Routine Follow Up of Major Trauma Patients From Trauma Registries: What are the Outcomes?

Health service use in major trauma survivors: A population-based cohort study from Ontario, Canada

BACKGROUND

Little is known about how major trauma survivors access health services in the years following their injury. Our study sought to characterize patterns of health services use in trauma survivors following discharge from a provincial trauma center and to identify sociodemographic factors associated with service utilization.

METHODS

We conducted a population-based retrospective case-control study using linked administrative data on trauma survivors' population-based controls between April 1, 2011, and March 31, 2021. For each major trauma survivor, we matched four cases based on age and sex. The primary outcome was the composite rate (sum) of health service use episodes including outpatient visits to family physicians and specialists, emergency department visits, and acute care hospital admissions during the 5-year period following discharge from the trauma center. We used multivariate regression to compute rate ratios comparing the rates of health service use in trauma survivors versus controls and to assess for associations between sociodemographic variables and health services use.

RESULTS

The study cohort consisted of a total of 273,406 individuals: 55,060 trauma survivors and 218,346 controls. Trauma survivors were predominately males (71%) with a median age of 46 years (interquartile range, 26-65 years). Health service use in trauma survivors peaked within a year of hospital discharge but remained increased throughout the follow-up period. Trauma survivorship was associated with a 56% increase in overall health services use (adjusted rate ratio, 1.56; 95% confidence interval, 1.55-1.57), including an 88% increase in hospital admissions (adjusted rate ratio, 1.88; 95% confidence interval, 1.85-1.92). Male sex and rural residence were associated with a reduced overall use of health services but greater use of emergency department services.

CONCLUSION

Major trauma survivors have long-term health services needs that persist for years after discharge from the trauma center. Future research should focus on the understanding why trauma survivors have prolonged health services requirements and ensure that care needs are aligned with service delivery.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

What can they expect? Decreased quality of life and increased postoperative complication rate in patients with a fracture-related infection

BACKGROUND

By gaining insight into the Quality of Life (QoL) status and occurrence of complications, critical facets in the care for patients with Fracture-Related Infection (FRI) can be mitigated and measures can be taken to improve their outcome. Therefore, the aims of this study were to 1) determine the QoL in FRI patients in comparison to non-FRI patients and 2) describe the occurrence of other complications in both FRI and non-FRI patients.

METHODS

An ambidirectional cohort study was conducted in a level 1 trauma centre between January 1st 2016 and November 1st 2021. All patients who underwent surgical stabilisation of an isolated long bone fracture were eligible for inclusion. To avoid confounding, only patients with an Injury Severity Score (ISS) <16 were included. Data regarding patient demographics, fracture characteristics, treatment, follow-up and complications were collected of both non-FRI and FRI patients. QoL was assessed through the use of five-level EuroQol five-dimension (EQ-5D-5L) questionnaires twelve months post-injury.

RESULTS

A total of 134 patients were included in this study, of whom 38 (28%) FRI patients and 96 (72%) non-FRI patients. In comparison to non-FRI patients, FRI patients scored significantly worse on the QoL assessment regarding the index value (p = 0.012) and the domains mobility (p<0.001), usual activities (p = 0.010) and pain/discomfort (p = 0.009). Other postoperative complications were more often reported (p<0.001) in FRI patients (66%, n = 25/38) compared to non-FRI patients (27%, n = 26/96). During the median follow-up of 14.5 months (interquartile range (IQR) 9.5-26.5), 25 FRI patients developed a total of 49 distinctive complications besides FRI. The complications nonunion (18%, n = 9/49), infection other than FRI (e.g. line infection, urinary tract infection, pneumonia) (18%, n = 9/49) and implant failure (14%, n = 7/49) were the most frequently described in the FRI group.

CONCLUSION

Patients who suffered from an FRI have a decreased QoL in comparison to those without an FRI. Moreover, patients with an FRI have a higher rate of additional complications. These findings can help in patient counselling regarding the potential physical and mental consequences of having a complicated course of recovery due to an infection.

Measuring long-term outcomes after injury: current issues and future directions

Maximizing long-term outcomes for patients following injury is the next challenge in the delivery of patient-centered trauma care. The following review outlines three important components in trauma outcomes: (1) data gathering and monitoring, (2) the impact of traumatic brain injury, and (3) trajectories in recovery and identifies knowledge gaps and areas for needed future research.

Pain and mental health symptom patterns and treatment trajectories following road trauma: a registry-based cohort study

PURPOSE

This study aimed to characterise recovery from pain and mental health symptoms, and identify whether treatment use facilitates recovery.

METHODS

Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry participants without neurotrauma who had transport injury claims with the Transport Accident Commission from 2007 to 2014 were included (n = 5908). Latent transition analysis of pain Numeric Rating Scale, SF-12, and EQ-5D-3L pain and mental health items from 6 to 12 months, and 12 to 24 months post-injury were used to identify symptom transitions.

RESULTS

Four transition groups were identified: transition to low problems by 12-months; transition to low problems at 24-months; stable low problems; and no transition from problems. Group-based trajectory modelling of pain and mental health treatments found three treatment trajectories: low/no treatment, a moderate treatment that declined to low treatment 3-12 months post-injury, and increasing treatment over time. Predictors of pain and mental health recovery transitions, identified using multinomial logistic regression, were primarily found to be non-modifiable socioeconomic and health-related characteristics (e.g., higher education, working pre-injury, and not having comorbidities), and low treatment trajectories.

CONCLUSIONS

Targeted and collaborative rehabilitation should be considered for people at risk of persistent pain or mental health symptoms to optimise their recovery, particularly patients with socioeconomic disadvantage.IMPLICATIONS FOR REHABILITATIONTwo-thirds of people experience pain and/or mental health within the first 24-months after hospitalization for road trauma, of whom only 6-7% recover by 12-months, and a further 6% recover by 24-months post-injury.There were three main trajectories of administrative records of treatments received in the first two years after injury: 76 and 83% had low treatment, 18 and 12% had moderate then declining treatment levels, and 6 and 5% had stable high treatment for pain or mental health, respectively.People who recovered from pain or mental health symptoms generally had lower treatment and higher socioeconomic position, highlighting that coordinated rehabilitation care should be prioritized for people living with socioeconomic disadvantage.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trauma Registry Data as a Policy-Making Tool: A Systematic Review on the Research Dimensions

Objective:

To review the research dimensions of trauma registry data on health policy making.

Methods:

PubMed and EMBASE were searched until July 2020. Keywords were used on the search process included Trauma, Injury, Registry and Research, which were searched by using appropriate search strategies. The included articles had to: 1. be extracted from data related to trauma registries; 2- be written in English; 3- define a time period and a patient population; 4- preferably have more details and policy recommendations; and 5- preferably have a discussion on how to improve diagnosis and treatment. The results obtained from the included studies were qualitatively analyzed using thematic synthesis and comparative tables.

Results:

In the primary round of search, 19559 studies were retrieved. According to PRISMA statement and also performing quality appraisal process, 30 studies were included in the final phase of analysis. In the final papers’ synthesis, 14 main research domains were extracted and classified in terms of the policy implication and research priority. The domains with the highest frequency were “The relationship between trauma registry data and hospital care protocols for trauma patients” and “The causes of Disability Adjusted Life Years (DALYs) due to trauma”.

Conclusion:

Using trauma registry data as a tool for policy-making could be helpful in several ways, namely increasing the quality of patient care, preventing injuries and decreasing their number, figuring out the details of socioeconomic status effects, and improving the quality of researches in practical ways. Also, follow-up of patients after trauma surgery as one of the positive effects of the trauma registry can be the focus of attention of policy-making bodies.

Epidemiology and 6- and 12-Month Outcomes of Intimate Partner Violence and Other Violence-Related Traumatic Brain Injury in Major Trauma: A Population-Based Trauma Registry Study

OBJECTIVE

To compare the epidemiology, in-hospital outcomes, and 6-month and 12-month patient-reported, outcomes of major trauma patients with intimate partner violence (IPV)-related traumatic brain injury (TBI) with other interpersonal violence (OV)-related TBI.

SETTING

Victoria, Australia.

PARTICIPANTS

Adult (≥18 years) major trauma cases with TBI (concussion, skull fracture, or intracranial injury), injured through IPV or OV, between July 2010 and June 2020, and included on the population-based Victorian State Trauma Registry. There were 133 adult major trauma cases due to IPV and 1796 due to OV. The prevalence of TBI was 39% (n = 52) in the IPV group and 56% (n = 1010) in the OV group.

DESIGN

Registry-based cohort study.

MAIN MEASURES

Trauma care indicators and 6- and 12-month patient-reported outcomes (self-reported disability, Glasgow Outcome Scale-Extended, EQ-5D-3L, and return to work).

RESULTS

The annual incidence (95% CI) of major trauma involving TBI was 0.11 (0.08-0.14) per 100 000 population for IPV and 2.11 (1.98-2.24) per 100 000 for OV. A higher proportion of IPV-related cases were women (73% vs 5%), had sustained a severe TBI (Glasgow Coma Scale score 3-8; 27% vs 15%), were admitted to intensive care (56% vs 37%), and died in hospital (14% vs 5%). The median (interquartile range) time to definitive care (4.7 hours vs 3.3 hours) and head computed tomographic scan (5.0 hours vs 3.1 hours) was longer in the IPV group. Follow-up rates at 6 and 12 months were 71% and 69%, respectively. The 6- and 12-month outcomes were generally poorer in the IPV-related group.

CONCLUSION

The incidence of IPV-related major trauma with TBI was low. However, the prevalence of severe TBI, the time to key aspects of clinical care, in-hospital mortality, and longer-term work-related disability were higher. However, power to detect differences was low due to the small number of IPV-related cases compared with the OV group.

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.

Long-term outcomes of major trauma with unstable open pelvic fractures: A population-based cohort study

Aims

The aims of this study were to describe the profile and longer-term outcomes of major trauma patients with unstable open pelvic fractures.

Patients and methods

An observational study was performed using data from the population-based Victorian State Trauma Registry. Adult (≥16 years) major trauma patients who had sustained an unstable open pelvic fracture between 1 July 2010 and 30 June 2017 in Victoria (Australia) were included. Patient demographics, injury event, severity and management data were extracted. Patients were followed up at 6, 12 and 24 months post-injury to collect information about health status, function and return to work.

Results

There were 67 patients. The mean (SD) age was 41.4 (18.3) years, and 66% were male. Seventy-six per cent were road traffic injuries, 96% were managed at Level 1 trauma centres and all were multi-trauma patients. A third were Tile C fractures and 80% underwent surgical stabilisation of the pelvic injury. Eighty per cent were admitted to intensive care. The in-hospital mortality rate was 9%. Most (89%) survivors were discharged to an inpatient rehabilitation facility. The proportion classified as ‘severe disability’ on the Glasgow Outcome-Scale Extended declined from 38% at 6 months to 19% at 24 months. The overall three-level EuroQoL five-dimensional instrument score increased with time indicating better health status, and 50% of patients returned to work by 24 months.

Conclusions

Major trauma with unstable, open pelvic fracture is rare. Low in-hospital mortality was observed. Most survived to hospital discharge and outcomes improved with time post-injury, but 75% of patients experienced persistent pain and ongoing mobility and activity restrictions.

Factors Associated With Long-term Outcomes After Injury: Results of the Functional Outcomes and Recovery After Trauma Emergencies (FORTE) Multicenter Cohort Study

OBJECTIVE

The aim of this study was to determine factors associated with patient-reported outcomes, 6 to 12 months after moderate to severe injury.

SUMMARY OF BACKGROUND DATA

Due to limitations of trauma registries, we have an incomplete understanding of factors that impact long-term patient-reported outcomes after injury. As 96% of patients survive their injuries, several entities including the National Academies of Science, Engineering and Medicine have called for a mechanism to routinely follow trauma patients and determine factors associated with survival, patient-reported outcomes, and reintegration into society after trauma.

METHODS

Over 30 months, major trauma patients [Injury Severity Score (ISS) ≥9] admitted to 3 Level-I trauma centers in Boston were assessed via telephone between 6 and 12 months after injury. Outcome measures evaluated long-term functional, physical, and mental-health outcomes. Multiple regression models were utilized to identify patient and injury factors associated with outcomes.

RESULTS

We successfully followed 1736 patients (65% of patients contacted). More than half (62%) reported current physical limitations, 37% needed help for at least 1 activity of daily living, 20% screened positive for posttraumatic stress disorder (PTSD), all SF-12 physical health subdomain scores were significantly below US norms, and 41% of patients who were working previously were unable to return to work. Age, sex, and education were associated with long-term outcomes, while almost none of the traditional measures of injury severity were.

CONCLUSION

The long-term sequelae of trauma are more significant than previously expected. Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery. This suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severity.

Long-term patient-reported outcome measures after injury: National Trauma Research Action Plan (NTRAP) scoping review protocol

Background

A significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics.

Objectives

To describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury.

Methods

A systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.

Dissemination

This scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals.

Measurement of mobility and physical function in hospitalised trauma patients: A systematic review of instruments and their measurement properties

Introduction

It is well recognised that organised trauma systems reduce trauma patient mortality. As established systems mature, there is an increasing need to better understand the patient recovery trajectory. Mobility and physical function are key aspects of recovery, but the optimal instruments for measurement in the acute hospital setting remain unclear.

Methods

A systematic review was undertaken to identify and describe mobility and physical function instruments scored by direct patient assessment, in adult trauma patients in an acute hospital setting. Databases were searched with no date restrictions. Instruments that were specific to subgroups or related to individual conditions, diseases or joints were excluded. The consensus-based standards for the selection of health measurement instruments checklist was used to assess risk of bias where relevant. Clinimetric properties were reported where possible, including reliability, validity and responsiveness.

Results

Fourteen thousand one hundred and fourteen articles were identified with 37 eligible for final review, including six instruments. None had been specifically designed for use in a heterogeneous range of trauma patients. The Functional Independence Measure was the most commonly cited (n = 10 studies), with evidence of construct validity, responsiveness and minimal floor/ceiling effects (<3%). The Acute Care Index of Function (n = 1 study) was found to be valid and responsive whilst the modified Iowa Level of Assistance (n = 2 studies) was reliable and responsive, but ceiling effects ranged from 26% to 37%. Little clinimetric data were available for other measures.

Conclusion

Evidence from a few studies show promise for the use of the Functional Independence Measure, Acute Care Index of Function and modified Iowa Level of Assistance to measure mobility and physical function in trauma patients, however comprehensive clinimetric data are lacking. Future research should test these scores in specifically designed clinimetric property studies in defined trauma patient populations. This would enable the identification of a gold standard measure for evaluating treatment effectiveness, enabling benchmarking between centres, allow prediction of recovery pathways and optimise trauma patient outcomes.

Long-term outcomes after operative treatment for tibial pilon fractures

OBJECTIVES

Aims of the present study were to establish generalizable outcome data on long-term functional outcomes and health-related quality of life (HRQoL) after operative treatment of pilon fractures on a large scale. Second, it was aimed to examine factors associated with these outcomes.

DESIGN

Retrospective cohort study with follow-up by questionnaire.

SETTING

Two level 1 trauma centers.

PATIENTS

Two hundred twenty-five of 480 eligible patients completed the survey (response rate 47%).

INTERVENTION

Open reduction internal fixation for tibial pilon fracture.

MAIN OUTCOME MEASUREMENTS

Ankle function measured using the Foot and Ankle Ability Measure, physical function using the Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire and HRQoL using the EuroQol 5-Dimensions 3-Level (EQ-5D-3L) questionnaire.

RESULTS

At a medium follow-up of 82 months (82 (interquartile range (IQR), 45-120), median Foot and Ankle Ability Measure was 74 (IQR, 57-82), median PROMIS PF 49 (IQR, 44-57), median EQ-5D-3L 0.81 (IQR, 0.71-0.84). HRQoL was significantly lower compared to a reference population (P < .001). In multivariable regression analyses, smoking was associated with poorer HRQoL. Higher body mass index, deep infection, and lower HRQoL were associated with worse ankle function.

CONCLUSIONS

Long-term patient-reported outcomes after operative treatment of pilon fractures reveal impaired functionality and lower HRQoL compared to an uninjured reference population. As pilon fractures can have significant effects on a patient's life, patients should be counseled about the expected long-term outcomes to set realistic expectations. This study emphasizes the importance of obtaining both general and region-specific measures when evaluating outcomes after injury, in order to evaluate the injury of interest in the accurate context.

LEVEL OF EVIDENCE

Prognostic level III.

Injury-related variation in patient-reported outcome after musculoskeletal trauma: a systematic review

PURPOSE

The purpose of this study was to explore injury-related characteristics that differentiate between patient-reported outcomes (PROs) following traumatic musculoskeletal injury.

METHODS

We reviewed English-language articles in PubMed/MEDLINE, Google Scholar, and the Cochrane Database of Systematic Reviews (January 1995 to September 2018). We included studies that compared patient-reported outcomes of musculoskeletal trauma based on injury characteristics, and excluded studies related to development or validation of outcome tools without implementation, measurement, or comparison. Studies on patients with isolated neurotrauma or spine trauma were not included. Study level of evidence was assessed by 2 reviewers using the modified Oxford Centre for Evidence-based Medicine rating system.

RESULTS

A total of 20 studies (21 articles) that reported on a total of 10,186 patients were included (4 were prospective cohort-studies, 8 were matched-control retrospective cohort-studies, and 8 were retrospective cohort-studies). Median minimum follow-up was 3 years (range 0.5-10 years). Injury-related factors associated with worse PROs were polytrauma or multiple injuries (10 studies), neurotrauma (11 studies), and high-energy injury mechanism (7 studies). Among all studies, 32 different outcome metrics were used (17 general health status metrics and 15 limb-specific metrics) making meta-analysis infeasible.

CONCLUSIONS

Based on the included studies, we propose a framework where musculoskeletal injuries occur in one of 4 scenarios that is associated with a different context-dependent outcome: (1) polytrauma with neurotrauma, (2) polytrauma without neurotrauma, (3) high-energy monotrauma, and (4) low-energy monotrauma. Our results suggest that standardization of outcome instruments is needed to facilitate future meta-analyses that assess PROs in this population.

Association of pain after trauma with long-term functional and mental health outcomes

BACKGROUND

Chronic pain after trauma is associated with serious clinical, social, and economic burden. Due to limitations in trauma registry data and previous studies, the current prevalence of chronic pain after trauma is unknown, and little is known about the association of pain with other long-term outcomes. We sought to describe the long-term burden of self-reported pain after injury and to determine its association with positive screen for posttraumatic stress disorder (PTSD), functional status, and return to work.

METHODS

Trauma survivors with moderate or severe injuries and one completed follow-up interview at either 6 months or 12 months after injury were identified from the Functional Outcomes and Recovery after Trauma Emergencies project. Multivariable logistic regression models clustered by facility and adjusting for confounders were used to obtain the odds of positive PTSD screening, not returning to work, and functional limitation at 6 months and 12 months after injury, in trauma patients who reported to have pain on a daily basis compared to those who did not.

RESULTS

We completed interviews on 650 patients (43% of eligible patients). Half of patients (50%) reported experiencing pain daily, and 23% reported taking pain medications daily between 6 months and 12 months after injury. Compared to patients without pain, patients with pain were more likely to screen positive for PTSD (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.97-8.85), have functional limitations for at least one daily activity (OR, 2.42; 95% CI, 1.38-4.26]), and not return to work (OR, 1.86; 95% CI, 1.02-3.39).

CONCLUSIONS

There is a significant amount of self-reported chronic pain after trauma, which is in turn associated with positive screen for PTSD, functional limitations, and delayed return to work. New metrics for measuring successful care of the trauma patient are needed that span beyond mortality, and it is important we shift our focus beyond the trauma center and toward improving the long-term morbidity of trauma survivors.

LEVEL OF EVIDENCE

Therapeutic/Care management, level III.

Long-term follow-up of patients treated for traumatic injury regarding physical and psychological function and health-related quality of life

PURPOSE

Trauma patients often suffer for long time after their injury with physical and psychological problems. Patient-reported outcome measurements (PROM) help us to understand outcomes beyond mortality. The aim of the study was to describe a sample of Swedish trauma patients, regarding their physical function, psychological morbidity, and quality of life after trauma.

METHODS

The study population was sourced from the Swedish Trauma Register: taking 1 month of data from five hospitals, over three consecutive years. 218 patients met the inclusion criteria, 147 data sets were used. Inclusion criteria included: age ≥ 18; New Injury Severity Scale (NISS) ≥ 9; and discharged alive. Data were collected at 3, 6, and 12 months after the trauma. EuroQol-5D (EQ-5D), Posttraumatic Symptom Scale-10 (PTSS-10) questionnaires and Glasgow Outcome Score (GOS) instrument were used with additional questions about pain and return to work.

RESULTS

12 months after the trauma: full functional recovery (GOS 5) was seen in 68% of the patients; 59% reported difficult or moderate pain or discomfort; and 44.5% of the patients had returned to work. In EQ-5D mobility dimension, no recovery was evident between 6 and 12 months. Twenty percent of the patients had significant symptoms for PTSD after 6 months and 16% after 3 months and 12 months.

CONCLUSION

Trauma patients had decreased physical function and psychological morbidity up to 1 year after the initial injury. Incorporating PROM in the follow-up after trauma is important to understand the patient's perspective of care and treatment.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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.

Retention strategies in longitudinal cohort studies: a systematic review and meta-analysis

BACKGROUND

Participant retention strategies that minimise attrition in longitudinal cohort studies have evolved considerably in recent years. This study aimed to assess, via systematic review and meta-analysis, the effectiveness of both traditional strategies and contemporary innovations for retention adopted by longitudinal cohort studies in the past decade.

METHODS

Health research databases were searched for retention strategies used within longitudinal cohort studies published in the 10-years prior, with 143 eligible longitudinal cohort studies identified (141 articles; sample size range: 30 to 61,895). Details on retention strategies and rates, research designs, and participant demographics were extracted. Meta-analyses of retained proportions were performed to examine the association between cohort retention rate and individual and thematically grouped retention strategies.

RESULTS

Results identified 95 retention strategies, broadly classed as either: barrier-reduction, community-building, follow-up/reminder, or tracing strategies. Forty-four of these strategies had not been identified in previous reviews. Meta-regressions indicated that studies using barrier-reduction strategies retained 10% more of their sample (95%CI [0.13 to 1.08]; p = .01); however, studies using follow-up/reminder strategies lost an additional 10% of their sample (95%CI [- 1.19 to - 0.21]; p = .02). The overall number of strategies employed was not associated with retention.

CONCLUSIONS

Employing a larger number of retention strategies may not be associated with improved retention in longitudinal cohort studies, contrary to earlier narrative reviews. Results suggest that strategies that aim to reduce participant burden (e.g., flexibility in data collection methods) might be most effective in maximising cohort retention.

Comparison of the performance of mental health, drug and alcohol comorbidities based on ICD-10-AM and medical records for predicting 12-month outcomes in trauma patients

Background

Many outcome studies capture the presence of mental health, drug and alcohol comorbidities from administrative datasets and medical records. How these sources compare as predictors of patient outcomes has not been determined. The purpose of the present study was to compare mental health, drug and alcohol comorbidities based on ICD-10-AM coding and medical record documentation for predicting longer-term outcomes in injured patients.

Methods

A random sample of patients (n = 500) captured by the Victorian State Trauma Registry was selected for the study. Retrospective medical record reviews were conducted to collect data about documented mental health, drug and alcohol comorbidities while ICD-10-AM codes were obtained from routinely collected hospital data. Outcomes at 12-months post-injury were the Glasgow Outcome Scale – Extended (GOS-E), European Quality of Life Five Dimensions (EQ-5D-3L), and return to work. Linear and logistic regression models, adjusted for age and gender, using medical record derived comorbidity and ICD-10-AM were compared using measures of calibration (Hosmer-Lemeshow statistic) and discrimination (C-statistic and R²).

Results

There was no demonstrable difference in predictive performance between the medical record and ICD-10-AM models for predicting the GOS-E, EQ-5D-3L utility sore and EQ-5D-3L mobility, self-care, usual activities and pain/discomfort items. The area under the receiver operating characteristic (AUC) for models using medical record derived comorbidity (AUC 0.68, 95% CI: 0.63, 0.73) was higher than the model using ICD-10-AM data (AUC 0.62, 95% CI: 0.57, 0.67) for predicting the EQ-5D-3L anxiety/depression item. The discrimination of the model for predicting return to work was higher with inclusion of the medical record data (AUC 0.69, 95% CI: 0.63, 0.76) than the ICD-10-AM data (AUC 0.59, 95% CL: 0.52, 0.65).

Conclusions

Mental health, drug and alcohol comorbidity information derived from medical record review was not clearly superior for predicting the majority of the outcomes assessed when compared to ICD-10-AM. While information available in medical records may be more comprehensive than in the ICD-10-AM, there appears to be little difference in the discriminative capacity of comorbidities coded in the two sources.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3248-x) contains supplementary material, which is available to authorized users.

Level of agreement between medical record and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients

Background:

Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records.

Objective:

The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population.

Method:

A random sample of patients ( n = 500) captured by the Victorian State Trauma Registry and definitively managed at the state’s adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record–based co-morbidities was determined using Cohen’s κ and prevalence-adjusted bias-adjusted kappa (PABAK) statistics.

Results:

The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46; 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52; 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40; 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46; 95% CI: 0.37, 0.54).

Conclusion:

Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development.

Implications:

This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.

Clinical Profile, Treatment Details and Survival of Trauma Patients Treated at Intensive Care Unit in a Level II Trauma Center

OBJECTIVE

This retrospective study evaluated all trauma patients who were admitted to intensive care unit in Turku University Central Hospital, Finland in 2000-2004.

METHODS

We reviewed details of demographic factors, injury mechanism, treatment details, and the overall recovery of patients after the hospital episode.

RESULTS

A total of 427 trauma patients were identified, 66% of these were severely injured (ISS > 15). 79% of patients were men. The median age of 44 years. The most frequent injury type was road traffic accidents, leisure-time accidents and injury mechanism a high-energy blunt trauma. Head injuries were the most frequently diagnosed severe injury and 59% of the patients were multiple traumatized.

CONCLUSIONS

Current results suggest that the overall survival of these patients is satisfactory, although, the head and cervical spine injuries are still often related to compromised prognosis. Despite the improvements in morbidity and mortality of these patients during last decades, still almost every tenth of trauma patient treated in the ICU dies to the complications of the injury.

Implementing Major Trauma Audit in Ireland

BACKGROUND

There are 27 receiving trauma hospitals in the Republic of Ireland. There has not been an audit system in place to monitor and measure processes and outcomes of care. The National Office of Clinical Audit (NOCA) is now working to implement Major Trauma Audit (MTA) in Ireland using the well-established National Health Service (NHS) UK Trauma Audit and Research Network (TARN).

AIMS

The aim of this report is to highlight the implementation process of MTA in Ireland to raise awareness of MTA nationally and share lessons that may be of value to other health systems undertaking the development of MTA.

METHODS

The National Trauma Audit Committee of the Royal College of Surgeons in Ireland, consisting of champions and stakeholders in trauma care, in 2010 advised on the adaptation of TARN for Ireland. In 2012, the Emergency Medicine Program endorsed TARN and in setting up the National Emergency Medicine Audit chose MTA as the first audit project. A major trauma governance group was established representing stakeholders in trauma care, a national project co-ordinator was recruited and a clinical lead nominated. Using Survey Monkey, the chief executives of all trauma receiving hospitals were asked to identify their hospital's trauma governance committee, trauma clinical lead and their local trauma data co-ordinator. Hospital Inpatient Enquiry systems were used to identify to hospitals an estimate of their anticipated trauma audit workload.

RESULTS

There are 25 of 27 hospitals now collecting data using the TARN trauma audit platform. These hospitals have provided MTA Clinical Leads, allocated data co-ordinators and incorporated MTA reports formally into their clinical governance, quality and safety committee meetings. There has been broad acceptance of the NOCA escalation policy by hospitals in appreciation of the necessity for unexpected audit findings to stimulate action.

CONCLUSION

Major trauma audit measures trauma patient care processes and outcomes of care to drive quality improvement at hospital and national level. MTA will facilitate the strategic development of trauma care in Ireland by monitoring processes and outcomes and the effects of changes in trauma service provision.

Impact of the introduction of an integrated adult retrieval service on major trauma outcomes

OBJECTIVES

The primary aim of this study was to examine the impact of the introduction of an integrated adult critical care patient retrieval system in Victoria, Australia, on early clinical outcomes for major trauma patients who undergo interhospital transfer. The secondary aims were to examine the impact on quality and process measures for interhospital transfers in this population, and on longer-term patient-reported outcomes.

METHODS

This is a cohort study using data contained in the Victorian State Trauma Registry (VSTR) for major trauma patients >18 years of age between 2009 and 2013 who had undergone interhospital transfer. For eligible patients, data items were extracted from the VSTR for analysis: demographics, injury details, hospital details, transfer details, Adult Retrieval Victoria (ARV) coordination indicator and transfer indicator, key clinical observations and outcomes.

RESULTS

There were 3009 major trauma interhospital transfers in the state with a transfer time less than 24 h. ARV was contacted for 1174 (39.0%) transfers. ARV-coordinated metropolitan transfers demonstrated lower adjusted odds of inhospital mortality compared with metropolitan transfers occurring without ARV coordination (OR 0.39, 0.15 to 0.97). Adjusting for destination hospital type demonstrates that this impact was principally due to ARV facilitation of a Major Trauma Service as the destination for transferred patients (OR 0.41, 0.16 to 1.02). The median time spent at the referral hospital was lower for ARV-coordinated transfers (5.4 h (3.8 to 7.5) vs 6.1 (4.2 to 9.2), p<0.0001).

CONCLUSIONS

In a mature trauma system, an effective retrieval service can further reduce mortality and improve long-term outcomes.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

[The TraumaRegister DGU® as data source for monitoring severe injuries]

BACKGROUND

The TraumaRegister DGU® of the German Society for Trauma Surgery (TR-DGU) has collected data on the treatment of severely injured accident victims in Germany since 1993. Due to the current number of more than 600 participating clinics which regularly receive quality comparison reports, these register data are becoming an increasingly more valuable source for healthcare research.

OBJECTIVES

The aims of this article are to describe the potential of the TR-DGU for dealing with epidemiological questions and for describing the quality of the process and results for treatment of severely injured patients.

MATERIAL AND METHODS

The TR-DGU includes approximately 100 details per patient on the person, the circumstances of the accident, the injury pattern, the preclinical and hospital treatment, the condition of the patient and the outcome. Using comparative analyses the observed mortality is adjusted by considering prognostically relevant findings. Some key features of the register are reported for patients who were treated in German hospitals between 2002 and 2012 with an injury severity score (ISS) of  ≥9 points.

RESULTS

Since 1993 more than 122,000 patients have been included in the register. The majority are traffic accident victims (57 %), followed by patients with falls from low heights (< 3 m, 17 %) or greater heights (> 3 m, 16 %). Among the traffic accident victims approximately one half are car drivers or passengers (46 %), one quarter are motorbike drivers (25 %) and the rest are cyclists (14 %) and pedestrians (13 %). The mortality of patients with an ISS ³ 9 is 12.8 %. This value is approximately 1-2 % below the expected prognosis based on data from the 1990s.

DISCUSSION

The TR-DGU is not only a successful instrument for external quality assurance of the treatment of severely injured patients but also an increasingly more valuable source for scientific evaluation within the framework of healthcare research. The introduction of regional trauma networks by the DGU has made a substantial contribution to the comprehensive compilation of severely injured patients and allows increasingly more detailed information on the epidemiology of severe injuries in Germany to be compiled.

Health outcome after major trauma: what are we measuring?

Importance

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

Objective

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

Data Sources

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

Study selection and data extraction

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

Results

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

Conclusion

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

Long-term mortality after admission to hospital for trauma: A review

Trauma is associated with significant acute morbidity and mortality. However, advances in the delivery of trauma care have resulted in considerable improvements in the short-term mortality from trauma. Recent studies have shown that survivors of trauma are at significant risk of delayed long-term mortality that is above that expected for a similar uninjured cohort of patients. Few studies have provided a detailed analysis of the determinants of this increased risk of death, and even fewer publications have examined the causes of death in these patients. This information is relevant because an increased number of patients will survive their injuries as acute trauma care continues to improve. It may also highlight opportunities for interventions that reduce the risk of delayed death in a population of patients that is generally young and healthy at the time of injury. As such, this article will review the literature on the long-term mortality rate and its determinants among patients who are hospitalized for severe injuries.

Emergency endovascular management of penetrating gunshot injuries to the arteries in the face and neck: a case series and review of the literature

INTRODUCTION

Penetrating gunshot injuries (GSI) to supra-aortic arteries that cause life-threatening blood loss or major neurologic deficits are increasingly managed using modern endovascular treatment (EVT). We report our experience with EVT of acute GSIs and review the existing literature.

METHODS

Emergency EVT was performed in nine of 10 patients (7 men, age 17-50 years) with acute GSIs to supra-aortic arteries requiring acute management. One patient presented with acute and delayed injuries and underwent EVT 4 weeks after initial admission. Patient selection was based on clinical presentation and radiographic findings from a cohort of 55 patients with GSIs to the face, neck or head between February 2009 and March 2012.

RESULTS

EVT was successfully performed in all patients. Two transections of the vertebral arteries were embolized with coils and/or liquid embolic agent (acrylic glue). Eight penetrated external carotid artery branches were occluded with liquid embolic agents (acrylic glue or Onyx) or particles. One severe dissection of the internal carotid artery with a subsequent thromboembolic event was treated with stenting. All except one patient survived with minor or no residual deficits.

CONCLUSIONS

Emergency management of GSI injuries to the head and neck may involve all aspects of current EVT. Understanding endovascular techniques and being able to make rapid and appropriate treatment decisions in the setting of acute GSI to the face and neck can be a life-saving measure and greatly benefits the patient's outcome.

Prevalence and predictors of return to work in hospitalised trauma patients during the first year after discharge: a prospective cohort study

OBJECTIVE

The aim of the study was to investigate the proportion of patients who return to work and predictors of return to pre-injury level of work participation the first year after trauma.

METHODS

A prospective single-centre study of 188 patients aged 18-65 years with different degrees of injury severity was carried out in a trauma referral centre. All patients were working or studying full or part time before the injury. The first assessments were performed a median time of 27 days after discharge. Participation in work/education was measured 3 and 12 months after the first assessment with self-report questionnaires. The Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale (IES) were independent measures of anxiety, depression and post-traumatic stress symptoms (PTS) at baseline and 3 months. The Life Orientation Test Revised (LOT-R) measured optimism and pessimism at baseline. Predictors of return to work were identified by multiple logistic regression analysis.

RESULTS

After one year, 131 patients (70%) had returned to the same level of participation in work or education; 95 (50%) had returned at 3 months. Independent predictors of return to work after 3 months were low age, low Injury Severity Score (ISS) score, not needing ventilator treatment and low score for depression symptoms, adjusted for gender (Nagelkerke R square 0.38). Low ISS, absence of serious head injury, low HADS depression score and an optimistic life orientation remained significant predictors of return to work at the same level after 12 months (Nagelkerke R square 0.38). In addition, good physical function (SF-36 PF score>65) at 3 months was an independent predictor of return to work at 12 months in the 93 patients who had not returned to work at 3 months.

CONCLUSION

Independent predictors of return to work at 3 months were low age, low ISS and absence of depression symptoms. At 12 months, independent predictors of return to work were low ISS, low depression score and an optimistic life orientation. To promote early return to work, trauma patients might be screened for depression symptoms and pessimism, and intervention or treatment provided for those in need.

Trauma Incidents Attended by Emergency Medical Services in Victoria, Australia

Introduction:

International literature describing the profile of trauma patients attended by a statewide emergency medical services (EMS) system is lacking. Most literature is limited to descriptions of trauma responses for a single emergency medical service, or to patients transported to a specific Level-1 trauma hospital. There is no Victorian or Australian literature describing the type of trauma patients transported by a state emergency medical service.

Purpose:

The purpose of this study was to define a profile of all trauma incidents attended by statewide EMS.

Methods:

A retrospective cohort study of all patient care records (PCR) for trauma responses attended by Victorian Ambulance Services for 2002 was conducted. Criteria for trauma categories were defined previously, and data were extracted from the PCRs and entered into a secure data repository for descriptive analysis to determine the trauma profile. Ethics committee approval was obtained.

Results:

There were 53,039 trauma incidents attended by emergency ambulances during the 12-month period. Of these, 1,566 patients were in physiological distress, 11,086 had a significant pattern of injury, and a further 8,931 had an identifiable mechanism of injury. The profile includes minor trauma (n = 9,342), standing falls (n = 20,511), no patient transported (n = 3,687), and deceased patients (n = 459).

Conclusions:

This is a unique analysis of prehospital trauma. It provides a baseline dataset that may be utilized in future studies of prehospital trauma care. Additionally, this dataset identifies a ten-fold difference in major trauma between the prehospital and the hospital assessments.

Longer term health of young and middle-aged adults following unintentional falls at home resulting in hospitalisation

Unintentional falls at home are a common cause of admissions to hospital amongst young and middle-aged adults. This population-based study investigated the longer-term health, physical and psychological outcomes following such injuries, and the predictors of these sequelae.

METHOD

Individuals aged 25-60 years admitted to hospital in the Auckland region between July 2005 and June 2006 following an unintentional fall at home were interviewed soon after the injury (baseline) and 15-months following the injury. Information collected at baseline on pre-injury status was analysed in relation to changes in general health and functioning, psychological outcomes, and role limitations at follow-up.

RESULTS

Of the 328 participants eligible for study, 251 (77%) completed the follow-up interview. Reductions in general health and overall functioning (compared with pre-injury status) were reported by 25% and 43% of participants, respectively. In multivariate analyses, predictors of specific adverse outcomes at follow-up included increasing age (reduction in functioning), lower limb injuries (reductions in general health and functioning); female gender (psychological sequelae); injury severity score ≥9 (anxiety and depression); and length of hospital stay (fear of falling and post-traumatic stress symptoms).

CONCLUSIONS

The significant longer-term reductions in health and levels of functioning reveal the importance of strengthening efforts to prevent falls amongst young and middle-aged adults, and identifying groups at increased risk of longer-term disability who could benefit from targeted interventions.

Long-term mortality outcome of victims of major trauma

INTRODUCTION

Although trauma is associated with major acute morbidity and mortality, its long-term outcome is less well defined. We sought to define the rate of readmission to hospital and long-term mortality of victims of major trauma.

PATIENTS AND METHODS

All Calgary Health Region residents presenting to the regional trauma program with an injury severity score (ISS) > or = 12 between April 1, 2002 and March 31, 2006 were included. Readmission to hospital within one-year and deaths occurring on or before September 30, 2008 were identified using regional and provincial databases.

RESULTS

A total of 2652 incident major trauma episodes occurred among 2630 residents; the median age was 41.3 [interquartile range (IQR); 23.1-59.2] years, 1,915 (72%) were male, the median ISS was 19 (IQR; 16-25), and 717 (27%) required intensive care unit admission. Among 2350 survivors to hospital discharge, 537 readmissions occurred (median length of stay 4.0; IQR; 1.6-7.5 days) among 386 patients within one-year of the incident trauma episode, and 323 (60%) required surgery. Re-admitted patients were older, had higher ISS, had longer initial admission length of stay, and were less likely to have sports related injuries. Two hundred and fifteen (8%) of 2350 survivors to hospital discharge died during the median study follow-up duration of 1543 (IQR; 1181-1934) days. Case-fatality rates for 28 days, 90 days, and 365 days were 304 (11%), 327 (12%), and 370 (14%), respectively. Among survivors to 28 days (n=2348), 66 (3%) suffered delayed one-year mortality (i.e. death occurred between 28 days and 365 days post-trauma). Age > or = 65 years of age, initial hospitalisation for > or = 28 days, and unintentional falls were independently associated with delayed one-year mortality.

CONCLUSIONS

Patients with major trauma are at risk for both acute and delayed adverse outcomes.

The value of trauma registries

Trauma registries are databases that document acute care delivered to patients hospitalised with injuries. They are designed to provide information that can be used to improve the efficiency and quality of trauma care. Indeed, the combination of trauma registry data at regional or national levels can produce very large databases that allow unprecedented opportunities for the evaluation of patient outcomes and inter-hospital comparisons. However, the creation and upkeep of trauma registries requires a substantial investment of money, time and effort, data quality is an important challenge and aggregated trauma data sets rarely represent a population-based sample of trauma. In addition, trauma hospitalisations are already routinely documented in administrative hospital discharge databases. The present review aims to provide evidence that trauma registry data can be used to improve the care dispensed to victims of injury in ways that could not be achieved with information from administrative databases alone. In addition, we will define the structure and purpose of contemporary trauma registries, acknowledge their limitations, and discuss possible ways to make them more useful.

Delivery of a brief motivational intervention to patients with alcohol-related facial injuries: role for a specialist nurse

In this paper we focus on providing an alcohol screening and intervention service within maxillofacial surgery. Two trained nurses screened patients with alcohol-related facial injuries who attended maxillofacial outpatient clinics, and gave brief motivational interventions to those who had been drinking to a hazardous level. Patients were followed up at 3 and 12 months after the intervention. 195/249 patients (78%) drank to a hazardous level. One hundred and ninety-five patients received an intervention. Duration of intervention was between 5 and 65 minutes. Reasons for refusal to participate included lack of interest or time, and the main reason for exclusion was length of time since injury. The follow up rate was 103 (53%) at 3 months and 134 (69%) at 12 months.

CONCLUSIONS

The high level of hazardous drinking among people with facial trauma suggests a clear need for alcohol screening and intervention. It is feasible for nursing staff to deliver brief interventions in a busy maxillofacial trauma clinic.