SHAPING QUALITY THROUGH VISION, STRUCTURE, AND MONITORING OF PERFORMANCE AND QUALITY INDICATORS: IMPACT STORY FROM THE QUEBEC TRAUMA NETWORK

Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review

INTRODUCTION

Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality.

METHODS AND ANALYSIS

We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach.

ETHICS AND DISSEMINATION

Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations. PROSPERO REGISTRATION NUMBER: (ID454728).

Development and Validation of a Hospital Indicator of Activity-Based Costs for Injury Admissions

OBJECTIVES

To develop a hospital indicator of resource use for injury admissions.

METHODS

We focused on resource use for acute injury care and therefore adopted a hospital perspective. We included patients ≥16 years old with an Injury Severity Score >9 admitted to any of the 57 trauma centers of an inclusive Canadian trauma system from 2014 to 2018. We extracted data from the trauma registry and hospital financial reports and estimated resource use with activity-based costing. We developed risk-adjustment models by trauma center designation level (I/II and III/IV) for the whole sample, traumatic brain injuries, thoraco-abdominal injuries, orthopedic injuries, and patients ≥65 years old. Candidate variables were selected using bootstrap resampling. We performed benchmarking by comparing the adjusted mean cost in each center, obtained using shrinkage estimates, to the provincial mean.

RESULTS

We included 38 713 patients. The models explained between 12% and 36% (optimism-corrected r²) of the variation in resource use. In the whole sample and in all subgroups, we identified centers with higher- or lower-than-expected resource use across level I/II and III/IV centers.

CONCLUSIONS

We propose an algorithm to produce the indicator using data routinely collected in trauma registries to prompt targeted exploration of potential areas for improvement in resource use for injury admissions. The r² of our models suggest that between 64% and 88% of the variation in resource use for injury care is dictated by factors other than patient baseline risk.

Impact of trauma centre accreditation on mortality and complications in a Canadian trauma system: an interrupted time series analysis

BACKGROUND

Periodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design.

METHODS

We included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation.

RESULTS

There were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to -9.08 (95% CI -13.29 to -4.87) and -9.60 (95% CI -15.77 to -3.43) percentage point reductions in mortality and complications, respectively.

CONCLUSION

Accreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

Conceptualizing the key components of rehabilitation following major musculoskeletal trauma: A mixed methods service evaluation

RATIONALE, AIMS, AND OBJECTIVES

The reorganization of acute major trauma pathways in England has increased survival following traumatic injury, resulting in an increased patient population with diverse and complex needs requiring specialist rehabilitation. However, national audit data indicate that only 5% of patients with traumatic injuries have access to specialist rehabilitation, and there are limited guidelines or standards to inform the delivery of rehabilitation interventions for individuals following major trauma. This group concept mapping project aimed to identify the clinical service needs of individuals accessing our major trauma rehabilitation service, prioritize these needs, determine whether each of these needs is currently being met, and plan targeted service enhancements.

METHODS

Participants contributed towards a statement generation exercise to identify the key components of rehabilitation following major trauma, and individually sorted these statements into themes. Each statement was rated based on importance and current success. Multi-dimensional scaling and hierarchical cluster analysis were applied to the sorted data to produce themed clusters of ideas within concept maps. Priority values were applied to these maps to identify key areas for targeted service enhancement.

RESULTS

Fifty-eight patients and health care professionals participated in the ideas generation activity, 34 in the sorting, and 49 in the rating activity. A 7-item cluster map was agreed upon, containing the following named clusters: Communication and Coordination; Emotional and psychological wellbeing; Rehabilitation environment; Early rehabilitation; Structured therapy input; Planning for home; and Long-term support. Areas for targeted service enhancement included access to timely and adequate information provision, collaborative goal setting, and specialist pain management across the rehabilitation pathway.

CONCLUSION

The conceptual framework presented in this article illustrates the importance of a continuum of rehabilitation provision across the injury trajectory, and provides a platform to track future service changes and facilitate the codesign of new rehabilitation interventions for individuals following major trauma.

Impact of wearing a helmet on the risk of hospitalization and intracranial haemorrhage after a sports injury

BACKGROUND

Despite their reported protective effect against the occurrence of head injuries, helmets are still used inconsistently in sports in which they are optional. We aimed to assess the impact of helmet use on the risk of hospitalization and intracranial haemorrhage for trauma occurring during sport activities.

METHODS

Retrospective cohort of all patients who presented themselves, over an 18-month period, at the emergency department of a tertiary trauma centre for an injury sustained in a sport or leisure activity where the use of a helmet is optional. Impact of helmet use was assessed using multivariable regression analyses (relative risks, RR).

RESULTS

Among the 1,022 patients included in the study, half were cyclists and 40% were skiers or snowboarders. A total of 40 % of patients wore a helmet at the time of injury, 18% had a head injury, 16% were hospitalized and 13% of patients with a head injury had an intracranial haemorrhage. Among all patients, no association was observed between hospital admission and helmet use. However, helmet use in patients with a head injury was associated with significant reductions in the risks of hospitalization (RR 0.41 [95% CI: 0.22-0.76]) and intracranial haemorrhage (RR 0.28 [95% CI: 0.11-0.71]).

CONCLUSIONS

Results suggest that, in recreational athletes who sustain a head injury, helmet use is associated with a reduced risk of hospitalization (all sports) and intracranial haemorrhage (cyclists).