPOSE

There is relatively limited large scale, long-term unified evidence to describe how quality of life (QoL) and functional outcomes are affected after polytrauma. The aim of this study is to review validated measures available to assess QoL and functional outcomes and make recommendations on how best to assess patents after major trauma.

METHODS

PubMed and EMBASE databases were interrogated to identify suitable patient-reported outcome measures (PROMs) for use in major trauma, and current practice in their use globally.

RESULTS

Overall, 81 papers met the criteria for inclusion and evaluation. Data from these were synthesised. A full set of validated PROMs tools were identified for patients with polytrauma, as well as critique of current tools available, allowing us to evaluate practice and recommend specific outcome measures for patients following polytrauma, and system changes needed to embed this in routine practice moving forward.

CONCLUSION

To achieve optimal outcomes for patients with polytrauma, we will need to focus on what matters most to them, including their needs (and unmet needs). The use of appropriate PROMs allows evaluation and improvement in the care we can offer. Transformative effects have been noted in cases where they have been used to guide treatment, and if embedded as part of the wider system, it should lead to better overall outcomes. Accordingly, we have made recommendations to this effect. It is time to seize the day, bring these measures even further into our routine practice, and be part of shaping the future.

Circulating endocannabinoids and genetic polymorphisms as predictors of posttraumatic stress disorder symptom severity: heterogeneity in a community-based cohort

The endocannabinoid signaling system (ECSS) regulates fear and anxiety. While ECSS hypoactivity can contribute to symptoms of established post-traumatic stress disorder (PTSD), the role of the ECSS in PTSD development following trauma is unknown. A prospective, longitudinal cohort study of 170 individuals (47% non-Hispanic Caucasian and 70% male) treated at a level 1 trauma center for traumatic injury was carried out. PTSD symptom assessments and blood were obtained during hospitalization and at follow-up (6-8 months post injury). Serum concentrations of the endocannabinoids N-arachidonoylethanolamine (AEA) and 2-arachidonoylglycerol (2-AG) were determined at both time points and selected genetic polymorphisms in endocannabinoid genes, including rs324420 in fatty acid amide hydrolase, were assessed. For the entire sample, serum concentrations of AEA at hospitalization were significantly higher in those diagnosed with PTSD at follow-up (p = 0.030). Serum concentrations of 2-AG were significantly, positively correlated with PTSD symptom severity at follow-up only in minorities (p = 0.014). Minority participants (mostly Black/African American) also demonstrated significant, negative correlations between serum AEA concentrations and PTSD symptom severity both measured at hospitalization (p = 0.015). The A/A genotype at rs324420 was associated with significantly higher PTSD symptom severity (p = 0.025) and occurred exclusively in the Black participants. Collectively, these results are contrary to our hypothesis and find positive associations between circulating endocannabinoids and risk for PTSD. Minority status is an important modulator of the association between endocannabinoids and risk for PTSD, suggesting that the ECSS contributes to risk most significantly in these individuals and the contextual factors related to these findings should be further explored.

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.

Main factors predicting somatic, psychological, and cognitive patient outcomes after significant injury: a pilot study of a simple prognostic tool

Background

There are still insufficient data on the complexity and predictability of patient-related outcomes following trauma. The aim of this study was to assess longer-term outcomes in patients with significant injury and to develop a simple scoring method to identify patients at high risk of subsequent deficits 1–2 years after injury.

Methods

We conducted a prospective cohort study of survivors of significant injury (New Injury Severity Score, NISS greater than or equal to 8), with analysis of patients’ 1- to 2-year health-related quality of life (HRQoL) and their functional outcomes based on Short Form-36 (SF-36), Trauma Outcome Profile (TOP), and Quality Of Life after Brain Injury (QOLIBRI). Documented variables suspected or known from the literature to be possible factors associated with outcome were first analysed by univariate analysis, and significant variables were entered into a stepwise logistic regression analysis. Scores predicting longer-term impaired outcome were constructed from risk factors resulting from multivariate analysis.

Results

Depending on the patient-reported outcome measure (PROM) used, up to 30 per cent of 1052 study patients (mean NISS 18.6) indicated somatic, 27 per cent psychological, and 54 per cent cognitive deficits. The investigated sociodemographic, injury-related, treatment, and early hospital outcome variables demonstrated only low associations with longer-term outcome in univariate analysis that were highest for preinjury pain or function (R = 0.4) and outcome at hospital discharge (R = 0.3). After logistic regression, the study variables explained a maximum variance of 23 per cent for somatic, 11 per cent for psychological, and 14 per cent for cognitive longer-term outcomes. The resulting Aarau trauma prognostic longer-term outcome scoring (ATPLOS) system, developed by checking eight risk factors, had a specificity of up to 80 per cent, and importantly may facilitate early detection of patients at risk of a poorer longer-term outcome.

Conclusion

Despite the high rate of deficits recorded for survivors of significant injury, particularly in loss of cognitive function, the multiple variables analysed only led to a limited characterization of patient-related longer-term outcomes. Until more is known about additional individual influencing factors, the proposed scoring system may serve well for clinical evaluation.

Registration number

NCT 02165137 (http://www.clinicaltrials.gov)

Quality of Life after Motorcycle Traffic Injuries: A Cohort Study in Northwest of Iran

Objective:

To investigate the quality of life (QOL) of injured motorcyclists and associated factors in a period of three months after the accident.

Methods:

In the present study, we were included 190 injured motorcyclists who admitted to two referral specialized hospitals (Emam Reza and Shohada) in Tabriz, between June 2018 and January 2019. All injured motorcyclists were contacted through the telephone one and 171 of them (90%) three months after their accident to complete an EQ-5D-3L questionnaire. The baseline measurements were gathered by using face to face interviews in the hospitals. The QOL score could vary between 1 and 3. The higher score showed a lower QOL.

Results:

The injured motorcyclist’s QOL score was relatively better in three months after the accident (mean±Standard Deviation (SD): 1.78±0.51) in comparison with their status a month after the accident (2.15±0.65) (p<0.001). The multivariable model showed that individuals with pelvis injuries (Coef: 0.29, (95% CI: 0.16, 0.42), p=0.001) and knee injuries (Coef: 0.26, (95% CI: 0.10, 0.42), p=0.001), experienced a higher QOL score. Also, those whose accident had happened in rainy weather experienced higher QOL score (Coef: 0.33, (95% CI: 0.12, 0.53), p=0.001). The patients who were in an accident with a vehicle were experienced a better QOL than others (Coef: -0.26, (95% CI: -0.43, -0.09), p=0.002).

Conclusion:

The assessment of three-months post-accident showed that the QOL score of the motorcyclists was reduced. It is recommended that the QOL of patients should be improved in hospital discharge victims.

[Rehabilitation after multiple traumata]

BACKGROUND

The reintegration into the social and professional environment and the achievement of the best possible quality of life after multiple injuries can often only be achieved after a lengthy rehabilitation process and belongs in the hands of experienced doctors, therapists, and rehabilitation managers.

REHABILITATION PHASES

Rehabilitation after serious accidents must be differentiated from "normal" orthopedic rehabilitation after elective surgery. The challenges of trauma rehabilitation require coordinated rehabilitation phases. This is the only way to avoid the so-called "rehab hole" between discharge from the acute clinic and the start of post-acute rehabilitation. A 6-phase model is described. After acute treatment (phase A) and any necessary early rehabilitation (phase B), phase C of post-acute rehabilitation places special demands on the rehabilitation facility. Phase D of the follow-up rehabilitation is established. The further rehabilitation (phase E) provides measures specifically tailored to the consequences of the accident, such as pain rehabilitation or activity-oriented procedures. Long-term follow-up care for previously severely injured patients is necessary (phase F).

PROSPECTS

An integration of trauma rehabilitation centers into the existing trauma network remains the goal to improve the outcome after polytrauma.

[Measurability of the quality of care of the severely injured]

The care of severely injured patients is characterized by the heterogeneity of the clinical picture and the time-critical aspects of many forms of treatment in the acute phase, so that quality measurement and assessment is always complex. In order to be able to operate a meaningful and structured quality management the quality must be validly measured and it must be defined what quality is. To handle this complex picture the quality of care for the severely injured is divided into three levels: structural quality, process quality and outcome quality. With respect to structural quality there are clear guidelines for personnel and structural equipment of hospitals for the optimal care of severely injured patients. This is regularly checked in Germany through trauma center certification as part of the TraumaNetzwerk DGU®. Process quality can also be measured in the care of severely injured patients. With the TraumaRegister DGU® annual report in 2017, 14 newly developed quality indicators were introduced. Due to the comprehensive participation of hospitals in the TraumaRegister DGU® structured external quality assurance is possible in addition to internal process analysis. With respect to the quality of the outcome patient reported outcome measures (PROM) have become increasingly more important in addition to the mortality. The PROMs that are used to assess the consequences of injuries are typically multidimensional and capture not only aspects of physical health but also enable self-assessment of the mental health status by the patient.

Long-term medical and productivity costs of severe trauma: Results from a prospective cohort study

Background

Through improvements in trauma care there has been a decline in injury mortality, as more people survive severe trauma. Patients who survive severe trauma are at risk of long-term disabilities which may place a high economic burden on society. The purpose of this study was to estimate the health care and productivity costs of severe trauma patients up to 24 months after sustaining the injury. Furthermore, we investigated the impact of injury severity level on health care utilization and costs and determined predictors for health care and productivity costs.

Methods

This prospective cohort study included adult trauma patients with severe injury (ISS≥16). Data on in-hospital health care use, 24-month post-hospital health care use and productivity loss were obtained from hospital registry data and collected with the iMTA Medical Consumption and Productivity Cost Questionnaire. The questionnaires were completed 1 week and 1, 3, 6, 12 and 24 months after injury. Log-linked gamma generalized linear models were used to investigate the drivers of health care and productivity costs.

Results

In total, 174 severe injury patients were included in this study. The median age of participants was 55 years and the majority were male (66.1%). The mean hospital stay was 14.2 (SD = 13.5) days. Patients with paid employment returned to work 21 weeks after injury. In total, the mean costs per patient were €24,760 with in-hospital costs of €11,930, post-hospital costs of €7,770 and productivity costs of €8,800. Having an ISS ≥25 and lower health status were predictors of high health care costs and male sex was associated with higher productivity costs.

Conclusions

Both health care and productivity costs increased with injury severity, although large differences were observed between patients. It is important for decision-makers to consider not only in-hospital health care utilization but also the long-term consequences and associated costs related to rehabilitation and productivity loss.

The Relationship between Hospital Volume and In-Hospital Mortality of Severely Injured Patients in Dutch Level-1 Trauma Centers

Centralization of trauma centers leads to a higher hospital volume of severely injured patients (Injury Severity Score (ISS) > 15), but the effect of volume on outcome remains unclear. The aim of this study was to determine the association between hospital volume of severely injured patients and in-hospital mortality in Dutch Level-1 trauma centers. A retrospective observational cohort study was performed using the Dutch trauma registry. All severely injured adults (ISS > 15) admitted to a Level-1 trauma center between 2015 and 2018 were included. The effect of hospital volume on in-hospital mortality was analyzed with random effects logistic regression models with a random intercept for Level-1 trauma center, adjusted for important demographic and injury characteristics. A total of 11,917 severely injured patients from 13 Dutch Level-1 trauma centers was included in this study. Hospital volume varied from 120 to 410 severely injured patients per year. Observed mortality rates varied between 12% and 24% per center. After case-mix correction, no statistically significant differences between low- and high-volume centers were demonstrated (adjusted odds ratio 0.97 per 50 extra patients per year, 95% Confidence Interval 0.90–1.04, p = 0.44). The variation in hospital volume of the included Level-1 trauma centers was not associated with the outcome of severely injured patients. Our results suggest that well-organized trauma centers with a similar organization of care could potentially achieve comparable outcomes.

Prevalence and association of anxiety and depression among orthopaedic trauma inpatients: a retrospective analysis of 1994 cases

Background

Patients with traumatic injuries are often accompanied by emotional disorders, which seriously impede functional gains. The objective of this study was to identify the prevalence and risk factors associated with underlying anxiety and depression in orthopaedic trauma patients.

Methods

From July 2015 to December 2017, all orthopaedic trauma patients were included in the retrospective study. Patients with conditions that might affect cognitive impairment were excluded from the study. Basic demographic data were collected. All patients were screened for emotional disorders on admission using a simple questionnaire called “Huaxi Emotional-Distress Index” (HEI). Bivariate analyses and logistic regression were used to identify the factors associated with a HEI score of > 8.

Results

One hundred and sixty-two patients (8.1%) had a HEI score of > 8. About 1.0% of enrolled patients had severe emotional disorders (HEI score ≥ 17). The reasons caused by emotional disorders in patients with orthopaedic trauma were a higher Injury Severity Score (ISS), a higher visual analogue score (VAS) and type of surgery. On logistic regression, marital status was a protective factor for emotional disorders, while VAS and ISS were the risk factors for emotional disorders.

Conclusions

Although a significantly low percentage of orthopaedic trauma patients in our setting have emotional disorders, traumatic orthopaedic surgeons still need to pay attention to the risk of emotional disorders and integrate effective screening tools into clinical practice to screen for these factors and stratify emotional disorders. Appropriate targeted psychological intervention and treatment should be adopted according to the stratification of emotional disorders.

The Economic and Clinical Impact of an Early Mobility Program in the Trauma Intensive Care Unit: A Quality Improvement Project

Traumatic injury survivors often face a difficult recovery. Surgical and invasive procedures, prolonged monitoring in the intensive care unit (ICU), and constant preventive vigilance by medical staff guide standards of care to promote positive outcomes. Recently, patients with traumatic injuries have benefited from early mobilization, a multidisciplinary approach to increasing participation in upright activity and walking. The purpose of this project was to determine the impact of an early mobility program in the trauma ICU on length of stay (LOS), ventilator days, cost, functional milestones, and rehabilitation utilization. A quality improvement project compared outcomes and cost before and after the implementation of an early mobility program. The trauma team assigned daily mobility levels to trauma ICU patients. Nursing and rehabilitation staff collaborated to set daily goals and provide mobility-based interventions. Forty-four patients were included in the preintervention group and 43 patients in the early mobility group. Physical therapy and occupational therapy were initiated earlier in the early mobilization group (p = .044 and p = .026, respectively). Improvements in LOS, duration of mechanical ventilation, time to out-of-bed activity and walking, and discharge disposition were not significant. There were no adverse events related to the early mobility initiative. Activity intolerance resulted in termination of 7.1% of mobility sessions. The development and initiation of a trauma-specific early mobility program proved to be safe and reduce patient care costs. In addition, the program facilitated earlier initiation of physician and occupational therapies. Although not statistically significant, retrospective data abstraction provides evidence of fewer ICU and total hospital days, earlier extubations, and greater proactive participation in functional activities.

Trajectories of health-related quality of life among people with a physical disability and/or chronic disease during and after rehabilitation: a longitudinal cohort study

Purpose

To identify Health-related Quality of Life (HR-QoL) trajectories in a large heterogeneous cohort of people with a physical disability and/or chronic disease during and after rehabilitation and to determine which factors before discharge are associated with longitudinal trajectory membership.

Methods

A total of 1100 people with a physical disability and/or chronic disease were included from the longitudinal cohort study Rehabilitation, Sports and Active lifestyle. All participants participated in a physical activity promotion programme in Dutch rehabilitation care. HR-QoL was assessed using the RAND-12 Health Status Inventory questionnaire at baseline (T0: 3–6 weeks before discharge) and at 14 (T1), 33 (T2) and 52 (T3) weeks after discharge from rehabilitation. A data-driven approach using Latent Class Growth Mixture modelling was used to determine HR-QoL trajectories. Multiple binomial multivariable logistic regression analyses were used to determine person-, disease- and lifestyle-related factors associated with trajectory membership.

Results

Three HR-QoL trajectories were identified: moderate (N = 635), high (N = 429) and recovery (N = 36). Trajectory membership was associated with person-related factors (age and body mass index), disease-related factors (perceived fatigue, perceived pain and acceptance of the disease) and one lifestyle-related factor (alcohol consumption) before discharge from rehabilitation.

Conclusions

Most of the people who participated in a physical activity promotion programme obtained a relatively stable but moderate HR-QoL. The identified HR-QoL trajectories among our heterogeneous cohort are disease-overarching. Our findings suggest that people in rehabilitation may benefit from person-centred advice on management of fatigue and pain (e.g. activity pacing) and the acceptance of the disability.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02647-7) contains supplementary material, which is available to authorized users.

Finnish translation and external validation of the Trauma Quality of Life questionnaire

BACKGROUND AND AIMS

Major trauma impairs health-related quality of life (HRQoL). The aim of this study was the Finnish translation and external validation of the Trauma Quality of Life (TQoL) questionnaire.

PATIENTS AND METHODS

The Finnish version of the TQoL questionnaire and the 15D, a generic HRQoL questionnaire, were sent by mail to 417 patients identified from the Helsinki Trauma Registry.

RESULTS

Altogether 222 patients (53.2%) returned the questionnaires. Participants' mean age was 49.9 ± 18.1 years and 68.8% were males. The mean 15D score was significantly lower than that of the age- and sex-standardized general Finnish population (0.817 vs. 0.918, p < 0.001). The correlation between the Finnish translation and 15D scores was high (0.805). Factor analysis revealed that the Finnish TQoL questionnaire and the 15D have four common factors. Internal validation identified some differences between the Finnish and the original versions.

CONCLUSIONS

The correlation between the Finnish TQoL questionnaire and the 15D was high. The factor structures of the original and Finnish versions of the TQoL questionnaire were not identical, which may be a consequence of cultural or patient population differences.Implications for rehabilitationTrauma causes a long-term decrease in health-related quality of life (HRQoL), and this impact should be assessed in rehabilitation.The Trauma-Specific Quality of Life (TQoL) questionnaire has many shared features with the generic HRQoL questionnaire, but it also contains features related to post-traumatic disorder syndrome.The TQoL questionnaire is a valid tool for monitoring HRQoL after trauma.

Detection of fractures of hand and forearm in whole-body CT for suspected polytrauma in intubated patients

Background

The aim of this study was to evaluate the potential of whole-body CT for diagnosis of hand and forearm fractures in intubated patients with suspected polytrauma.

Methods

We performed a retrospective analysis on data collected from two trauma centres in Germany, including demographics, ISS, clinical symptoms, depiction in whole-body CT, and time to diagnosis.

Results

Out of 426 patients included in the study, 66 (15.5%) suffered a hand or forearm fracture. The total number of fractures was 132, the whole-body CT report mentioned 98 (74.2%). 16 (12,1%) fractures of 12 patients were diagnosed later than 24 h after admission. Late diagnoses of fractures of the hand occurred more often if the hand was not fully included in the CT scan field. The sensitivity of whole-body CT for cases with fractures of hand and/or forearm with full inclusion of the corresponding area in the scan field was 80.2%.

Conclusions

This study shows that whole-body CT is a valuable diagnostic tool for hand fractures in polytrauma patients. Hands should be evaluated regardless of clinical presentation in intubated patients after suspected polytrauma if they are included in the whole-body CT.

Polytrauma outcome: implementation of health-related quality of life assessment into the German Trauma Registry

INTRODUCTION

As a result of improvement in polytrauma management within the last years, more patients survive a significant trauma. Trauma registers, such as the TraumaRegister DGU^®, played a role in identifying risk factors of poor outcomes which led to an improvement of survival rates. In recent years the health-related quality of life (HRQoL) after trauma got into the focus of trauma studies.

MATERIALS AND METHODS

Under the sponsorship of the German Society of Trauma Surgery (DGU) the members of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) convened intending to identify an assessment tool for implementation into the TraumaRegister DGU^®.

RESULTS

After the conduct of a systematic literature review, the working group decided to choose the 12-item Short-Form Health Survey (SF-12) and five more questions, capturing the satisfaction of treatment, work capacity and trauma-related medical treatment.

CONCLUSION

The data collection of HRQoL and the additional variables started in 2017 in participating clinics as a part of the regular data collection of the TraumaRegister DGU^®.

Posttraumatic stress disorder after minor trauma - A prospective cohort study

BACKGROUND

Posttraumatic stress disorder (PTSD) can arise as a reaction to a traumatic experience. While many data concerning PTSD in severely injured patients are available, little is known about this disease in slightly injured patients after road traffic accidents. It is rather assumed that PTSD does not exist after objectively slight injuries.

METHODS

In total, 36 patients (Injury Severity Score < 16) after road traffic accidents were included in this prospective cohort study. Next to demographic and accident-specific data, the PDI (Peritraumatic Distress Inventory: individual experienced distress directly during or immediately after the traumatic event), THQ (Trauma History Questionnaire) and the BDI-II (Beck Depression Inventory-II: self-report measurement tool to examine the severity of depression) were assessed immediately after trauma (t0). Six weeks (t1) and 3 months (t2) after trauma the Impact of Event Scale - Revised (IES-R), a screening instrument for PTSD, and the BDI-II were collected.

RESULTS

Overall 2 patients showed critical measurement values in IES-R after 6 weeks. A strong correlation between PDI and IES-R at t1 and t2 could be detected (p < 0.05). Furthermore, a significant correlation of BDI-II and IES-R after 6 weeks and 3 months was found (p < 0.05). Neither age or sex showed a significant correlation to IES-R (p ≥ 0.05).

CONCLUSION

The present study showed that symptoms of PTSD can also occur after minor trauma. Especially high peritraumatic distress is associated with developing a PTSD. The occurrence of PTSD should be considered not only in severely injured patients, but also in slightly injured patients after road traffic accidents.

A concept analysis and overview of outcome measures used for evaluating patients with proximal humerus fractures

PURPOSE

It is unclear to which degree existing studies evaluate the primary goal of treatment for patients with proximal humerus fractures (restoration of daily activities). Our purpose was to systematically review and analyze the concepts reflected by outcome measures used in studies of patients with proximal humerus fractures.

METHODS

We reviewed three databases from 2000 to 2018. Two reviewers categorized outcomes in each study into concepts of the International Classification of Functioning, Disability and Health framework.

RESULTS

The most commonly represented concept across 35 studies was "Body Function/Structure Impairment", followed by aggregate measures that reflect multiple concepts to varying degrees. All patient-reported aggregate measures such as the Disabilities of the Arm, Shoulder, and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores better reflected "Activity Limitations", however, these measures were only reported in 34% of studies.

CONCLUSION

There may be misalignment between what studies measure, and the primary goal of treatment for patients with proximal humerus fractures. The Disabilities of the Arm, Shoulder and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores reflect concepts that more adequately address the restoration of daily activities following these injuries, and future studies should include at least one of these measures.Implications for rehabilitationWe have shown that there is a misalignment between what existing studies are measuring (primarily objective measures of impairment) and the primary goal of treatment and rehabilitation (restoring activities of daily living).This suggests that existing studies evaluating different treatment types for proximal humerus fracture patients are providing inadequate information to make evidence-based treatment and rehabilitation decisions following theses injuries.Our results tentatively suggest that the Disabilities of the Arm, Shoulder and Hand, the American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores may better reflect limitations in daily activities following these injuries and should be used in future studies and by clinicians.

Quality of life after multiple trauma: results from a patient cohort treated in a certified trauma network

PURPOSE

Besides mortality, the patient-reported outcome (PRO) in survivors of multiple trauma is of increasing interest. So far, no data on patient-reported outcome measures (PROMs) after multiple trauma from an entire trauma network are available. Within this study, the course of the PRO over time and differences between level I and level II trauma centers within an entire trauma network was evaluated.

METHODS

Multiple injured patients, treated in a rural trauma network over 2 years, were prospectively included in this study. After 6, 12 and 24 months the results of the European Quality of Life (EuroQoL) EQ-5D outcome instrument were evaluated. To adjust for differences in trauma severity between level I and level II centers, the Revised Injury Severity Classification II (RISC II) and the Functional Capacity Index (FCI) were used to adjust the life-quality results of patients.

RESULTS

501 patients were included, 118 patients with an ISS < 16 points, 383 patients reached 16 points or more. Despite a steady increase of EQ-5D index over time (6 months: 0.71 ± 0.31; 12 months: 0.74 ± 0.28; 24 months: 0.76 ± 0.27; p < 0.001), the values of a reference population could not be reached even 2 years after trauma (EQ-5D reference population: 0.9). After adjustment for trauma severity, no significant differences in PROMs between level I and level II centers could be detected (p = 0.188).

CONCLUSION

The consistently low EQ-5D index relative the reference population and the lack of a difference between level I and II centers suggest that improved strategies for polytrauma aftercare are called for.

Trauma-Induced Long-Term Alterations of Human T Cells and Monocytes-Results of an Explorative, Cross-Sectional Study

BACKGROUND

Major trauma leads to complex immune reactions, known to result in a transient immunodeficiency. The long-term consequences of severe trauma on immune function and regulation as well as its clinical impact remain unclear.

METHODS

Six months (ranging from -12 to +5 days) after a major trauma event, 12 former trauma patients (Injury Severity Score ≥ 16) and 12 healthy volunteers were enrolled. The current clinical status and infection history since discharge were assessed by a standardized questionnaire. Immune cell subsets (cluster of differentiation (CD)4, CD8, CD14), cell surface receptor expression (programmed cell death protein 1 (PD-1), B- and T-lymphocyte attenuator (BTLA), cytotoxic T-lymphocyte-associated protein 4, toll-like receptor (TLR)-2, -4, and -5, Dectin-1, programmed death ligand 1 (PD-1L)), and human leucocyte antigen D-related receptor (HLA-DR)-expression were quantified by flow cytometry. Cytokine secretion (IL-2, -4, -6, -10, and 17A, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ) was assessed after stimulation of whole blood with LPS-, α-CD3/28, or zymosan.

RESULTS

Analysis of surface receptors on T cells revealed a significant elevation of PD-1 expression on CD4 T cells, whereas BTLA expression on CD4 and CD8 T cells was significantly suppressed in the trauma cohort. Monocytes showed a significantly reduced expression of TLR-2 and -4 as well as a reduced proportion of TLR-4 monocytes. HLA-DR receptor density revealed no significant changes between both cohorts. LPS-induced IL-6 and TNF-α secretion showed non-significant trends toward reduced values. No differences regarding clinical apparent infections could be detected.

CONCLUSIONS

Six months following major trauma, changes of cell surface receptors on CD4 and CD8 T cells as well as on CD14 monocytes were present, hinting toward an immunosuppressive phenotype. Following major trauma, although IL-6 and TNF-α release after stimulation were reduced, they did not reach statistical significance. Overall, further studies are necessary to evaluate the clinical implications of these findings.

TRIAL REGISTRATION

DRKS00009876, Internet Portal of the German Clinical Trials Register (DRKS), registration date 11.08.2016, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00009876.

Introduction of a novel questionnaire to assess the quality of postdischarge outpatient care and socioeconomic state after severe multiple injury

BACKGROUND AND AIM

Trauma registries provide knowledge about the pathophysiological events that follow severe injuries but only little is known about outpatient care and socioeconomic consequences at later stages in case of survival. We introduce a novel questionnaire to specifically assess the quality of postdischarge outpatient care and socioeconomic burden up to two years after severe multiple injury.

DESIGN

Observational Study.

SETTING

Postdischarge outpatient treatment and socioeconomic burden within two years after severe trauma.

POPULATION

Severely injured adult trauma patients (Injury Severity Score 9 and ICU admission).

METHODS

A new questionnaire was introduced in context of a two-year follow-up mail survey.

RESULTS

The response rate was 57% (150/264 patients; 73% male, mean 45 years, mean ISS 17/New ISS 22; 99% blunt trauma). Rehabilitation measures were conducted in 70% of patients while 87% underwent outpatient treatment after discharge from the acute care facility. Further in-hospital stays were observed in 63% of patients and 19% reported the need for ongoing permanent care. Pain medication was taken by 74% of patients after discharge while 32% were still on pain medication at two years. 35% had been on sick leave >1 year while 18% had entirely lost their job. Every second patient reported financial disadvantages.

CONCLUSIONS

The questionnaire yielded detailed information about the quality of outpatient care after discharge and confirmed the high socioeconomic burden among patients at two years after severe multiple injury.

CLINICAL REHABILITATION IMPACT

Long- term impairments after severe trauma are described frequently. Evaluation of ambulant treatment is the first step to optimize long- term rehabilitation and re-integration.

Predictors of Change in Functional Outcome at six months and twelve months after Severe Injury: A Retrospective Cohort Study

Background

There is increasing focus on long-term survival, function and quality-of-life for trauma patients. There are few studies tracking longitudinal changes in functional outcome over time. The goal of our study was to compare the Glasgow Outcome Scale-Extended (GOSE) at 6 months and 12 months in blunt trauma survivors with an Injury Severity Score (ISS) of more than 15.

Methods

Using the Singapore National Trauma Registry 2011–2013, patients with 6-month GOSE and 12-month GOSE scores were analysed. Patients were grouped into three categories—those with the same score at 6 months and 12 months, an improvement in score, and a worse score at 12 months. Ordinal regression was used to identify risk factors for improved score. Patients with missing scores at either 6 months or 12 months were excluded.

Results

We identified 478 patients: 174 had an improvement in score, 233 stayed the same, and 71 had worse scores at 12 months compared to 6 months. On univariate ordinal regression, the following variables were associated with same or better function at 12-months compared to 6-months: male gender, being employed pre-injury, thoracic Abbreviated Injury Scale (AIS) of 3 or more, anatomical polytrauma (AIS of 3 or more in 2 or more body regions), and road traffic injury mechanism. Older age, low fall, increasing Charlson comorbidity scores, new injury severity score, and head and neck AIS of 3 or more were associated with worse function at 12 months compared to 6 months. ISS and revised trauma score were not significant predictors on univariate or multivariable analysis.

On multivariable ordinal regression, motor vehicle mechanism (OR 2.78, 1.51–5.12, p = 0.001) was associated with improved function, while male gender (OR 1.36, 95% CI 1.02–1.82, p = 0.039) predicted improved function at 12 months.

Conclusions

Females experience worse functional outcomes at 12 months, potentially due to majority of female injuries being low falls in the elderly. In contrast, motor vehicle injury patients had better functional outcomes at 12 months. Additional interventional strategies for high-risk groups should be explored.

What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review

BACKGROUND

Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.

QUESTIONS/PURPOSES

(1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients' upper extremity injuries?

METHODS

We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the "upper extremity", "outcome measurement", and "impairment, psychological, social or symptomatic" variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.

RESULTS

Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.

CONCLUSIONS

Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Acetabular fractures: Is it possible to regain the same patient's related quality of life before trauma?

INTRODUCTION

acetabular fractures are difficult to treat with often an unsatisfactory results for patients. The aim of this study is to investigate about the health-related quality-of-life outcome of patients with a traumatic acetabular fracture, as recorded at least 24 months after their surgery.

METHODS

a cohort of patients underwent a dedicated acetabular surgical reconstruction for a pelvic trauma between November 2011 and May 2016, were enrolled to investigate, at least two years after injury, their midterm quality of life; SF-36 and LiSat-11 were used.

RESULTS

35 patients were enrolled but only 28 patients were revisited, 20 males (714%) and 8 females (286%) with a mean age of 43 years (19-73). The most common cause was motor vehicle accident (655%). Lower score after trauma are reported in both tests, SF-36 and LiSat 11, for all items.

DISCUSSION

comparing the SF-36 score in the Italian normative sample with our SF-36 score before the trauma there is no statistically significant difference (p = 0.1661) underlining how the patients before the trauma were healthy and in good health. Both scores, SF-36 and LiSat-11, before and after trauma are statistically different with respectively p = 0,0002 and p = 0,049 which proves the lower quality of life after trauma in comparison to their life before trauma.

CONCLUSIONS

Although the treatment protocols of acetabular fractures have greatly improved over the years, these continue to have disabling consequences that hardly allow to recover a good quality of life two years after the trauma.

Patient-Reported Outcomes Measurement Information System Outcome Measures and Mental Health in Orthopaedic Trauma Patients During Early Recovery

OBJECTIVES

This study explored the relationships between negative affective states (depression and anxiety), physical/functional status, and emotional well-being during early treatment and later in recovery after orthopaedic trauma injury.

DESIGN

This was a secondary observational analysis from a randomized controlled study performed at a Level-1 trauma center.

PATIENTS

Patients with orthopaedic trauma (N = 101; 43.5 ± 16.4 years, 40.6% women) were followed from acute care to week 12 postdischarge.

MAIN OUTCOME MEASURES

Patient-reported outcomes measurement information system measures of Physical Function, Psychosocial Illness Impact-Positive and Satisfaction with Social Roles and Activities and the Beck Depression Inventory-II and the State-Trait Anxiety Inventory were administered during acute care and at weeks 2, 6, and 12. Secondary measures included hospital length of stay, adverse readmissions, injury severity, and surgery number.

RESULTS

At week 12, 20.9% and 35.3% of patients reported moderate-to-severe depression (Beck Depression Inventory-II score ≥20 points) and anxiety (State-Anxiety score ≥40 points), respectively. Depressed patients had greater length of stay, complex injuries, and more readmissions than those without. The study sample improved patient-reported outcomes measurement information system T-scores for Physical Function and Satisfaction with Social Roles and Activities by 40% and 22.8%, respectively (P < 0.0001), by week 12. Anxiety attenuated improvements in physical function. Both anxiety and depression were associated with lower Psychosocial Illness Impact-Positive scores by week 12.

CONCLUSIONS

Although significant improvements in patient-reported physical function and satisfaction scores occurred in all patients, patients with depression or anxiety likely require additional psychosocial support and resources during acute care to improve overall physical and emotional recovery after trauma.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Physical injury, health, and well-being: Role of stress perception

OBJECTIVE

Physical injuries are common occurrences that can have substantial implications for mental health and well-being. Ample studies indicated that increased levels of perceived stress is associated with increased prevalence of general health problems, as well as reduced health-related quality of life. Thus, the goal of the present study was to examine the long-lasting association between bodily injuries and general health. In addition, the role of stress perception in moderating the association between injury and general health was assessed.

METHODS

Two-hundred and forty victims of past injury and 251 non-injured participants completed a self-report health inventory questionnaire assessing illness prevalence during the six-month period prior to the study. In addition, they completed the short-form Medical Outcomes Survey (MOS SF-36) questionnaire and the Perceived Stress Scale.

RESULTS

Victims of past injuries reported higher incidences of illness, mainly upper respiratory infections and fever, compared to non-injured participants. In addition, injured participants reported poorer perceived health status, including reduced general health, physical functioning, and health beliefs. Perceived stress levels were similar in injured and non-injured participants, however, correlations between perceived stress and self-reported medical outcomes were stronger in injured participants compared to non-injured controls.

CONCLUSIONS

Past physical injuries are associated with increased incidence of general health concerns and poorer health-related well-being. Moreover, injured individuals do not report increased stress perception; however, when stressed, injured individuals are more affected and health-related quality of life is reduced. Promoting well-being in individuals who have suffered a significant injury is, thus, a clinical necessity and a pressing social priority. This study highlights the role of stress perception in the association between physical injury and health, and may assist in providing better multi-disciplinary care for the injured.

Rural versus urban pediatric non-accidental trauma: different patients, similar outcomes

Objective

Our aim was to compare urban and rural non-accidental trauma for trends and characterize where injury prevention efforts can be focused. Pediatric trauma patients (age 0–14 years) at two level I adult and pediatric trauma centers, one rural and one urban, were included and data from the trauma registries at each center was abstracted.

Results

Of 857 pediatric admissions, 10% of injuries were considered non-accidental. The mean age for all non-accidental trauma patients was significantly lower than the overall pediatric trauma population (2.6 vs. 7.7 years, P < 0.001). Significantly more fatalities occurred in the non-accidental trauma cohort (5.7% vs. 1% P = 0.007). In nearly half of all non-accidental trauma patients, the primary insurance was government programs (49%) and 46% were commercial insurance. The proportion of government insurance in non-accidental trauma was higher in both urban and rural cohorts. There were similar rates of urban and rural patients sustaining non-accidental trauma who were uninsured (6.5 vs. 5.3%). Patients that were younger, in a rural location, and receiving government insurance were at higher risk of non-accidental trauma on univariable analysis. However, only age remained an independent predictor on multivariable analysis.

Prospective evaluation of the Quality of Life after Brain Injury (QOLIBRI) score: minor differences in patients with major versus no or mild traumatic brain injury at one-year follow up

Background

The Quality of Life after Brain Injury (QOLIBRI) score was developed to assess disease-specific health-related quality of life (HRQoL) after traumatic brain injury (TBI). So far, validation studies on the QOLIBRI were only conducted in cohorts with traumatic brain injury. This study investigated the longer-term residuals in severely injured patients, focusing specifically on the possible impact of major TBI.

Methods

In a prospective questionnaire investigation, 199 survivors with an injury severity score (ISS) > 15 participated in one-year follow-up. Patients who had sustained major TBI (abbreviated injury scale, AIS head > 2) were compared with patients who had no or only mild TBI (AIS head ≤ 2). Univariate analysis (ANOVA, Cohen’s kappa, Pearson’s r) and stepwise linear regression analysis (B with 95% CI, R, R²) were used.

Results

The total QOLIBRI revealed no differences in one-year outcomes between patients with versus without major TBI (75 and 76, resp.; p = 0.68). With regard to the cognitive subscore, the group with major TBI demonstrated significantly more limitations than the one with no or mild TBI (p < 0.05). The AIS head correlated significantly with the cognitive dimension of the QOLIBRI (r = − 0.16; p < 0.05), but not with the mental components of the SF-36 or the TOP. In multivariate analysis, the influence of the severity of head injury (AIS head) on total QOLIBRI was weaker than that of injured extremities (R² = 0.02; p < 0.05 vs. R² = 0.04; p = 0.001) and equal to the QOLIBRI cognitive subscore (R² = 0.03, p < 0.01 each).

Conclusions

Given the unexpected result of similar mean QOLIBRI total score values and only minor differences in cognitive deficits following major trauma independently of whether patients sustained major brain injury or not, further studies should investigate whether the QOLIBRI actually has the discriminative capacity to detect specific residuals of major TBI. In effect, the score appears to indicate mental deficits following different types of severe trauma, which should be evaluated in more detail.

Trial registration

NCT02165137; retrospectively registered 11 June 2014.

Quality of life and level of post-traumatic stress disorder among trauma patients: A comparative study between a regional and a university hospital

BACKGROUND

The aim of this study was to assess outcome in long-term quality of life (QoL) and post-traumatic stress disorder (PTSD) among adult survivors of trauma. Secondary aim was to compare levels of the outcome with injury severity and specialization level of two trauma centres.

METHODS

A retrospective study included patients received by the trauma response teams at two hospitals in 2013 aged 18 or more at follow-up. We assessed QoL and PTSD with one mailed questionnaire to each patient at either 12 or 24 months of follow-up. Health status was measured by EuroQol EQ-5D and the Glasgow Outcome Scale. PTSD symptoms were classified according to the Post-Traumatic Stress Disorder Checklist (PCL) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).

RESULTS

A questionnaire was mailed to 774 patients at end of 2014 or early 2015, 455 were included for analysis; median age 44 (IQR 25-57; 68% male); median NISS 9 (IQR 2-17); At follow-up 24% (95% CI 20-28) reported a EQ index score value equivalent to the lowest 2.3% in the Danish population norm. Probable PTSD was present in 19% (95% CI 13-27) of patients with severe injuries (NISS> 15), and 23% (95% CI 19-28) of those with NISS < 15.

CONCLUSION

Severe trauma has substantial impact on QoL and PTSD assessed at 12-24 months after the trauma. The QoL was well below the Danish population norm. The presence of PTSD was independent of injury severity. Trauma Centres should consider to include this as part of the treatment principles.

Pre-injury depression and anxiety in patients with orthopedic trauma and their treatment

PURPOSE

Depressive symptoms have a known negative impact on outcomes following musculoskeletal injury. This study determined the pre-injury prevalence of psychiatric diagnoses of depression and anxiety, medication lapses and psychiatric consult services among patients admitted for orthopaedic trauma.

METHODS

This is a retrospective study of data from our Level-1 trauma center. Patients admitted to the orthopaedic trauma service during 2010-2015 were included (N = 4053). Demographics, Injury Severity Scores (ISS), mental health diagnoses, psychotropic medications, medication type and delay, psychiatric consultation use, intensive care unit (ICU) stay and total hospital length of stay (LOS) were abstracted from medical records and the institutional trauma registry.

RESULTS

The 12-month prevalence of a major depressive episode is 6.6%-8.6% in adults in the United States. In our database, only 152/4053 (3.8%) of the patients had documented medical history of depression (80%) or anxiety (30%), and these patients had a 32% longer LOS (p < 0.016). Nearly two-thirds of patients who used psychotropic medications prior to injury experienced a delay in receiving these medications in the hospital (median = 1.0 day, range 0-14 days). Sixteen percent of patients also received a new psychotropic medication while hospitalized: an antipsychotic (8/16 patients, to treat delirium), an anxiolytic (3/16 patients for acute anxiety), or an antidepressant (1/16). Among patients with depression or anxiety, 16.7% received a psychiatric consult. Patients with psychiatric consults had higher ISS, were more likely to have longer ICU LOS and had longer hospital LOS than those without consults (all p < 0.05).

CONCLUSION

The prevalence of depression and anxiety is grossly under-reported in our registry compared to national prevalence data. Patients with pre-existing disease had longer LOS and a higher rate of extended ICU care. Further studies are needed to characterize the true prevalence of disease in this patient population and its effect on patient outcomes after traumatic orthopaedic injury.

Measuring and assessing risk of quality of life loss following a road traffic injury: A proposed methodology for use of a composite score

INTRODUCTION

Assessments of the impact of road traffic injuries (RTIs) on quality of life (QoL) can benefit from the use of combined characteristics of the injurious event.

AIM

The burden of having sustained a RTI was computed using a composite score that comprised three elements (i.e. number of injuries sustained in the crash, body parts affected, and severity of the injuries) that relate to the probability of subsequent long-term QoL lost by individuals 1-4 years after the crash.

METHODOLOGY

The QoL of injured victims aged 11-90 years that crashed in Sweden between 2007 and 2009 was compared with that of a random sample of non-injured individuals frequency-matched by sex and age. Injury information to build the composite score was obtained from a national register that contains data on the number of injuries, their severity, and the body parts affected. The QoL was assessed in 2010 for both injured and non-injured individuals using the standardized Euro Quality of Life questionnaire. Logistic regression was used to investigate whether the composite score was predictive of low QoL (<90% of the mean of non-injured referents) adjusting for sex, age, and time elapsed since the injury occurrence. The composite score was grouped into five exposure categories (0.01-1, 1.01-1.5, 1.51-2, 2.01-3 and 3.01-9 units).

RESULTS

Compared with the non-injured reference group, all exposure categories showed statistically significant increased adjusted ORs for low QoL ranging from 2.35 (95% CI 1.48-3.72) in the 0.01-1.00 lowest injury category to 6.10 (95% CI 3.65-10.2) in the highest 3.01-9.00 with a slightly decreasing plateau in the intermediate categories (point ORs between 3.86 and 3.06). Yet, all 95% CIs across the exposure categories overlapped.

CONCLUSION

Long-term reduction in QoL is a burden experienced by the victims of mild to severe RTCs. The proposed composite score can be an initial step in the development of more elaborated instruments that can be useful in policy making and regulation.

Reduced Quality of Life, Fatigue, and Societal Participation After Polytrauma

Objective:

This cross-sectional study analyzed associations between and determinants for health-related quality of life (HRQoL), fatigue, and societal participation in polytrauma patients.

Summary of background data:

More polytrauma patients survive their injuries, often resulting in long-term disabilities. HRQoL is therefore an important outcome of trauma care. Fatigue and societal participation may be related to HRQoL. Also, their relation to severe injuries has not been studied to date.

Methods:

A total of 283 polytrauma patients (injury severity score ≥ 16) admitted to the Dutch level 1 Trauma Centre West were analyzed. HRQoL was measured by the physical component summary (PCS) and mental component summary (MCS) scores of the SF-36, fatigue by the multidimensional fatigue inventory, and societal participation by the Utrecht scale for evaluation of rehabilitation-participation. Age, sex, comorbidity, injury pattern, injury severity, and time since trauma were analyzed as potential determinants.

Results:

A total of 122 patients (43%) responded after a median follow-up of 15 (range, 10–23) months after polytrauma; 44% reported reduced physical health (PCS &lt; 45) and 47% reported reduced mental health (MCS &lt; 45). HRQoL was highly correlated with all fatigue and participation subscales. Severe head injury was associated with worse mental health. Female patients reported more general and mental fatigue and were less satisfied with their ability to perform daily activities. Patients with pre-existing comorbidity experienced worse physical health, more fatigue, and reduced societal participation.

Conclusions:

One to 2 years after trauma, polytrauma patients report reduced HRQoL, which is associated with more fatigue and reduced societal participation. Trauma rehabilitation strategies should focus on early recognition of reduced HRQoL, fatigue, and societal participation and facilitate early intervention to improve these outcomes.

The Epidemiology of Chronic Critical Illness After Severe Traumatic Injury at Two Level-One Trauma Centers

OBJECTIVE

To determine the incidence and risk factors of chronic critical illness after severe blunt trauma.

DESIGN

Prospective observational cohort study (NCT01810328).

SETTING

Two level-one trauma centers in the United States.

PATIENTS

One hundred thirty-five adult blunt trauma patients with hemorrhagic shock who survived beyond 48 hours after injury.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Chronic critical illness was defined as an ICU stay lasting 14 days or more with evidence of persistent organ dysfunction. Three subjects (2%) died within the first 7 days, 107 (79%) exhibited rapid recovery and 25 (19%) progressed to chronic critical illness. Patients who developed chronic critical illness were older (55 vs 44-year-old; p = 0.01), had more severe shock (base deficit, -9.2 vs -5.5; p = 0.005), greater organ failure severity (Denver multiple organ failure score, 3.5 ± 2.4 vs 0.8 ± 1.1; p < 0.0001) and developed more infectious complications (84% vs 35%; p < 0.0001). Chronic critical illness patients were more likely to be discharged to a long-term care setting (56% vs 34%; p = 0.008) than to a rehabilitation facility/home. At 4 months, chronic critical illness patients had higher mortality (16.0% vs 1.9%; p < 0.05), with survivors scoring lower in general health measures (p < 0.005). Multivariate analysis revealed age greater than or equal to 55 years, systolic hypotension less than or equal to 70 mm Hg, transfusion greater than or equal to 5 units packed red blood cells within 24 hours, and Denver multiple organ failure score at 72 hours as independent predictors of chronic critical illness (area under the receiver operating curve, 0.87; 95% CI, 0.75-0.95).

CONCLUSIONS

Although early mortality is low after severe trauma, chronic critical illness is a common trajectory in survivors and is associated with poor long-term outcomes. Advancing age, shock severity, and persistent organ dysfunction are predictive of chronic critical illness. Early identification may facilitate targeted interventions to change the trajectory of this morbid phenotype.