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Sabbaghi M, Miri K, Namazinia M. Effects of the COVID-19 pandemic on trauma-related emergency medical service in older people: a retrospective cohort study. BMC Emerg Med 2023; 23:98. [PMID: 37633933 PMCID: PMC10463572 DOI: 10.1186/s12873-023-00874-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/22/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION The ever-increasing human life expectancy has currently resulted in a noticeable rise in the world's older population. Addressing the healthcare needs of the older people has become a significant concern for many countries. Moreover, the older people are particularly vulnerable to traumatic events. This study aimed to examine the impact of the COVID-19 pandemic on prehospital care provided by Emergency Medical Services (EMS) for trauma-related cases among the older people in Iran. METHODS This retrospective cohort study involved analyzing the medical records of 1,111 older people aged above 60 who experienced traumatic injuries and received pre-hospital emergency services from March 2018 to March 2022. In order to collect the data, the checklist made by the researcher was used and data analysis in SPSS16 was done using the Chi-square test and Fisher's exact test. RESULTS The age group of 60-74 received the highest number of services both before and after the COVID-19 pandemic. The older men experienced more traumatic events compared to women throughout the study period. The majority of the traumatic events occurred between 8 a.m. and 12 p.m. both before and after the COVID-19 pandemic. CONCLUSIONS The high prevalence rate of geriatric traumas can be primarily attributed to their physical problems and no control over movements caused by old age, as well as unsafe living conditions. To address these issues, it is suggested that facilities be provided to assist with mobility problems. Moreover, constructing suitable pedestrian bridges and regularly checking neighborhoods and surroundings to identify potential risk factors should be prioritized. Once these risk factors are identified, efforts can be made to adjust and eliminate them, thereby minimizing traumatic events and enhancing a safe and friendly environment for the older people.
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Affiliation(s)
- Mohammadreza Sabbaghi
- Department of Medical Emergency, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Kheizaran Miri
- Department of Nursing, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
| | - Mohammad Namazinia
- Department of Nursing, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
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Priestap F, Veens J, Vogt K. Transfer status may not be associated with worse outcomes in elderly trauma patients. Injury 2023; 54:1314-1320. [PMID: 36737269 DOI: 10.1016/j.injury.2023.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 01/05/2023] [Accepted: 01/26/2023] [Indexed: 01/30/2023]
Abstract
PURPOSE To compare outcomes of elderly patients who arrive directly to a lead trauma centre to those who are transferred from a peripheral hospital. METHODS This study used a retrospective cohort design and data obtained from the local trauma registry. The study population was patients 65 years and older who presented with an Injury Severity Score (ISS) of 12 or greater, or for whom the trauma team was activated, over a 10-year period. Patients were excluded from the study if they arrived direct from the scene and died within 3 hours of arrival, they were found to have no injuries, or they were directly admitted more than 2 days from the time of injury. Following the use of multiple imputation, multivariable logistic regression analysis was used to evaluate the relationship between in-hospital mortality and directness of transport, while adjusting for potentially confounding variables. RESULTS Of the 1619 patients included in the analyses over half (54.2%) were transported directly from the scene of injury to the lead trauma hospital (LTH). The remaining 45.8% initially presented to a non-tertiary hospital and were later transferred to the LTH. Crude mortality was 18.7% in the direct group and 14.0% in the transfer group (p = 0.015). The unadjusted odds of death for patients arriving to LTH by referral was 0.71 (95% confidence interval, 0.54, 0.93), compared to patients arriving to the LTH directly. After adjustment for age, ISS, presence of severe head injury, Charlson Comorbidity Index, shock, initial GCS, and ICU admission from the emergency department, the mortality risk did not differ significantly for transferred patients compared to those arriving directly (OR = 0.77 (95% confidence interval, 0.54, 1.09). CONCLUSION There was no significant difference in in-hospital mortality between elderly patients transported directly to the trauma centre and those who were transferred from peripheral hospitals.
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Affiliation(s)
- Fran Priestap
- London Health Sciences Centre - Victoria Hospital, 800 Commissioners Rd E., London, Ontario N6A 5W9, Canada.
| | - Juliet Veens
- Huron Perth Health Alliance - Stratford General Hospital, 46 General Hospital Dr., Stratford, Ontario, Canada; Division of Emergency Medicine, Schulich School of Dentistry and Medicine, Western University, London, Ontario, Canada
| | - Kelly Vogt
- London Health Sciences Centre - Victoria Hospital, 800 Commissioners Rd E., London, Ontario N6A 5W9, Canada; Department of Surgery, Schulich School of Dentistry and Medicine, Western University, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
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Premji EN, Kilindimo SS, Sawe HR, Yussuf AO, Simbila AN, Manji HK, Mfinanga JA, Weber EJ. Patterns and Predictors of Timely Presentation and Outcomes of Polytrauma Patients Referred to the Emergency Department of a Tertiary Hospital in Tanzania. Emerg Med Int 2022; 2022:9611602. [PMID: 36387014 PMCID: PMC9652091 DOI: 10.1155/2022/9611602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Polytrauma patients require special facilities to care for their injuries. In HICs, these patients are rapidly transferred from the scene or the first-health facility directly to a trauma center. However, in many LMICs, prehospital systems do not exist and there are long delays between arrivals at the first-health facility and the trauma center. We aimed to quantify the delay and determine the predictors of mortality among polytrauma patients. Methodology. We consecutively enrolled adult polytrauma patients (≥18 years) with ISS >15 referred to the Emergency Medicine Department of Muhimbili National Hospital, a major trauma center in Tanzania between August 2019 and January 2020. Based on a pilot study, the arrival of >6 hours after injury was considered a delay. The outcome of interest was factors associated with delayed presentation and the association of timeliness with 7-day mortality. Results We enrolled 120 (4.5%) referred polytrauma adult patients. The median age was 30 years (IQR 25-39) and the ISS was 29 (IQR 24-34). The majority (85%) were males. While the median time from injury to first-health facility was 40 minutes (IQR 33-50), the median time from injury to arrival at EMD-MNH, was 377 minutes (IQR 314-469). Delayed presentation was noted in more than half (54.2%) of participants, with the odds of dying being 1.4 times higher in the delayed group (95% CI 0.3-5.6). Having a GCS <8 (AOR 16.3 (95% CI 3.1-86.3), hypoxia <92% (AOR 8.3 (95% CI 1.4-50.9), and hypotension <90 mmHg (R 7.3 (95% CI 1.6-33.6) were all independent predictors of mortality. Conclusion The majority of polytrauma patients arrive at the tertiary facilities delayed for more than 6 hours and a distance of more than 8 km between facilities is associated with delay. Hypotension, hypoxia, and GCS of less than 8 are independent predictors of poor outcome. In the interim, there is a need to expedite the transfer of polytrauma patients to trauma care capable centers.
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Affiliation(s)
- Elishah N. Premji
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Said S. Kilindimo
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Hendry R. Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Amne O. Yussuf
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Alphonce N. Simbila
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Hussein K. Manji
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Juma A. Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Ellen J. Weber
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
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Bharat A, Verma V, Afaque SF, Raikwar A, Chand S, Singh A. Effect of COVID 19 pandemic on time to care, use of ambulance, admission characteristics, demography, injury characteristics, management and outcome of Paediatric Orthopaedic trauma patients admitted to the trauma centre. INDIAN JOURNAL OF COMMUNITY HEALTH 2022. [DOI: 10.47203/ijch.2022.v34i03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: Lockdown imposed to limit the spread of COVID 19 may have had a significant effect on the time to care, demography, injury causation, injury characteristics, volume and nature of admission, management and outcome of paediatric orthopaedic trauma patients. Objective: To document the effect of lockdown on the time to care at KGMU, use of ambulance, volume and type of admissions, demography, injury causation, injury characteristics, management and outcome of paediatric orthopaedic trauma patients. Methods:. This record review compared age, sex, type of admission, mechanism of injury, injury characteristics, type of treatment, vehicle used for transport, and outcome among patients admitted in pre-lockdown, lockdown and post lockdown. Results: Lockdown was associated with decrease in the number of cases (p<0.01), increase in the time since injury to reception (p<0.040), a rise in the share of referred admission (p<0.040), time since reception at KGMU, time to definitive care (p<0.001), high energy falls (p<0.001), injuries at home (p<0.001), higher ISS (p<0.001), non operative treatment (p=0.038) and greater use of ambulance (p=0.003). Conclusion: Lockdown resulted in a significant change in the causation and management of injury, significant delays in timeliness of care, reduction in the volume of admissions, an increase in injury severity and share of referral admissions.
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Morgan JM, Calleja P. Emergency trauma care in rural and remote settings: Challenges and patient outcomes. Int Emerg Nurs 2020; 51:100880. [PMID: 32622226 DOI: 10.1016/j.ienj.2020.100880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 04/16/2020] [Accepted: 05/07/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Trauma is a global public health concern, with higher mortality rates acknowledged in rural and remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary objective of this integrative literature review was to examine the challenges associated with providing emergency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective was to explore strategies to improve trauma patient outcomes. METHODS An integrative review approach was used to inform the methods of this study. A systematic search of databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other search methods included hand searching journal references. RESULTS 2157 articles were identified for screening and 87 additional papers were located by hand searching. Of these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique challenges in the provision of emergency trauma care such as large distances, delays transferring patients to definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors, weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural and remote populations often experience higher mortality rates in comparison to urban populations although this may be different for specific mechanisms of injury or population subsets. While an increased risk of death was associated with an increase in remoteness, research also found it costs substantially less to provide care to rural patients in their rural environment than their urban counterparts. Other factors found to influence mortality rates were severity of injury and differences in characteristics between rural and urban populations. Trauma systems vary around the world and must address local issues that may be affected by distance, geography, seasonal population variations, specific population risk factors, trauma network operationalisation, referral and retrieval and involvement of hospitals and services which have no trauma designation. CONCLUSIONS The challenges acknowledged for rural and remote trauma patients may be lessened and mortality rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma systems that are responsive to local needs and resources. Additional research to determine which of these challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve this.
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Affiliation(s)
- Janita M Morgan
- School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan 4111, QLD, Australia; Gympie Hospital, Queensland Health, 12 Henry Street, Gympie 4570, QLD, Australia.
| | - Pauline Calleja
- School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan 4111, QLD, Australia; School of Nursing Midwifery & Social Sciences, CQUniversity, Level 3 Cairns Square, Corner Abbott and Shields Street, Cairns 4870, QLD, Australia; Retrieval Services Queensland, Department of Health, 125 Kedron Park Road, Kedron 4031, QLD, Australia.
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Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. A comparison of major trauma patient transport destination in metropolitan Perth, Western Australia. Australas Emerg Care 2019; 23:90-96. [PMID: 31668941 DOI: 10.1016/j.auec.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/25/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite evidence of a lower risk of death, major trauma patients are not always transported to Trauma Centres. This study examines the characteristics and outcomes of major trauma patients between transport destinations. METHODS A retrospective cohort study of major trauma patients (Injury Severity Score >15) transported by ambulance was undertaken. Cases were divided into transport destination groups: (1) Direct, those transported to the Trauma Centre directly from the scene; (2) Indirect, those transported to another hospital prior to Trauma Centre transfer and (3) Non-transfers, those transported to a non-Trauma Centre and never subsequently transferred. Median and interquartile range (IQR) were used to describe the groups and differences were assessed using the Kruskal-Wallis test for continuous variables and Pearson chi-square for categorical. RESULTS A total of 1625 patients were included. The median age was oldest in the non-transfers cohort (72 years IQR 46-84). This group had the highest proportion of falls from standing and head injuries (n = 298/400, 75%, p < 0.001). The non-transfers had the highest proportion of 30-day mortality (n = 134/400, 34%). CONCLUSIONS There were significant differences between the groups with older adults, falls and head injuries over-represented in the non-transfer group. Considering the ageing population, trauma systems will need to adapt.
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Affiliation(s)
- Elizabeth Brown
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia.
| | - Paul Bailey
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Daniel Fatovich
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Emergency Medicine, Royal Perth Hospital, University of Western Australia, Bentley, WA, Australia; Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, WA, Australia.
| | - Gavin Pereira
- School of Public Health, Curtin University, Bentley, WA, Australia; Telethon Kids Institute, WA, Australia.
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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Viel IL, Moura BRS, Martuchi SD, de Souza Nogueira L. Factors Associated With Interhospital Transfer of Trauma Victims. J Trauma Nurs 2019; 26:257-262. [PMID: 31503199 DOI: 10.1097/jtn.0000000000000452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study aimed to identify the factors associated with interhospital transfer of trauma victims treated in the emergency department of a nontertiary hospital. Retrospective analysis of medical records of trauma victims treated from January to July 2014 in the emergency department of a hospital not specialized in trauma care and located in Brazil was undertaken. The inclusion criteria were as follows: being 15 years or older; being a trauma victim; having received prehospital care; and being admitted to the hospital directly from the scene of the accident. Pearson's chi-square, Mann-Whitney U, Fisher's exact tests, and multiple logistic regression were used in the analyses. The sample was made up of 246 patients, mostly men (67.9%) and blunt trauma victims (97.6%). The mean age of the trauma victims was 44.2 (SD = 22.1). Falls were the most frequent external cause (41.1%). Forty patients were transferred to a tertiary care center, mostly for orthopedic treatment (70%). The factors associated with interhospital transfer of victims were severity of the trauma according to the Injury Severity Score ([ISS]; mean ±SD of ISS = 8.1 ± 4.5; odds ratio = 1.14; 95% confidence interval [1.06, 1.24]; p = .001) and extremities/pelvic girdle as the body region most severely injured (mean ±SD of extremities/pelvic girdle Abbreviated Injury Scale score = 2.9 ± 0.5; odds ratio = 3.86; 95% confidence interval [1.71, 8.72; p = .001). Identification of the risk factors for interhospital transfer of trauma victims treated in hospitals without a trauma center provides important information for the creation of referral and counter-referral policies to facilitate the process and ensure definitive early treatment and improved patient survival.
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Affiliation(s)
- Isabelle Lauria Viel
- Hospital Alemão Oswaldo Cruz, Sao Paulo, SP, Brazil (Ms Viel); and School of Nursing, University of São Paulo, Sao Paulo, SP, Brazil (Ms Moura, Mr Martuchi, and Dr Nogueira)
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Brown E, Williams TA, Tohira H, Bailey P, Finn J. Epidemiology of trauma patients attended by ambulance paramedics in Perth, Western Australia. Emerg Med Australas 2018; 30:827-833. [PMID: 30044053 DOI: 10.1111/1742-6723.13148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 05/29/2018] [Accepted: 06/24/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of the study was to describe the epidemiology of trauma in adult patients attended by ambulance paramedics in Perth, Western Australia. METHODS A retrospective cohort study of trauma patients aged ≥16 years attended by St John Ambulance Western Australia (SJA-WA) paramedics in greater metropolitan Perth between 2013 and 2016 using the SJA-WA database and WA death data. Incidence and 30 day mortality rates were calculated. Patients who died prehospital (immediate deaths), on the day of injury (early deaths), within 30 days (late deaths) and those who survived longer than 30 days (survivors) were compared for age, sex, mechanism of injury and acuity level. Prehospital interventions were also reported. RESULTS Overall, 97 724 cases were included. A statistically significant increase in the incidence rate occurred over the study period (from 1466 to 1623 per 100 000 population year P ≤ 0.001). There were 2183 deaths within 30 days (n = 2183/97 724, 2.2%). Motor vehicle accidents were responsible for most immediate and early deaths (n = 98/203, 48.3% and n = 72/156, 46.2%, respectively). The majority of transported patients were low acuity (acuity levels 3 to 5, n = 60 594/79 887, 75.8%) and high-acuity patients accounted for 2.7% (n = 2176/79 997). Analgesia administration was the most frequently performed intervention (n = 32 333/80 643, 40.1%), followed by insertion of intravenous catheters (n = 25 060/80 643, 31.1%). Advanced life support interventions such as endotracheal intubation were performed in <1% of patients. CONCLUSION The trauma incidence rate increased over time and the majority of patients had low-acuity injuries. Focusing research, training and resources solely on high-acuity patients will not cater for the needs of the majority of patients.
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Affiliation(s)
- Elizabeth Brown
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia
| | - Teresa A Williams
- Intensive Care Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Hideo Tohira
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul Bailey
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia.,Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia
| | - Judith Finn
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Direct transport to a PCI-capable hospital is associated with improved survival after adult out-of-hospital cardiac arrest of medical aetiology. Resuscitation 2018; 128:76-82. [DOI: 10.1016/j.resuscitation.2018.04.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 04/23/2018] [Accepted: 04/30/2018] [Indexed: 11/21/2022]
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Becker A, Peleg K, Olsha O, Givon A, Kessel B. Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less. Chin J Traumatol 2018; 21:152-155. [PMID: 29776836 PMCID: PMC6034161 DOI: 10.1016/j.cjtee.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/20/2018] [Accepted: 02/18/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients. METHODS A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant. RESULTS There were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3-12 that including 6351 (72%) patients with GCS of 3-8 and 2380 (28%) patient with GCS of 9-12. In these 8731 patients with GCS of 3-12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12, 1256 (89%) patients with GCS 3-8, 148 (11%) patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI. CONCLUSION The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.
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Affiliation(s)
- Alexander Becker
- Department of Surgery A, Emek Medical Center, Afula, Israel,Rappoport Medical School, Technion, Haifa, Israel,Corresponding author. Department of Surgery A, Emek Medical Center, Afula, Israel.
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel,Disaster Medicine Department, School of Public Health, Faculty of Medicine, TelAviv University, Israel
| | - Oded Olsha
- Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel,Rappoport Medical School, Technion, Haifa, Israel
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Mans S, Reinders Folmer E, de Jongh MAC, Lansink KWW. Direct transport versus inter hospital transfer of severely injured trauma patients. Injury 2016; 47:26-31. [PMID: 26510409 DOI: 10.1016/j.injury.2015.09.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 08/30/2015] [Accepted: 09/26/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Several studies have suggested that severely injured patients should be transported directly to a trauma centre bypassing the nearest hospital. However, the evidence remains inconclusive. The purpose of this study was to examine the benefits in terms of mortality of direct transport to a trauma centre versus primary treatment in a level II or III centre followed by inter hospital transfer to a trauma centre for severely injured patients without Traumatic Brain Injury (TBI). PATIENTS AND METHODS We used the regional trauma registry and included all patients with an Injury Severity Score (ISS) >15 and an Abbreviated Injury Score <4 for head injury. We adjusted for survival bias by including "potential transfers": patients who died at the nearest hospitals before transportation to a trauma centre. RESULTS A total of 439 patients was included. The majority of patients (349/439, 79%) was transported directly to the level I trauma centre (direct group). The transferred group was formed by the remaining 90 patients, of whom 81 were transferred to the level I trauma centre after initial stabilisation elsewhere and 9 patients died in the emergency room before transfer to a level 1 trauma centre could occur. There were no significant differences in baseline and injury characteristics between the groups. Overall, 60 patients died in-hospital including 41 of the 349 patients (12%) in the direct group and 19 of the 90 patients (21%) in the transferred group. Nine of the 19 deaths in the transferred group were ascribed to potential transfers. After adjusting for prehospital Revised Trauma Score (RTS) and ISS, the odds ratio of death was 2.40 (95%CI: 1.07-5.40) for patients in the transfer group. When potential transfer patients were excluded from the analysis, the adjusted odds ratio of death was 1.14 (95%CI: 0.43-3.01). CONCLUSIONS After adjusting for survivor bias by including potential transfers, the results of this study suggest a lower risk of death for patients who are directly transported to a level I trauma centre than for patients who receive primary treatment in a level II or III centre and are transferred to a trauma centre. However, this finding was only significant when adjusting for survival bias and therefore we conclude that it is still uncertain if there is a lower risk of death for patients who are transported directly to a level I trauma centre.
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Affiliation(s)
- Stefan Mans
- Trauma Centre Brabant, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
| | | | | | - Koen W W Lansink
- Trauma Centre Brabant, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands; Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Verma V, Singh GK, Kumar S, Sharma V, Gautam V, Kumar S. Direct (presenting primarily to trauma center) versus indirect (referred or transferred) admission of patients to the Trauma Centre of King George Medical University: One-year prospective pilot study. Int J Crit Illn Inj Sci 2015; 5:155-9. [PMID: 26557485 PMCID: PMC4613414 DOI: 10.4103/2229-5151.164938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: India does not have a trauma registry. There is lack of base line demographic data of trauma victims that present directly to the trauma center and those that are transferred to the trauma center. Aim: To compare the clinical and demographic profile of directly admitted (presenting primarily to the trauma center) and referred (transferred to trauma center) patients at the trauma centre of King George Medical University. Materials and Methods: The demographic and clinical profiles of patients admitted on thirty-three consecutive Mondays were collected and compared. In addition, the demographic data of patients admitted on Mondays and eight randomly selected Wednesdays and Saturdays were analyzed to ascertain the representativeness of the studied sample. Results: Of the 572 patients in the study, 327 were referred and 245 were directly admitted. There was 27% mortality in the referred group and 22% mortality in the directly admitted group, the difference been statistically insignificant (P value 0.20). Patients referred from peripheral hospitals were more severely injured with a lower GCS and a higher TRISS, and had a higher proportion of multi system major trauma and severe head injury. Conclusion: Referred admitted (transferred) patients at the KGMU trauma center are more seriously injured than the patients presenting directly. Yet there is no statistically significant difference in the overall mortality. A future study focusing on certain sub-categories of patients such as those demonstrating subdural hematoma, GCS less than 9 or ISS more than 15 may yield interesting data.
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Affiliation(s)
- Vikas Verma
- Department of Orthopaedics, King George Medical Universtity, Lucknow, Uttar Pradesh, India
| | - Girish K Singh
- Department of Orthopaedics, King George Medical Universtity, Lucknow, Uttar Pradesh, India
| | - Santosh Kumar
- Department of Orthopaedics, King George Medical Universtity, Lucknow, Uttar Pradesh, India
| | - Vineet Sharma
- Department of Orthopaedics, King George Medical Universtity, Lucknow, Uttar Pradesh, India
| | | | - Suresh Kumar
- Department of General Surgery, King George Medical Universtity, Lucknow, Uttar Pradesh, India
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Verma V, Singh GK, Calvello EJ, Santoshkumar, Sharma V, Harjai M. Predictors of 1 year mortality in adult injured patients admitted to the trauma center. Int J Crit Illn Inj Sci 2015; 5:73-9. [PMID: 26157648 PMCID: PMC4477399 DOI: 10.4103/2229-5151.158389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Traditional approach to predicting trauma-related mortality utilizes scores based on anatomical, physiological, or a combination of both types of criteria. However, several factors are reported in literature to predict mortality independent of severity scores. The objectives of the study were to identify predictors of 1 year mortality and determine their magnitude and significance of association in a resource constrained scenario. MATERIALS AND METHODS Prospective observational study enrolled 572 patients. Information regarding factors known to affect mortality was recorded. Other factors which may be important in resource constrained settings were also included. This included referral from a peripheral hospital, number of surgeries performed on the patient, and his socioeconomic status (below poverty line (BPL) card). Patients were followed till death or upto a period of 1year. Logistic regression, actuarial survival analysis, and Cox proportionate hazard model were used to identify predictors of 1year mortality. Limited estimate of external validity of the study was obtained using bootstrapping. RESULTS Age of patient, Injury Severity Score (ISS), abnormal activated partial thromboplastin time (APTT), Glasgow Coma Scale (GCS) score at admission, and systolic blood pressure (BP) at admission were found to significantly predict mortality on logistic regression and Cox proportionate hazard models. Abnormal respiratory rate at admission was found to significantly predict mortality in the logistic regression model, but no such association was seen in Cox proportionate hazard model. Bootstrapping of the logistic regression model and Cox proportionate hazard model provide us with a set of factors common to both the models. These were age, ISS, APTT, and GCS score at admission. CONCLUSION Multivariate analysis (logistic and Cox proportionate hazard analysis) and subsequent bootstrapping provide us with a set of factors which may be considered as valid predictors universally. However, since bootstrapping only provides limited estimates of external validity, there is a need to test these factors against the well accepted requirements of external validity namely population, ecological, and temporal validity.
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Affiliation(s)
- Vikas Verma
- Department of Orthopaedics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Girish Kumar Singh
- Department of Orthopaedics, All India Institute of Medical Sciences, Patna, Bihar, India
| | | | - Santoshkumar
- Department of Orthopaedics, King George's Medical University Trauma Centre, King George's Medical University, Lucknow, India
| | - Vineet Sharma
- Department of Orthopaedics, King George's Medical University Trauma Centre, King George's Medical University, Lucknow, India
| | - Mamta Harjai
- Department of Anaesthesia, Ram ManoharLohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Impact of prehospital transfer strategies in major trauma and head injury: systematic review, meta-analysis, and recommendations for study design. J Trauma Acute Care Surg 2015; 78:164-77. [PMID: 25539218 DOI: 10.1097/ta.0000000000000483] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND It is unclear whether trauma patients should be transferred initially to a trauma center or local hospital. METHODS A systematic review and meta-analysis assessed the evidence for direct transport to specialist centers (SCs) versus initial stabilization at non-SCs (NSCs) for major trauma or moderate-to-severe head injury. Nine databases were searched from 1988 to 2012. Limitations in the study design informed recommendations for future studies. RESULTS Of 19 major trauma studies, five (n = 19,910) included patients not transferred to SCs and adjusted for case mix. Meta-analysis showed no difference in mortality for initial triage to NSCs versus SCs (odds ratio [OR] 1.03; 95% confidence interval [CI], 0.85-1.23). Within studies excluding patients not transferred to SCs, unadjusted analyses of mortality nonsignificantly favored transfer via NSCs (16 studies; n = 37,079; OR, 0.83; 95% CI, 0.68-1.01), whereas adjusted analysis nonsignificantly favored direct triage to SCs (9 studies; n = 34,266; OR, 1.18; 95% CI, 0.96-1.44). Of 11 head injury studies, all excluded patients not transferred to SCs and half were in remote locations. There was no significant mortality difference between initial triage to NSCs versus SCs within adjusted analyses (3 studies; n = 1,507; OR, 0.74; 95% CI, 0.31-1.79) or unadjusted analyses (10 studies; n = 3,671; OR, 0.87; 95% CI, 0.62-1.23). CONCLUSION This systematic review demonstrated no difference in outcomes for direct transport to a trauma center versus initial triage to a local hospital. Many studies had significant limitations in the design, and heterogeneity was high. Recommendations for future studies include the following: (i) inclusion of patients not transferred to SCs and those dying during transport; (ii) clear description of centers plus transport distances/times; (iii) adjustments for case mix; and (iv) assessment of morbidity and mortality. LEVEL OF EVIDENCE Systematic review, level IV.
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The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2015; 23:20. [PMID: 25882601 PMCID: PMC4329665 DOI: 10.1186/s13049-015-0095-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 01/19/2015] [Indexed: 11/20/2022] Open
Abstract
Background Because most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours. Methods This was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002–2005, 2006–2009, and 2010–2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models. Results Of the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure < 90 mmHg on admission (p = 0.021), ISS >15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1–2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours. Conclusions At a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome.
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Morrissey BE, Delaney RA, Johnstone AJ, Petrovick L, Smith RM. Do trauma systems work? A comparison of major trauma outcomes between Aberdeen Royal Infirmary and Massachusetts General Hospital. Injury 2015; 46:150-5. [PMID: 25270693 DOI: 10.1016/j.injury.2014.08.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 08/10/2014] [Accepted: 08/30/2014] [Indexed: 02/02/2023]
Abstract
Trauma is an important matter of public health and a major cause of mortality. Since the late 1980s trauma care provision in the United Kingdom is lacking when compared to the USA. This has been attributed to a lack of organisation of trauma care leading to the formation of trauma networks and Major Trauma Centres in England and Wales. The need for similar centres in Scotland is argued currently. We assessed the activity of two quite different trauma systems by obtaining access to comparative data from two hospitals, one in the USA and the other in Scotland. Aggregate data on 5604 patients at Aberdeen Royal Infirmary (ARI) from 1993 to 2002 was obtained from the Scottish Trauma Audit Group. A comparable data set of 16,178 patients from Massachusetts General Hospital (MGH). Direct comparison of patient demographics; injury type, mechanism and Injury Severity Score (ISS); mode of arrival; length of stay and mortality were made. Statistical analysis was carried out using Chi-squared and Cochran-Mantel-Haenszel. There were significant differences in the data sets. There was a higher proportion of penetrating injuries at MGH, (8.6% vs 2.6%) and more severely injured patients at MGH, patients with an ISS>16 accounted for nearly 22.1% of MGH patients compared to 14.0% at ARI. ISS 8-15 made up 54.6% of ARI trauma with 29.6% at MGH. Falls accounted for 50.1% at ARI and 37.9% at MGH. Despite the higher proportion of severe injuries at MGH and crude mortality rates showing no difference (4.9% ARI vs 5.2% MGH), pooled odds ratio of mortality was 1.4 (95% confidence interval 1.2-1.6) showing worse mortality outcomes at ARI compared to MGH. In conclusion, there were some differences in case mix between both data sets making direct comparison of the outcomes difficult, but the effect of consolidating major trauma on the proportion and number of severely injured patients treated in the American Level 1 centre was clear with a significant improvement in mortality in all injury severity groups.
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Affiliation(s)
- Brian E Morrissey
- University of Aberdeen, School of Medicine and Dentistry, Foresterhill, Aberdeen, Scotland AB25 2ZD, United Kingdom.
| | - Ruth A Delaney
- Trauma Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States
| | - Alan J Johnstone
- Trauma Orthopaedic Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland AB25 2ZD, United Kingdom
| | - Laurie Petrovick
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States
| | - R Malcolm Smith
- Trauma Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States
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Gillman L, Fatovich D, Jacobs I. Mortality of interhospital transfers originating from an emergency department in Perth, Western Australia. ACTA ACUST UNITED AC 2013; 16:144-51. [PMID: 24199899 DOI: 10.1016/j.aenj.2013.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 07/26/2013] [Accepted: 07/28/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND Interhospital transfer (IHT) is an integral part of emergency practice and required to access specialist care. AIM To identify factors that predict in-hospital mortality for IHT originating from an Emergency Department (ED). METHOD A retrospective cohort study utilising linked health data from the ED Information System database, Death Register and the Hospital Morbidity Data examined all IHTs originating from a public hospital ED and transferred to a tertiary hospital ED (ED-ED IHT), January 1st 2002-December 31st 2006. RESULTS There were 27,776 ED-ED IHTs. In-hospital mortality was 2.1% (95% CI 1.9-2.3%). Age, male sex, clinical deterioration by one or ≥2 levels on the Australasian Triage Scale (ATS) and circulatory or respiratory disease increased risk of mortality. Clinical improvement by one level on the ATS, injury or poisoning, digestive disease, transfer from 2004 to 2006 and exposure to access block reduced risk of mortality. Other than year of transfer, injury or poisoning, digestive and respiratory disease, these factors were also predictive of mortality within 1-day of transfer. CONCLUSION Multiple factors influence mortality following IHT from an ED. Awareness of these factors helps to optimise risk reduction. The limited infrastructure and resourcing available in non-tertiary hospitals are important considerations.
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Affiliation(s)
- Lucia Gillman
- University of Western Australia, School of Primary, Aboriginal and Rural Health Care, Faculty of Medicine, Dentistry and Health Sciences, Perth, Australia; The Education Centre, Royal Perth Hospital, Australia.
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Williams T, Finn J, Fatovich D, Jacobs I. Outcomes of different health care contexts for direct transport to a trauma center versus initial secondary center care: a systematic review and meta-analysis. PREHOSP EMERG CARE 2013; 17:442-57. [PMID: 23845080 DOI: 10.3109/10903127.2013.804137] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Within a trauma system, pre-hospital care is the first step in managing the trauma patient. Timely and appropriate transport of the injured patient to the most appropriate facility is important. Many trauma systems mandate that serious trauma cases are transported directly to a level I trauma center unless transfer to a closer hospital is deemed necessary to resuscitate and stabilize the patient prior to onward transfer to definitive care. Statistical and clinical heterogeneity is often high and is likely to be influenced by the heath care context. METHODS We conducted a systematic review and meta-analysis to compare patient outcomes for patients with serious trauma transported directly to a Level I/II trauma center ('direct' group) to those transported to a healthcare facility before transfer to the Level I/ II trauma center ('transfer' group). A search of bibliographic databases and secondary sources that focus on trauma was made. Studies were grouped by region: United States of America, Canada, Europe, Asia, Australia and New Zealand and South Africa. RESULTS The review included 43,554 patients from the 30 studies that met the selection criteria. Heterogeneity of the studies was high (I(2) 71%) overall but low for European, Asian, and Australian and New Zealand studies. There was considerable variation between studies in the structure, policies and practices of the respective trauma systems. The effect of "directness" on patient outcomes was inconsistent. CONCLUSION The current research evidence does not support nor refute a position that all serious trauma patients be routinely transported directly to a level I/II trauma center. As this is a complex issue, local health-care context and injury profile influence trauma policy and practice.
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Affiliation(s)
- Teresa Williams
- Faculty of Health Sciences, Curtin University, Perth, Western Australia.
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Radjou AN, Mahajan P, Baliga DK. Where do I go? A trauma victim's plea in an informal trauma system. J Emerg Trauma Shock 2013; 6:164-70. [PMID: 23960371 PMCID: PMC3746436 DOI: 10.4103/0974-2700.115324] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 09/24/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The three pillars of a good trauma system are the prehospital care, definitive care, and rehabilitative services. The prehospital care is a critical component of the efforts to lower trauma mortality. OBJECTIVE To study the prehospital profile of patients who died due to trauma, compute the time taken to reach our facility, find the cause of delay, and make feasible recommendations. MATERIALS AND METHODS A hospital-based study was performed at a trauma center in Puducherry from June 2009 to August 2010. Puducherry is a union territory of India in the geographical terrain of the state of Tamil Nadu. A total of 241deaths due to trauma were included. Apart from the demographic and injury characteristics, a detailed prehospital log was constructed regarding the time of incident, the referral patterns, care given in the prehospital phase, the distance travelled, and the total time taken to reach our center. RESULTS The majority (59%) of patients were referred, with stopovers at two consecutive referral centers (30%), needing at least two vehicles to transport to definitive care (70%), clocking unnecessary distances (67%), and delayed due to non therapeutic intervention (87%). The majority of deaths (66%) were due to head injury. Only 2.96% of referred cases reached us within the first hour. Few of the patients coming directly to us had vehicle change due to local availability and lack of knowledge of predestined definitive care facility. Overall, 94.6% of direct cases arrived within 4 h whereas 93.3% of referred cases required up to 7 h to arrive at definitive care. CONCLUSIONS Seriously injured patients lose valuable prehospital time because there is no direction regarding destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. The lack of direction is compounded in geographical areas that are situated at the border of political jurisdictions.
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Affiliation(s)
- Angeline N Radjou
- Department of Surgery, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - Preetam Mahajan
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Dillip K Baliga
- Department of Health and Family Welfare, Government of Puducherry, Puducherry, India
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Hoskins W, Jacob A, Wijeratne S, Campbell I, Taylor P. Splenic injury admitted to a rural Level 3 trauma centre: a 10-year audit. Aust J Rural Health 2013; 21:163-9. [PMID: 23782284 DOI: 10.1111/ajr.12035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2013] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE There is paucity of research documenting the management of splenic injury in rural Australia. No data exists for Rural, Remote and Metropolitan Area 4 locations. DESIGN A retrospective review of prospectively collected data. Records were additionally sought from transfer hospitals. A qualitative assessment of splenic trauma management in the Wimmera Region was also performed. SETTING Wimmera Health Care Group: Horsham Campus, a Level 3 trauma hospital between January 2000 and July 2011. PARTICIPANTS Patients coded with injury of spleen or excision procedure on spleen. INTERVENTIONS Nil MAIN OUTCOME MEASURES surgical vs. non-surgical management RESULTS Nineteen patients were included (mean age 27.8, range 8-54). Only 26% were from Horsham. Most injuries were due to sporting trauma/falls (53%) and motor vehicle accidents (37%). One patient died in theatre from massive trauma. Eleven patients were managed non-operatively. Seven patients had splenectomy performed. Four of these had delay in computed tomography scanning, delay to theatre and suffered major postoperative complication. The age (mean 39.9 versus 20.8) and Injury Severity Score (mean 21.9 versus 13.8) of patients requiring splenectomy was higher than those managed non-operatively. Six of the splenic injury admissions (32%) were transferred from surrounding general practitioner-run Rural, Remote and Metropolitan Area 5 hospitals. All of these patients had Victorian State Trauma Service-defined major trauma with an Injury Severity Score >15. There was an approximate 4-hour delay in transfer of these patients, with transfer occurring when clinical deterioration occurred. CONCLUSIONS Although splenic injury is uncommon in the Wimmera region, improved trauma triaging is required, with early transfer of unstable patients and high-energy trauma mechanisms. A lower threshold for computed tomography scanning is recommended.
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Affiliation(s)
- Wayne Hoskins
- Department of Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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The effect of age, severity, and mechanism of injury on risk of death from major trauma in Western Australia. J Trauma Acute Care Surg 2013; 74:647-51. [PMID: 23354264 DOI: 10.1097/ta.0b013e3182788065] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We examined the association between age, mechanism of injury, and Injury Severity Score (ISS) on mortality in major trauma. METHODS We used 9 years of population-based linked major trauma (ISS >15) registry data for Western Australia (N = 4,411). These were categorized using the Sampalis classification of injury severity: survivable (ISS 16-24), probably survivable (ISS 25-49), and nonsurvivable (ISS 50+). Age was categorized as younger than 15 years, 15 to 64 years, and 65 years or older. Multivariable linear logistic regression analysis was used to examine the risk of death. RESULTS Motor vehicle crashes (MVCs) were most prominent for those younger than 65 years, and falls dominated the 65 years and older group. The median ISS for the three age groups were 20, 25, and 24, respectively (p = 0.001). The proportion of deaths in the three groups were 7.2%, 11.5%, and 30.1%, respectively (p = 0.0001). Falls were the most common cause of death. The inflexion point, above which the risk of death increases exponentially, was age 47 years. For the potentially survivable ISS 25 to 49 group, the inflexion point was age 25 years. After adjusting for age and ISS, falls had the greatest risk for death (odds ratio, 1.62; 95% confidence interval, 1.21-2.18). A lower ISS had a disproportionate effect on the elderly. CONCLUSION The risk for major trauma death increases as age increases, with the inflexion point at age 47 years. Those younger than 15 years have a significantly lower ISS. The elderly have an increased risk for death following falls. LEVEL OF EVIDENCE Epidemiologic study, level II.
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Hill AD, Fowler RA, Nathens AB. Impact of Interhospital Transfer on Outcomes for Trauma Patients: A Systematic Review. ACTA ACUST UNITED AC 2011; 71:1885-900; discussion 1901. [DOI: 10.1097/ta.0b013e31823ac642] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVE Some major trauma (Injury Severity Score [ISS] >15) patients transported to a secondary hospital in Perth do not survive. We sought to describe this cohort and assess preventability. METHODS A cohort study from a previously developed cohort of trauma deaths in Western Australia from 1 July 1997 to 30 June 2006. A preformatted data sheet was used to collect a range of descriptive, time, physiological, and autopsy data. Trauma scores were calculated. Preventability was assessed using three approaches, based on ISS, Trauma Revised Injury Severity Score (TRISS) and individual case review. RESULTS There were 74 major trauma deaths, mean age 55.6 ± 26.3 years (range 3-95). Thirty-seven (50%) were motor vehicle crashes. The mean Revised Trauma Score was 3.84 ± 3.09 (0-7.84), median ISS 31 (interquartile range [IQR] 25-51), median TRISS 0.127 (IQR 0.031-0.772) and median time to death was 80 min (IQR 20 min-10 h 8 min). Severe head and chest injuries were the most common. Almost half (36, 48.6%) were receiving CPR on arrival to the hospital. The crude proportion of potentially preventable deaths, based on ISS, TRISS and case review, were 16.2%, 32.4% and 6.7%, respectively. However, these were predominantly elderly patients and a decision against resuscitation was recorded in 54%. CONCLUSIONS The proportion of potentially preventable major trauma deaths at Perth secondary hospitals is low. The most notable group were the elderly after falls, and trauma system efforts should be focused on this group. Primary prevention of major trauma represents the biggest opportunity for improvements in trauma survival.
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Affiliation(s)
- Daniel M Fatovich
- Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia.
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