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Miclau TA, Pascual L, Ndoja S, Frazer A, Beaupre L, Schemitsch EH. Rehabilitation after musculoskeletal injury: an overview of systems in the United States and Canada. OTA Int 2024; 7:e311. [PMID: 39135904 PMCID: PMC11318513 DOI: 10.1097/oi9.0000000000000311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/14/2023] [Indexed: 08/15/2024]
Abstract
As North America is largely industrialized with a variety of available private transportation options, trauma is a common occurrence, resulting in significant burdens of disability and costs to the health care system. To meet increasing trauma care needs, there is a robust organization of trauma and rehabilitation systems, particularly within the United States and Canada. The American and Canadian health care systems share multiple similarities, including well-equipped Level I trauma centers, specialized inpatient rehabilitation units for polytrauma patients, and thorough evaluations for recovery and post-discharge placement. However, they also have several key differences. In Canada, the criteria for admission to inpatient rehabilitation vary by location, and inpatient rehabilitation is universally accessible, whereas outpatient rehabilitation services are generally not covered by insurance. In the United States, these admission criteria for post-acute inpatient rehabilitation are standardized, and both inpatient and outpatient services are covered by private and government-funded insurance with varying durations. Overall, both health care systems face challenges in post-acute rehabilitation, including benefit limitations and limited provider access in rural areas, and must continue to evolve to meet the rehabilitation needs of injured patients as they reintegrate into their communities.
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Affiliation(s)
- Theodore A. Miclau
- School of Medicine, University of California San Francisco, San Francisco, CA
| | - Lisa Pascual
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Silvio Ndoja
- Division of Orthopedic Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Abigail Frazer
- Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Lauren Beaupre
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - Emil H. Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
- Division of Orthopaedic Surgery, Western University, London, ON, Canada
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Charyk Stewart T, Lakha N, Milton L, Bérubé M. Current trauma team activation processes at Canadian trauma centres: A national survey. Injury 2024; 55:111220. [PMID: 38012901 DOI: 10.1016/j.injury.2023.111220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/20/2023] [Accepted: 11/15/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Trauma team activation (TTA) allows the provision of specialized and timely care to improve outcomes for severely injured patients. Limited information is available on the current state of TTA in Canadian trauma centres (TC). Study objectives were to describe TTA processes, data and reports, along with the challenges and successes from a national perspective. METHODS A mixed-methods, cross-sectional survey was undertaken with Canadian trauma leadership, utilizing a total population sampling strategy. The questionnaire, containing 108-items, was administered online between February-April 2022, utilizing a modified Dillman technique. Descriptive statistics and thematic analyses were performed. RESULTS Trauma leaders from 9 out of 10 provinces responded for a response rate of 68% (32/47). Two-thirds (67%) of respondents worked in adult TC; 63% in a level I center. A higher proportion of pediatric TC had a two-tiered TT response (60% pediatric; 35% adult). The most common criteria were neurologic compromise (100% one-level TTA) and hypotension (pediatric: 100% one-level, 100% tier 1; adult: 92% one-level, 86% tier 1). All one-level TTA included penetrating trauma criteria. One-third of respondents reported using TTA subgroup criteria for pediatric, pregnant, and/or geriatric patients. There was variability with disciplines responding to TTA, with largest, most comprehensive teams for tier 1. Two-thirds of TC review activation compliance (under/overtriage), while 55% focus on non-compliance and reasons for missed TTA. The most frequent challenges related to TTA practices were reliable data collection (60%) while successes included were the establishment of TTA guidelines to improve team compliance (33%) and RN initiated TTA. CONCLUSIONS Some TTA practices were similar among Canadian TC, while others showed variability. Findings provide opportunities for improvement, including a two-tier system, geriatric-specific criteria, and RN initiated TTA, and could help establish national standards and best practices. Compliance with standards has the potential to improve Canadian TTA practices and patient outcomes.
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Affiliation(s)
- Tanya Charyk Stewart
- London Health Sciences Centre, London, ON, Canada; Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada; Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
| | - Nasira Lakha
- Vancouver General Hospital, Vancouver, BC, Canada
| | | | - Mélanie Bérubé
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Practices Research Unit Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada
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Leslie C, DiMagno K. Identification of Performance Improvement Objectives After Management of a Mass Shooting Incident: A Retrospective Study. Cureus 2023; 15:e47529. [PMID: 38022271 PMCID: PMC10664770 DOI: 10.7759/cureus.47529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Mass shootings are firearm incidents involving four or more victims at one or more locations close to one another. Although some American College of Surgeons designated trauma centers have the experience and resources to adequately treat mass shooting victims who arrive simultaneously or in close proximity to each other, many others do not. Therefore, the objective of this retrospective case series was to evaluate the effectiveness of the treatment of five consecutive gunshot wound victims who presented to a Level II trauma center within 36 minutes of each other. Lessons learned from that experience were used to identify the most effective pre-hospital and hospital management interventions. Opportunities for performance improvement were analyzed with respect to the current literature and the American College of Surgeons 2022 consensus recommendations for mass shootings.
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Affiliation(s)
- Cynthia Leslie
- Division of Trauma and Critical Care, Good Samaritan University Hospital, West Islip, USA
| | - Kevin DiMagno
- Medical School, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
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Vallier HA. Continuous improvement in optimizing the timing of axial, hip, and femoral fracture fixation. Bone Joint J 2023; 105-B:361-364. [PMID: 36924163 DOI: 10.1302/0301-620x.105b4.bjj-2022-1025.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.
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Jones SM, West C, Rappoport J, Akhtar K. Rehabilitation outcomes based on service provision and geographical location for patients with multiple trauma: A mixed-method systematic review. Injury 2023; 54:887-895. [PMID: 36801069 DOI: 10.1016/j.injury.2023.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Previous research has highlighted the benefit of regionalised trauma networks in relation to decreased mortality. However, patients who now survive increasingly complex injuries continue to navigate the challenges of recovery, often with a poor view of their experiences of the rehabilitation journey. Geographical location, unclear rehabilitation outcomes and limited access to the provision of care are increasingly noted by patients as negatively influencing their view of recovery. STUDY DESIGN This mixed-methods systematic review included research that addresses the impact of service provision and geographical location of rehabilitation services for multiple trauma patients. The primary aim of the study was to analyse functional independence measure (FIM) outcomes. The secondary aim of the research was to examine the rehabilitation needs and experiences of multiple trauma patients by identifying themes around the barriers and challenges to rehabilitation provision. Finally, the study aimed to contribute to the gap in literature around the rehabilitation patient experience. METHODS An electronic search of seven databases was undertaken against pre-determined inclusion/exclusion criteria. The Mixed Methods Appraisal Tool was utilised for quality appraisal. Following data extraction, both quantitative and qualitative analysis methods were utilised. In total, 17,700 studies were identified and screened against the inclusion/exclusion criteria. Eleven studies met the inclusion criteria (five quantitative, four qualitative, two mixed method). RESULTS FIM scores showed no significant difference in all studies after long-term follow-up. However, statistically significantly less FIM improvement was noted in those with unmet needs. Patients with physiotherapist assessed unmet rehabilitation needs were statistically less likely to improve than patients whose needs were reportedly met. In contrast, there was a differing opinion regarding the success of structured therapy input, communication and coordination, long-term support and planning for home. Common qualitative themes revealed lack of rehabilitation post-discharge, often with long waiting times. CONCLUSION Stronger communication pathways and coordination within a trauma network, particularly when repatriating outside of a network catchment area is recommended. This review has exposed the many rehabilitation variations and complexities a patient may experience following trauma. Furthermore, this highlights the importance of arming clinicians with the tools and expertise to improve patient outcomes.
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Affiliation(s)
- Suzannah M Jones
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Department of Physiotherapy, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Christopher West
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline Rappoport
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Kash Akhtar
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Sharwood LN, Whyatt D, Vaikuntam BP, Cheng CL, Noonan VK, Joseph AP, Ball J, Stanford RE, Kok MR, Withers SR, Middleton JW. A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study. BMC Health Serv Res 2021; 21:292. [PMID: 33794879 PMCID: PMC8015029 DOI: 10.1186/s12913-021-06235-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. METHODS This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. RESULTS Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. CONCLUSIONS Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.
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Affiliation(s)
- Lisa N Sharwood
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Reserve Road, St Leonards, NSW, 2065, Australia.
- University of New South Wales, Faculty of Medicine and Health, NSW Black Dog Institute, Sydney, Australia.
- University of Technology Sydney, Faculty of Engineering, Sydney, NSW, Australia.
- Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, VIC, Australia.
| | - David Whyatt
- University of Western Australia, (M706), 35 Stirling Highway, Perth, 6009, Australia
| | - Bharat P Vaikuntam
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Reserve Road, St Leonards, NSW, 2065, Australia
| | - Christiana L Cheng
- Praxis Spinal Cord Institute, 6400-818 W 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Vanessa K Noonan
- Praxis Spinal Cord Institute, 6400-818 W 10th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Anthony P Joseph
- Royal North Shore Hospital, Trauma Department, Reserve Road, St Leonards, NSW, 2065, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jonathon Ball
- Royal North Shore Hospital, Neurosurgery, St Leonards, NSW, 2065, Australia
| | - Ralph E Stanford
- Prince of Wales Hospital, Spinal Cord Injury Unit, Randwick, NSW, 2033, Australia
| | - Mei-Ruu Kok
- University of Western Australia, (M706), 35 Stirling Highway, Perth, 6009, Australia
| | - Samuel R Withers
- Australian Institute of Robotic Orthopaedics, Perth, Western Australia, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Reserve Road, St Leonards, NSW, 2065, Australia
- Agency for Clinical Innovation, NSW Health, Reserve Road, St Leonards, NSW, 2065, Australia
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