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Barbieri G, Cipriano A, Coccolini F, Pini S, Dell'Agnello D, Ranalli A, Cremonini C, Santini M, Ghiadoni L, Chiarugi M. Trauma Center model application in the University Hospital of Pisa: a single-center comparative study. Intern Emerg Med 2024:10.1007/s11739-024-03644-1. [PMID: 38940990 DOI: 10.1007/s11739-024-03644-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/09/2024] [Indexed: 06/29/2024]
Abstract
The Trauma Center, Hub, is a highly specialized hospital indicated for complex major trauma management after stabilization at a 1st level hospital, Spoke. Although in the United States this organization demonstrated its effectiveness in mortality, in the Italian context, data available are limited. On 30 September 2018, the University Hospital of Pisa formalized the introduction of the Trauma Center, optimizing Emergency Department (ED) organization to guarantee the highest standard of care. The aim of this study was to demonstrate that the new model led better outcomes. We conducted a comparative retrospective study on 1154 major traumas over 24 months: the first 12 months (576 patients) correspond to the period before Trauma Center introduction, and the following 12 (457 patients) to the subsequent period. Results showed increase in greater dynamics and primary centralization by helicopter (p < 0.001, p 0.006). A systematic assessment with ABCDE algorithm was performed in a higher number of patients in the most recent period, from 38.4% to 80.3% (p < 0.001). Focused Assessment with Sonography for Trauma (FAST) performed by the emergency doctor increased after Trauma Center introduction, p value < 0.001. The data show an increase of ATLS certification among staff from 51.9 to 71.4% and a reduction in early and late mortality after the Trauma Center introduction (p value 0.05 and < 0.01). Fewer patients required intensive and surgical treatments, with a shorter hospital stay. The results demonstrate the advantage in terms of outcomes in the organization of the Trauma Center in the Italian context.
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Affiliation(s)
- Greta Barbieri
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy.
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Via Savi, 10, 56126, Pisa, Italy.
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Silvia Pini
- Department of Anaesthesia and Critical Care Medicine, Pisa University Hospital, Pisa, Italy
| | | | | | - Camilla Cremonini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Via Savi, 10, 56126, Pisa, Italy
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Massimo Santini
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimo Chiarugi
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Via Savi, 10, 56126, Pisa, Italy
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
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Kim H, Song KJ, Hong KJ, Park JH, Kim TH, Lee SGW. Effects of Transport to Trauma Centers on Survival Outcomes Among Severe Trauma Patients in Korea: Nationwide Age-Stratified Analysis. J Korean Med Sci 2024; 39:e60. [PMID: 38374629 PMCID: PMC10876434 DOI: 10.3346/jkms.2024.39.e60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/14/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea. METHODS Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19-65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted. RESULTS Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group. CONCLUSION We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.
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Affiliation(s)
- Hakrim Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul Metropolitan Government-Seoul National University Hospital Boramae Medical Center, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Tae Han Kim
- Department of Emergency Medicine, Seoul Metropolitan Government-Seoul National University Hospital Boramae Medical Center, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul Metropolitan Government-Seoul National University Hospital Boramae Medical Center, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
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Cuevas-Østrem M, Thorsen K, Wisborg T, Røise O, Helseth E, Jeppesen E. Care pathways and factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe traumatic brain injury: a population-based study from the Norwegian trauma registry. Scand J Trauma Resusc Emerg Med 2023; 31:34. [PMID: 37365649 DOI: 10.1186/s13049-023-01097-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals. METHODS A population-based cohort study from the national Norwegian Trauma Registry (2015-2020) of adult patients (≥ 16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head ≥ 3, AIS Body < 3 and maximum 1 AIS Body = 2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability. RESULTS The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P < 0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P < 0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤ 13: 55% vs. 27, P < 0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients < 77 years, and increasing NISSs until the effect was inverted at higher scores. Decreased transfer probability was significantly associated with increasing age and comorbidity, and distance between the acute care trauma hospital and the nearest neurotrauma center, except for extreme NISSs. CONCLUSIONS Acute care trauma hospitals managed a substantial burden of isolated moderate-to-severe TBI patients primarily and definitively, highlighting the importance of high-quality neurotrauma care in non-neurosurgical hospitals. The transfer probability declined with increasing age and comorbidity, suggesting that older patients were carefully selected for transfer to specialized care.
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Affiliation(s)
- Mathias Cuevas-Østrem
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.
- C/O Norwegian Air Ambulance Foundation, Postboks 414 Sentrum, Oslo, 0103, Norway.
| | - Kjetil Thorsen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Torben Wisborg
- INTEREST: Interprofessional Rural Research Team-Finnmark, Faculty of Health Sciences, University of Tromsø-the Arctic University of Norway, Hammerfest, Norway
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Hammerfest Hospital, Department of Anaesthesiology and Intensive Care, Finnmark Health Trust, Hammerfest, Norway
| | - Olav Røise
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Norwegian Trauma Registry, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eirik Helseth
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Elisabeth Jeppesen
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
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Bedell BR, Boggs KM, Espinola JA, Sullivan AF, Hasegawa K, Samuels-Kalow M, Zachrison KS, Camargo CA. Development of a unified national trauma center database, 2018. Injury 2023; 54:461-468. [PMID: 36464502 DOI: 10.1016/j.injury.2022.11.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/08/2022] [Accepted: 11/26/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Trauma center certifications across the United States (U.S.) are not unified. Participation in the national trauma certification program established through the American College of Surgeons (ACS) is not universal, and many states maintain unique trauma certification systems with varying criteria. We investigated degree of similarity between the ACS national trauma certification program and state trauma certifications, then combined these distinct certifications into a unified national trauma center database. METHODS We performed a cross-sectional study of all non-specialty, non-federal emergency U.S. departments (EDs) open in 2018 to determine availability and levels of trauma centers. We created a "Standard" definition of trauma levels using ACS criteria as a benchmark. ACS similar trauma levels were then assigned to state levels I-III by comparing trauma receiving protocol, maximum response times, and general surgical coverage; through this process, levels across distinct systems established through different criteria were standardized. RESULTS In 2018, ACS certifications spanned 47 states and DC; 3 states did not participate in ACS (Mississippi, Pennsylvania, and Washington). A distinct, non-ACS state certification system was present in 47 states and DC; 3 states had no ongoing state certification system in 2018 (Maine, Rhode Island, and Vermont). Among 5,514 US EDs open in 2018, we identified 2,132 associated with adult and pediatric trauma centers (39%) holding certification (ACS, state, or both); 1,083 (51%) were certified levels I-III, and the rest (1,049, 49%) were levels IV-V. Of the 1,083 centers with any level I-III certification, 498 (46%) held ACS certification, and 1,059 (98%) held state certification. Applying ACS-similar criteria to centers with state levels I-III (n=1,059) resulted in a level change for 124 centers (12%). Using our "Standard" definition of a trauma level based on ACS criteria, our unified level I-III database included 959 (89%) adult and pediatric centers, with 24 (3%) ACS-certified only, 461 (48%) state-certified only, and 474 (49%) certified by both. CONCLUSIONS Discrepancies exist between ACS and state trauma certification systems. The differences in level I-III state criteria confirm discrepant standards for a given trauma "level" across the U.S. We combined these certifications into a unified national trauma center database available to researchers and the public.
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Affiliation(s)
- Brandon-R Bedell
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101
| | - Krislyn-M Boggs
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101.
| | - Janice-A Espinola
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101.
| | - Ashley-F Sullivan
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101.
| | - Kohei Hasegawa
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101.
| | - Margaret Samuels-Kalow
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101.
| | - Kori-S Zachrison
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101.
| | - Carlos-A Camargo
- Emergency Medicine Network, Massachusetts General Hospital, 125 Nashua St, Suite 920, Boston, MA, United States 02114-1101.
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Gilmartin S, Brent L, Hanrahan M, Dunphy M, Deasy C. A retrospective review of patients who sustained traumatic brain injury in Ireland 2014-2019. Injury 2022; 53:3680-3691. [PMID: 36167689 DOI: 10.1016/j.injury.2022.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/30/2022] [Accepted: 09/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the most significant cause of death and disability resulting from major trauma. The aim of this study is to describe the demographics of TBI patients, the current pathways of care and outcomes in the Republic of Ireland from 2014 to 2019. METHODS We performed a retrospective review of all TBI patients meeting inclusion criteria in Ireland's Major Trauma Audit (MTA) from 2014 to 2019. Severe TBI was defined as an abbreviated injury scale (AIS) ≥3 and GCS ≤8. RESULTS During the study period, 30,891 patients sustained major trauma meeting inclusion criteria for MTA, of which 7,393 (23.9%) patients met the inclusion criteria for TBI; 1,025 (13.9%) were classified as severe. The median age was 60.6 years (IQR 36.9-78.0), 54.3 years (32.8-73.4) for males and 71.7 years (50.0-83.0) for females (p<0.001). Of patients with severe TBI, 185 (18.0%) were brought direct to a neurosurgical centre, 389 (37.9%) were transferred to a neurosurgical centre and 321 (31.3%) had a neurosurgical intervention performed. In patients sustaining severe TBI, older patients (Adjusted OR, 0.96,95% CI 0.95-0.97) and patients requiring another surgery (OR 0.31, 95%CI 0.18-0.53) were less likely to be secondarily transferred to a neurosurgical centre. There were 47 (4.6%) patients with severe TBI discharged to rehabilitation. The 30-day mortality in Ireland was 11.6% in all TBI patients and 45.5% in severe TBI patients. Older patients and patients with higher ISS had a higher chance of death. Male patients, patients treated in neurosurgical centre, patients who had neurosurgery or non-neurosurgical surgery had a higher chance of survival. CONCLUSION This population-based study bench marks the 'as is' for patients with TBI in Ireland. We found that presently in Ireland, the mortality rate from severe TBI appears to be higher than that reported in international literature, and only a minority of severe TBI patients are brought directly from the incident to a neurosurgical centre. The new major trauma system should focus on providing effective and efficient access to neurosurgical, neuro-critical and neuro-rehabilitative care for patients who sustain TBI.
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Affiliation(s)
- Stephen Gilmartin
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland.
| | - Louise Brent
- Major Trauma Audit, National Office of Clinical Audit, Ireland
| | | | - Michael Dunphy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Conor Deasy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland; Major Trauma Audit, National Office of Clinical Audit, Ireland
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Mansour T, Beck B, Gabbe B, Farhat I, Belcaid A, Neveu X, Moore L. International comparison of injury care structures, processes, and outcomes between integrated trauma systems in Québec, Canada, and Victoria, Australia. Injury 2022; 53:2907-2914. [PMID: 35688707 DOI: 10.1016/j.injury.2022.06.001] [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: 03/12/2022] [Revised: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Quality improvement activities in trauma systems are widely based on comparisons between trauma centers within the same system. Comparisons across different trauma systems may reveal further opportunities for quality improvement. OBJECTIVES This study aimed to compare the integrated trauma systems in Québec, Canada and in Victoria, Australia, regarding their structures, care processes and patient outcomes. METHODOLOGY The elements recommended by the American College of Surgeons were used to compare trauma systems structures. Comparisons of care processes and patient outcomes were based on data from major trauma admissions extracted from trauma registries (2013 and 2017). Care processes included time to reach a definitive care facility, time spent in the emergency department, and time lapsed before the first head computed tomography (CT) scan. These care processes were compared using a z-test of log-transformed times. Hospital mortality and hospital length of stay (LOS) were compared using indirect standardization based on multiple logistic and linear regression. RESULTS Major differences in trauma system structure were Advanced Trauma Life Support at the scene of injury (Victoria), the use of validated prehospital triage tools (Québec), and mandatory accreditation of all trauma centers (Québec). Patients in Québec arrived at their definitive care hospital earlier than their counterparts in Victoria (median: 1.93 vs. 2.13 h, p = 0.002), but spent longer in the emergency department (median: 8.23 vs. 5.15 h, p<0.0001) and waited longer before having their first head CT (median: 1.90 vs. 1.52 h, p<0.0001). In-hospital mortality and hospital LOS were higher in Québec than in Victoria (standardized mortality ratio: 1.15, 95% CI: 1.09 - 1.20; standardized LOS ratio: 1.10, 95% CI: 1.09 - 1.11). CONCLUSION We observed important differences in the structural components and care processes in Québec and Victoria's trauma systems, which might explain some of the observed differences in patient outcomes. This study shows the potential value of international comparisons in trauma care and identifies possible opportunities for quality improvement.
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Affiliation(s)
- Thowiba Mansour
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada; Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Imen Farhat
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Québec, QC, Canada
| | - Amina Belcaid
- Institut National d'Excellence en Santé et en Services Sociaux (INESSS), Québec, QC, Canada
| | - Xavier Neveu
- Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada; Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada.
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van Maarseveen OEC, Ham WHW, van Cruchten S, Duhoky R, Leenen LPH. Evaluation of validity and reliability of video analysis and live observations to assess trauma team performance. Eur J Trauma Emerg Surg 2022; 48:4797-4803. [PMID: 35817942 DOI: 10.1007/s00068-022-02004-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION A trauma resuscitation is dynamic and complex process in which failures could lead to serious adverse events. In several trauma centers, evaluation of trauma resuscitation is part of a hospital's quality assessment program. While video analysis is commonly used, some hospitals use live observations, mainly due to ethical and medicolegal concerns. The aim of this study was to compare the validity and reliability of video analysis and live observations to evaluate trauma resuscitations. METHODS In this prospective observational study, validity was assessed by comparing the observed adherence to 28 advanced trauma life support (ATLS) guideline related tasks by video analysis to life observations. Interobserver reliability was assessed by calculating the intra class coefficient of observed ATLS related tasks by live observations and video analysis. RESULTS Eleven simulated and thirteen real-life resuscitations were assessed. Overall, the percentage of observed ATLS related tasks performed during simulated resuscitations was 10.4% (P < 0.001) higher when the same resuscitations were analysed using video compared to live observations. During real-life resuscitations, 8.7% (p < 0.001) more ATLS related tasks were observed using video review compared to live observations. In absolute terms, a mean of 2.9 (during simulated resuscitations) respectively 2.5 (during actual resuscitations) ATLS-related tasks per resuscitation were not identified using live observers, that were observed through video analysis. The interobserver variability for observed ATLS related tasks was significantly higher using video analysis compared to live observations for both simulated (video analysis: ICC 0.97; 95% CI 0.97-0.98 vs. live observation: ICC 0.69; 95% CI 0.57-0.78) and real-life witnessed resuscitations (video analyse 0.99; 95% CI 0.99-1.00 vs live observers 0.86; 95% CI 0.83-0.89). CONCLUSION Video analysis of trauma resuscitations may be more valid and reliable compared to evaluation by live observers. These outcomes may guide the debate to justify video review instead of live observations.
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Affiliation(s)
- Oscar E C van Maarseveen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Wietske H W Ham
- Emergency Department, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Institute of Nursing Studies, University of Applied Science, Heidelberglaan 7, 3584 CS, Utrecht, The Netherlands
| | - Stijn van Cruchten
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rauand Duhoky
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Emergency Department, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Cooper BH. Exploring the factors that influence trauma team activation in emergency department staff. Emerg Nurse 2022; 30:e2133. [PMID: 35502574 DOI: 10.7748/en.2022.e2133] [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: 02/24/2022] [Indexed: 11/09/2022]
Abstract
Regional trauma networks enable the rapid and safe management and transfer of patients with traumatic injury between designated trauma units and one of 27 major trauma centres throughout the UK. Multispecialty trauma teams are available 24 hours a day, seven days a week, and are activated immediately upon receipt of a patient presenting with major trauma. With most serious trauma patients going direct to major trauma centres rather than a less specialised hospital-based trauma unit, it can be challenging for hospital-based trauma unit staff to gain experience and skill in this area, leading to potential inconsistencies in the process of activating the trauma team. The aim of this service evaluation was to identify factors influencing the decision to activate the trauma team in emergency department (ED) staff working within a 700-bed trauma unit. A questionnaire was sent to 107 staff and 70 completed it, a response rate of 65%. Results indicated that shortfalls in trauma-specific training, lack of clinical experience, undefined roles and responsibilities, department culture, ambulance handover, knowledge of clinical guidelines and previous experience of trauma team activation all affected the decision to activate the trauma team. Trauma-specific training and the support of senior staff could enhance confidence and appropriate trauma team activation rates.
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Wang CJ, Yang TH, Hung KS, Wu CH, Yen ST, Yen YT, Shan YS. Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study. BMC Emerg Med 2021; 21:150. [PMID: 34861821 PMCID: PMC8641219 DOI: 10.1186/s12873-021-00543-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/21/2021] [Indexed: 11/22/2022] Open
Abstract
Background Undertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes. Method This retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed. Results A total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p < 0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076). Conclusion This study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.
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Affiliation(s)
- Chih-Jung Wang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shu-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, Tainan, Taiwan.
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Wiegers EJA, Trapani T, Gabbe BJ, Gantner D, Lecky F, Maas AIR, Menon DK, Murray L, Rosenfeld JV, Vallance S, Lingsma HF, Steyerberg EW, Cooper DJ. Characteristics, management and outcomes of patients with severe traumatic brain injury in Victoria, Australia compared to United Kingdom and Europe: A comparison between two harmonised prospective cohort studies. Injury 2021; 52:2576-2587. [PMID: 33910683 DOI: 10.1016/j.injury.2021.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this manuscript is to compare characteristics, management, and outcomes of patients with severe Traumatic Brain Injury (TBI) between Australia, the United Kingdom (UK) and Europe. METHODS We enrolled patients with severe TBI in Victoria, Australia (OzENTER-TBI), in the UK and Europe (CENTER-TBI) from 2015 to 2017. Main outcome measures were mortality and unfavourable outcome (Glasgow Outcome Scale Extended <5) 6 months after injury. Expected outcomes were compared according to the IMPACT-CT prognostic model, with observed to expected (O/E) ratios and 95% confidence intervals. RESULTS We included 107 patients from Australia, 171 from UK, and 596 from Europe. Compared to the UK and Europe, patients in Australia were younger (median 32 vs 44 vs 44 years), a larger proportion had secondary brain insults including hypotension (30% vs 17% vs 21%) and a larger proportion received ICP monitoring (75% vs 74% vs 58%). Hospital length of stay was shorter in Australia than in the UK (median: 17 vs 23 vs 16 days), and a higher proportion of patients were discharged to a rehabilitation unit in Australia than in the UK and Europe (64% vs 26% vs 28%). Mortality overall was lower than expected (27% vs 35%, O/E ratio 0.77 [95% CI: 0.64 - 0.87]. O/E ratios were comparable between regions for mortality in Australia 0.86 [95% CI: 0.49-1.23] vs UK 0.82 [0.51-1.15] vs Europe 0.76 [0.60-0.87]). Unfavourable outcome rates overall were in line with historic expectations (O/E ratio 1.32 [0.96-1.68] vs 1.13 [0.84-1.42] vs 0.96 [0.85-1.09]). CONCLUSIONS There are major differences in case-mix between Australia, UK, and Europe; Australian patients are younger and have a higher rate of secondary brain insults. Despite some differences in management and discharge policies, mortality was less than expected overall, and did not differ between regions. Functional outcomes were similar between regions, but worse than expected, emphasizing the need to improve treatment for patients with severe TBI.
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Affiliation(s)
- Eveline J A Wiegers
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Tony Trapani
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Health Data Research UK, Swansea University, United Kingdom
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, Alfred Hospital, Melbourne, Australia
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK; Emergency Department, Salford Royal Hospital, Salford, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Shirley Vallance
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, Alfred Hospital, Melbourne, Australia
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Earnest A, Palmer C, O'Reilly G, Burrell M, McKie E, Rao S, Curtis K, Cameron P. Development and validation of a risk-adjustment model for mortality and hospital length of stay for trauma patients: a prospective registry-based study in Australia. BMJ Open 2021; 11:e050795. [PMID: 34426470 PMCID: PMC8383878 DOI: 10.1136/bmjopen-2021-050795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Adequate risk adjustment for factors beyond the control of the healthcare system contributes to the process of transparent and equitable benchmarking of trauma outcomes. Current risk adjustment models are not optimal in terms of the number and nature of predictor variables included in the model and the treatment of missing data. We propose a statistically robust and parsimonious risk adjustment model for the purpose of benchmarking. SETTING This study analysed data from the multicentre Australia New Zealand Trauma Registry from 1 July 2016 to 30 June 2018 consisting of 31 trauma centres. OUTCOME MEASURES The primary endpoints were inpatient mortality and length of hospital stay. Firth logistic regression and robust linear regression models were used to study the endpoints, respectively. Restricted cubic splines were used to model non-linear relationships with age. Model validation was performed on a subset of the dataset. RESULTS Of the 9509 patients in the model development cohort, 72% were male and approximately half (51%) aged over 50 years . For mortality, cubic splines in age, injury cause, arrival Glasgow Coma Scale motor score, highest and second-highest Abbreviated Injury Scale scores and shock index were significant predictors. The model performed well in the validation sample with an area under the curve of 0.93. For length of stay, the identified predictor variables were similar. Compared with low falls, motor vehicle occupants stayed on average 2.6 days longer (95% CI: 2.0 to 3.1), p<0.001. Sensitivity analyses did not demonstrate any marked differences in the performance of the models. CONCLUSION Our risk adjustment model of six variables is efficient and can be reliably collected from registries to enhance the process of benchmarking.
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Affiliation(s)
- Arul Earnest
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Cameron Palmer
- Trauma Service, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Gerard O'Reilly
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred, Melbourne, Victoria, Australia
| | - Maxine Burrell
- State Trauma Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Emily McKie
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Sudhakar Rao
- State Trauma Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Kate Curtis
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
- Illawarra Shoalhaven, Local Health District, Sydney, New South Wales, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
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Schopow N, Botzon A, Schneider K, Fuchs C, Josten C, von Dercks N, Fakler J, Osterhoff G. [Is polytrauma treatment in deficit in the aG-DRG system?]. Unfallchirurg 2021; 125:305-312. [PMID: 34100961 PMCID: PMC8940839 DOI: 10.1007/s00113-021-01015-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The interdisciplinary care of severely injured patients is staff and resource intensive. Since the introduction of the G‑DRG system in Germany in 2003, most studies have identified a financial deficit in the care of severely injured patients. The aim of this study was to analyze the effects of the new aG-DRG system introduced in 2020 on cost recovery in the treatment of severely injured patients. For the first time, the costs for organization, certification and documentation as well as the costs for non-seriously injured shock room patients were included. METHODS All patients who were treated in the surgical shock room of the emergency department of the Leipzig University Hospital in 2017 were included. For the analysis, the cost model according to Pape et al. was extended by the module organization, documentation and certification and for the first time the costs for overtriaged patients were considered. A cost calculation was performed for the years 2017-2020 as well a comparison with the respective earnings. RESULTS A total of 834 patients were treated in the shock room and 258 severely injured patients were divided into 3 groups: ISS 9-15 + ICU (n 72; ∅ ISS 11.9; costs per patient 14,715 €),ISS ≥ 16 (n 186; ∅ ISS 27.7; costs per patient 30,718 €) and DRG polytrauma (n 59; ∅ ISS 32.4; costs per patient 26,102 €). CONCLUSION Polytrauma care under the aG-DRG 2020 is in deficit. Overall, in 2020 a deficit of 5858 € per severely injured patient resulted.
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Affiliation(s)
- Nikolas Schopow
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - Anja Botzon
- Bereich 3 - Finanzen, Planung und Controlling, Universitätsklinikum Leipzig, Liebigstraße 18, 04103, Leipzig, Deutschland
| | - Kristian Schneider
- Klinik für Allgemein Orthopädie und Tumororthopädie, Universitätsklinikum Münster, Albert Schweitzer Campus 1, 48149, Münster, Deutschland
| | - Carolin Fuchs
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Christoph Josten
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Nikolaus von Dercks
- Bereich 3 - Finanzen, Planung und Controlling, Universitätsklinikum Leipzig, Liebigstraße 18, 04103, Leipzig, Deutschland
| | - Johannes Fakler
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Georg Osterhoff
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland
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13
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Varachhia S, Ramcharitar Maharaj V, Paul JF, Robertson P, Nunes P, Sammy I. Factors affecting mortality in major trauma patients in Trinidad and Tobago – A view from the developing world. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619885505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction There are few data on major trauma in the developing world. This study investigated the characteristics and outcomes of seriously injured patients in Trinidad and Tobago, using Trauma and Injury Severity Score (TRISS) methodology. We also aimed to assess the predictive accuracy of the TRISS model in patients in Trinidad and Tobago. Methods Retrospective data from major trauma patients attending the Emergency Department of a tertiary hospital in Trinidad between 2010 and 2014 were analysed. Patients ≥18 years having an Injury Severity Score >15 were included. The impact of age, gender, comorbidities, mechanisms and patterns of injury on mortality was investigated. Using TRISS methodology, predicted mortality was calculated and compared to actual mortality. Results Of 323 patients analysed, 284 were male and 24 were aged ≥65 years. The commonest injury mechanisms in younger people were motor vehicle accidents (34.1%) and stabbings (30.8%) compared to falls (66.7%) and motor vehicle accidents (20.8%) in people aged ≥65 years. The commonest areas injured were the chest in younger patients (81.9%) and the head and neck in patients aged ≥65 years (58.3%). Women’s mortality rates were similar to men (RR 1.8; 95% CI 0.7–4.9). Mortality was higher with age ≥65 years (RR 7.0; 95% CI 3.1–15.9), blunt trauma (RR 7.6; 95% CI 1.8–32.4) and Charlson Comorbidity Index of 1 or more (RR 3.2; 95% CI 1.3–8.0). The TRISS model performed well at lower ISS scores and was excellent at predicting survival (discrimination statistic 0.94). Conclusion Multiple factors influence mortality in major trauma patients in Trinidad and Tobago, including age, co-morbidities and injury mechanism. TRISS methodology accurately predicted survival in this population but was better at predicting mortality in patients with lower Injury Severity Score.
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Affiliation(s)
- Saleem Varachhia
- Emergency Department, San Fernando General Hospital, San Fernando, Trinidad and Tobago
| | | | - Joanne F Paul
- Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies, St Augustine, Trinidad and Tobago
| | - Paula Robertson
- North Central Regional Health Authority, Champs Fleurs, Trinidad and Tobago
| | - Paula Nunes
- Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Ian Sammy
- Emergency Department, Scarborough General Hospital, Lower Scarborough, Trinidad and Tobago
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M Selveindran S, Tango T, Khan MM, Simadibrata DM, Hutchinson PJA, Brayne C, Hill C, Servadei F, Kolias AG, Rubiano AM, Joannides AJ, Shabani HK. Mapping global evidence on strategies and interventions in neurotrauma and road traffic collisions prevention: a scoping review. Syst Rev 2020; 9:114. [PMID: 32434551 PMCID: PMC7240915 DOI: 10.1186/s13643-020-01348-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/02/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Neurotrauma is an important global health problem. The largest cause of neurotrauma worldwide is road traffic collisions (RTCs), particularly in low- and middle-income countries (LMICs). Neurotrauma and RTCs are preventable, and many preventative interventions have been implemented over the last decades, especially in high-income countries (HICs). However, it is uncertain if these strategies are applicable globally due to variations in environment, resources, population, culture and infrastructure. Given this issue, this scoping review aims to identify, quantify and describe the evidence on approaches in neurotrauma and RTCs prevention, and ascertain contextual factors that influence their implementation in LMICs and HICs. METHODS A systematic search was conducted using five electronic databases (MEDLINE, EMBASE, CINAHL, Global Health on EBSCO host, Cochrane Database of Systematic Reviews), grey literature databases, government and non-government websites, as well as bibliographic and citation searching of selected articles. The extracted data were presented using figures, tables, and accompanying narrative summaries. The results of this review were reported using the PRISMA Extension for Scoping Reviews (PRISMA-ScR). RESULTS A total of 411 publications met the inclusion criteria, including 349 primary studies and 62 reviews. More than 80% of the primary studies were from HICs and described all levels of neurotrauma prevention. Only 65 papers came from LMICs, which mostly described primary prevention, focussing on road safety. For the reviews, 41 papers (66.1%) reviewed primary, 18 tertiary (29.1%), and three secondary preventative approaches. Most of the primary papers in the reviews came from HICs (67.7%) with 5 reviews on only LMIC papers. Fifteen reviews (24.1%) included papers from both HICs and LMICs. Intervention settings ranged from nationwide to community-based but were not reported in 44 papers (10.8%), most of which were reviews. Contextual factors were described in 62 papers and varied depending on the interventions. CONCLUSIONS There is a large quantity of global evidence on strategies and interventions for neurotrauma and RTCs prevention. However, fewer papers were from LMICs, especially on secondary and tertiary prevention. More primary research needs to be done in these countries to determine what strategies and interventions exist and the applicability of HIC interventions in LMICs.
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Affiliation(s)
- Santhani M Selveindran
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Tamara Tango
- Faculty of Medicine, University of Indonesia, Depok, Jawa Barat Indonesia
| | - Muhammad Mukhtar Khan
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Northwest School of Medicine and Northwest General Hospital and Research Centre, Peshawar, Pakistan
| | | | - Peter J. A. Hutchinson
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Christine Hill
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
- World Federation of Neurosurgical Societies, Nyon, Switzerland
| | - Angelos G. Kolias
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Andres M. Rubiano
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Universidad El Bosque, Bogota, Colombia
| | - Alexis J. Joannides
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Hamisi K. Shabani
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Neurological Surgery Unit, Muhimbili Orthopaedic Institute and Muhimbili University College of Allied Health Sciences, Dar es Salaam, Tanzania
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Kelly ML, He J, Roach MJ, Moore TA, Steinmetz MP, Claridge JA. Regionalization of Spine Trauma Care in an Urban Trauma System in the United States: Decreased Time to Surgery and Hospital Length of Stay. Neurosurgery 2020; 85:773-778. [PMID: 30329091 DOI: 10.1093/neuros/nyy452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/13/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The effect of regionalized trauma care (RT) on hospital-based outcomes for traumatic spine injury (TSI) in the United States is unknown. OBJECTIVE To test the hypothesis that RT would be associated with earlier time to surgery and decreased length of stay (LOS). METHODS TSI patients >14 yr were identified using International Classification of Diseases Ninth Revision Clinical Modification diagnostic codes. Data from 2008 through 2012 were analyzed before and after RT in 2010. RESULTS A total of 4072 patients were identified; 1904 (47%) pre-RT and 2168 (53%) post-RT. Injury severity scores, Spine Abbreviated Injury Scale scores, and the percentage of TSIs with spinal cord injury (tSCI) were similar between time periods. Post-RT TSIs demonstrated a lower median intensive care unit (ICU) LOS (0 vs 1 d; P < 0.0001), underwent spine surgery more frequently (13% vs 11%; P = 0.01), and had a higher rate of spine surgery performed within 24 h of admission (65% vs 55%; P = 0.02). In patients with tSCI post-RT, ICU LOS was decreased (1 vs 2 d; P < 0.0001) and ventilator days were reduced (average days: 2 vs 3; P = 0.006). The post-RT time period was an independent predictor for spine surgery performed in less than 24 h for all TSIs (odds ratio [OR] 1.52, 95% confidence interval [CI]: 1.04-2.22, C-stat = 0.65). Multivariate linear regression analysis demonstrated an independent effect on reduced ICU LOS post-RT for TSIs (OR -1.68; 95% CI: -2.98 to 0.39; R2 = 0.74) and tSCIs (OR -2.42, 95% CI: -3.99-0.85; R2 = 0.72). CONCLUSION RT is associated with increased surgical rates, earlier time to surgery, and decreased ICU LOS for patients with TSI.
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Affiliation(s)
- Michael L Kelly
- Department of Neurosurgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Jack He
- Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Mary Jo Roach
- Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Timothy A Moore
- Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | | | - Jeffrey A Claridge
- Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio.,Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio.,Northern Ohio Trauma System, Case Western Reserve University School of Medicine, Cleveland, Ohio
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The Evaluation of Trauma Care: The Comparison of 2 High-Level Pediatric Emergency Departments in the United States and Turkey. Pediatr Emerg Care 2020; 35:611-617. [PMID: 28419017 DOI: 10.1097/pec.0000000000001110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of the study is to compare the outcomes of pediatric trauma patients with motor vehicle crashes (MVCs) and motor vehicle versus pedestrian crashes (MPCs) at a level 1 pediatric trauma center in the United States and a pediatric trauma center in Turkey. METHODS The medical records of all pediatric MVC and MPC subjects presenting to the emergency departments (EDs) of a level 3 hospital in Turkey (Izmir Tepecik Training and Research Hospital [ITTRH]) and a level 1 pediatric trauma center in the United States (Children's Medical Center Dallas [CMCD]) over a 1-year period were reviewed. Data that were collected include patient demographics, prehospital report (mechanism of injury, mode of transportation), injury severity score (ISS), abbreviated injury scale score, Glasgow Coma Scale score, ED length of stay, ED interventions, ED and hospital disposition, and mortality. Patients with moderate (ISS, 5-15) and severe (ISS, >15) trauma scores were included in the study. RESULTS One hundred six patient charts from the ITTRH and 125 patient charts from the CMCD with moderate and severe ISS due to MVCs and MPCs were reviewed. Most of the patients were pedestrians (86%) in the ITTRH group and passengers (60%) in the CMCD group. The percentage of patients transferred by ambulance (ground or air) to the CMCD and the ITTRH was 97.9% and 85%, respectively. Fifteen percent of ITTRH patients and 2.1% of CMCD patients arrived by private vehicle. Emergency department arrival ISS and Glasgow Coma Scale were similar between the 2 hospitals (P > 0.05). The overall mortality rate in the study population was 8.8% (11/125) at the CMCD and 4.7% (5/106) at the ITTRH. (P = 0.223). Blood product utilization was significantly higher in the CMCD group compared with the ITTRH group (P = 0.005). The use of hypertonic saline/mannitol/hyperventilation in patients with significant head trauma and increased intracranial pressure was higher in the ITTRH group (P = 0.000). CONCLUSIONS This is the first study that compared pediatric trauma care and outcome at a level 1 pediatric trauma center in the United States and a pediatric hospital in Turkey. Our findings highlight the opportunities to improve pediatric trauma care in Turkey. Specifically, there is a need for national trauma registries, enhanced trauma education, and standardized trauma patient care protocols. In addition, efforts should be directed toward improving prehospital care through better integration within the health care system and physician participation in educating prehospital providers. Data and organized trauma care will be instrumental in system-wide improvement and developing appropriate injury-prevention strategies.
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Ayton D, Soh SE, Morello R, Ahern S, Earnest A, Brennan A, Lefkovits J, Evans S, Reid C, Ruseckaite R, McNeil J. Development of a percutaneous coronary intervention patient level composite measure for a clinical quality registry. BMC Health Serv Res 2020; 20:44. [PMID: 31952535 PMCID: PMC6969470 DOI: 10.1186/s12913-019-4814-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 06/12/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Composite measures combine data to provide a comprehensive view of patient outcomes. Despite composite measures being a valuable tool to assess post-intervention outcomes, the patient perspective is often missing. The purpose of this study was to develop a composite measure for an established cardiac outcome registry, by combining clinical outcomes following percutaneous coronary interventions (PCI) with a patient-reported outcome measure (PROM) developed specifically for this population (MC-PROM). METHODS Two studies were undertaken. Study 1: Patients who had undergone a PCI at one of the three participating registry hospital sites completed the 5-item MC-PROM. Clinical outcome data for the patients (e.g. death, myocardial infarction, repeat vascularisation, new bleeding event) were collected 30 days post-intervention as part of routine data collection for the cardiac registry. Exploratory factor analysis of clinical outcomes and MC-PROM data was conducted to determine the minimum number of constructs to be included in a composite measure. Study 2: Clinical experts participated in a Delphi technique, consisting of three rounds of online surveys, to determine the clinical outcomes to be included and the weighting of the clinical outcomes and MC-PROM score for the composite measure. RESULTS Study 1: Routine clinical outcomes and the MC-PROM data were collected from 266 patients 30 days post PCI. The MC-PROM score was not significantly correlated with any clinical outcomes. Study 2: There was a relatively consistent approach to the weighting of the clinical outcomes and MC-PROM items by the expert panel (n = 18) across the three surveys with the exception of the clinical outcome of 'deceased at 30 days'. The final composite measure included five clinical outcomes within 30 days weighted at 90% (new heart failure, new myocardial infarction, new stent thrombosis, major bleeding event, new stroke, unplanned cardiac rehospitalisation) and the MC-PROM score (comprising 10% of the total weighting). CONCLUSIONS A single patient level composite score, which incorporates weighted clinical outcomes and a PROM was developed. This composite score provides a more comprehensive reported measure of individual patient wellbeing at 30 days post their PCI-procedure, and may assist clinicians to further assess and address patient level factors that potentially impact on clinical recovery.
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Affiliation(s)
- Darshini Ayton
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sze-Ee Soh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Physiotherapy, Monash University, Melbourne, Australia
| | - Renata Morello
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Susannah Ahern
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Arul Earnest
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Susan Evans
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- NHMRC Centre for Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Bentley, Western Australia Australia
| | - Rasa Ruseckaite
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - John McNeil
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Heathcote K, Wullschleger M, Gardiner B, Morgan G, Barbagello H, Sun J. The Importance of Place of Residence on Hospitalized Outcomes for Severely Injured Trauma Patients: A Trauma Registry Analysis. J Rural Health 2019; 36:381-393. [PMID: 31840316 DOI: 10.1111/jrh.12407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Socioecological factors are understudied in relation to trauma patients' outcomes. This study investigated the association of neighborhood socioeconomic disadvantage (SED) and remoteness of residence on acute length of hospital stay days (ALSD) and inpatient mortality. METHODS A retrospective cohort study was conducted on adults hospitalized for major trauma in a Level 1 trauma center in southeast Queensland from 2014 to 2017. Neighborhood SED and remoteness indices were linked to individual patient variables. Step-wise multivariable negative binomial regression and proportional hazards regression analyses were undertaken, adjusting for injury and patient factors. Outcomes were ALSD and inpatient mortality. FINDINGS We analyzed 1,025 patients. Statistically significant increased hazard of inpatient mortality was found for older age (HR 3.53, 95% CI: 1.77-7.11), injury severity (HR 5.27, 95% CI: 2.78-10.02), remoteness of injury location (HR 1.75, 95% CI: 1.06-2.09), and mechanisms related to intentional self-harm or assault (HR 2.72, 95% CI: 1.48-5.03,). Excess mortality risk was apparent for rural patients sustaining less severe injuries (HR 4.20, 95% CI: 1.35-13.10). Increased risk for longer ALSD was evident for older age (RR 1.35, 95% CI: 1.07-1.71), head injury (RR 1.39, 95% CI: 1.19-1.62), extremity injuries (RR 1.82, 95% CI: 1.55-2.14), and higher injury severity scores (ISS) (RR 1.51, 95%: CI: 1.29-1.76). CONCLUSIONS Severely injured rural trauma patients are more likely to be socioeconomically disadvantaged and sustain injuries predisposing them to worse hospital outcomes. Further research is needed to understand more about care pathways and factors influencing the severity, mechanism and clinical consequences of rural-based traumatic injuries.
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Affiliation(s)
| | - Martin Wullschleger
- Division of Specialty and Procedural Services, Gold Coast University Hospital and School of Medicine, Griffith University, Parkland, Gold Coast, Queensland, Australia
| | - Ben Gardiner
- Division of Specialty and Procedural Services, Gold Coast University Hospital and School of Medicine, Griffith University, Parkland, Gold Coast, Queensland, Australia
| | - Geoffrey Morgan
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Holly Barbagello
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Jing Sun
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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20
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Rosenkrantz L, Schuurman N, Hameed M. Trauma registry implementation and operation in low and middle income countries: A scoping review. Glob Public Health 2019; 14:1884-1897. [PMID: 31232227 DOI: 10.1080/17441692.2019.1622761] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Injury is a major public health crisis contributing to more than 4.48 million deaths annually. Trauma registries have proven highly effective in reducing injury morbidity and mortality rates in high income countries. They are a critical source of information for injury prevention, benchmarking care, quality improvement, and resource allocation. Historically, low and middle income countries (LMICs) have largely been excluded from trauma registry development due to limited resources. Recently, this has begun to change with low-resource hospitals adopting innovative strategies to implement trauma registries. Nonetheless, dissemination of these strategies remains fragmented. Hospitals looking to develop their own trauma registries have no current, comprehensive resource that summarises the implementation decisions of other registries in similar contexts. This scoping review aims to identify where trauma registries are located in LMICs, bringing up to date previous estimates, and to identify the most common approaches to registry implementation and operation in these settings.
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Affiliation(s)
- Leah Rosenkrantz
- Department of Geography, Simon Fraser University , Burnaby , Canada
| | - Nadine Schuurman
- Department of Geography, Simon Fraser University , Burnaby , Canada
| | - Morad Hameed
- Divisions of General Surgery, Vancouver General Hospital, University of British Columbia , Vancouver , Canada
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21
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Traynor MD, Hernandez MC, Shariq O, Bekker W, Bruce JL, Habermann EB, Glasgow AE, Laing GL, Kong VY, Buitendag JJP, Klinkner DB, Moir C, Clarke DL, Zielinski MD, Polites SF. Trauma registry data as a tool for comparison of practice patterns and outcomes between low- and middle-income and high-income healthcare settings. Pediatr Surg Int 2019; 35:699-708. [PMID: 30790034 DOI: 10.1007/s00383-019-04453-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE There is a lack of data-driven, risk-adjusted mortality estimates for injured children outside of high-income countries (HIC). To inform injury prevention and quality improvement efforts, an upper middle-income country (UMIC) pediatric trauma registry was compared to that of a HIC. METHODS Clinical data, injury details, and mortality of injured children (< 18 years) hospitalized in two centers (USA and South African (SA)) from 2013 to 2017 were abstracted. Univariate and multivariable analyses evaluated risk of mortality and were expressed as odds ratios (OR) with 95% confidence intervals (CI). RESULTS Of 2089 patients, SA patients had prolonged transfer times (21.1 vs 3.4 h) and were more likely referred (78.2% vs 53.9%; both p < 0.001). Penetrating injuries were more frequent in SA (23.2% vs 7.4%, p < 0.001); injury severity (9 vs 4) and shock index (0.90 vs 0.80) were greater (both p < 0.001). SA utilized cross-sectional imaging more frequently (66.4% vs 37.3%, p < 0.001). In-hospital mortality was similar (1.9% SA, 1.3% USA, p = 0.31). Upon multivariable analysis, ISS > 25 [210.50 (66.0-671.0)] and penetrating injury [5.5 (1.3-23.3)] were associated with mortality, while institution [1.7 (0.7-4.2)] was not. CONCLUSIONS Despite transfer time, the centers demonstrated comparable survival rates. Comparison of registry data can alert clinicians to problematic practice patterns, assisting initiatives to improve trauma systems.
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Affiliation(s)
- Michael D Traynor
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Hernandez
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Omair Shariq
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Wanda Bekker
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - John L Bruce
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Amy E Glasgow
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Grant L Laing
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Victor Y Kong
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Johan J P Buitendag
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Denise B Klinkner
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Christopher Moir
- Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Damian L Clarke
- Department of Surgery, Pietermaritzburg Metropolitan Complex, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Stephanie F Polites
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
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22
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Chesser TJ, Moran C, Willett K, Bouillon B, Sturm J, Flohé S, Ruchholtz S, Dijkink S, Schipper IB, Rubio-Suarez JC, Chana F, de Caso J, Guerado E. Development of trauma systems in Europe-reports from England, Germany, the Netherlands, and Spain. OTA Int 2019; 2:e019. [PMID: 37675253 PMCID: PMC10479367 DOI: 10.1097/oi9.0000000000000019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 11/26/2018] [Indexed: 09/08/2023]
Abstract
Major trauma systems have evolved in many European countries and have resulted in improved care in terms of mortality and morbidity. Many of the systems have similar history, with reports of either poor services, or a single disaster, driving change of policy and set up. We report on 4 European systems, looking at the background, set up and some of the results. Similar issues are identified including the importance of triage, the concentration of specialist skills which require patients to bypass hospitals, and the standardization of treatment protocols. The issues of rehabilitation and the increasing importance of measuring outcome with patient reported metrics are discussed.
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Affiliation(s)
- Tim Js Chesser
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Bristol
| | - Chris Moran
- National Clinical Director for Trauma, Professor of Orthopaedic Trauma Surgery, Nottingham University Hospitals NHS Trust, Nottingham
| | - Keith Willett
- National Director for Acute Care to NHS England, Professor of Orthopaedic Trauma Surgery, University of Oxford, Oxford, UK
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany
| | | | - Sascha Flohé
- Department of Trauma and Orthopaedic Surgery, City Hospital Solingen
| | - Steffen Ruchholtz
- Department of Trauma and Orthopaedic Surgery, University Hospital Marburg Germany
| | - Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Francisco Chana
- Hospital Universitario Gregorio Marañon. University Complutense of Madrid, Madrid
| | - Julio de Caso
- Hospital Universitario Santa Creu i Sant Pau. University Autonoma of Barcelona Barcelona
| | - Enrique Guerado
- Professor and Chairman Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol. University of Malaga. Marbella Malaga, Spain
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23
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Roberts J, Watts S, Klim S, Ritchie P, Kelly A. Yield of serious axial injury from pan scans after blunt trauma in haemodynamically stable low‐risk trauma patients. Emerg Med Australas 2018; 31:399-404. [DOI: 10.1111/1742-6723.13174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/04/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Jessica Roberts
- Department of Emergency MedicineWestern Health Melbourne Victoria Australia
| | - Sara Watts
- Department of Emergency MedicineWestern Health Melbourne Victoria Australia
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine ResearchWestern Health Melbourne Victoria Australia
| | - Peter Ritchie
- Department of Emergency MedicineWestern Health Melbourne Victoria Australia
| | - Anne‐Maree Kelly
- Joseph Epstein Centre for Emergency Medicine ResearchWestern Health Melbourne Victoria Australia
- Department of Medicine, Melbourne Medical School – Western PrecinctThe University of Melbourne Melbourne Victoria Australia
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24
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Moran CG, Lecky F, Bouamra O, Lawrence T, Edwards A, Woodford M, Willett K, Coats TJ. Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008-17. EClinicalMedicine 2018; 2-3:13-21. [PMID: 31193723 PMCID: PMC6537569 DOI: 10.1016/j.eclinm.2018.07.001] [Citation(s) in RCA: 192] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/28/2018] [Accepted: 07/09/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Trauma care in England was re-organised in 2012 with ambulance bypass of local hospitals to newly designated Major Trauma Centres (MTCs). There is still controversy about the optimal way to organise health series for patients suffering severe injury. METHODS A longitudinal series of annual cross-sectional studies of care process and outcomes from April 2008 to March 2017. Data was collected through the national clinical audit of major trauma care. The primary analysis was carried out on the 110,863 patients admitted to 35 hospitals that were 'consistent submitters' throughout the study period. The main outcome was longitudinal analysis of risk adjusted survival. FINDINGS Major Trauma networks were associated with significant changes in (1) patient flow (with increased numbers treated in Major Trauma Centres), (2) treatment systems (more consultant led care and more rapid imaging), (3) patient factors (an increase in older trauma), and (4) clinical care (new massive transfusion policies and use of tranexamic acid). There were 10,247 (9.2%) deaths in the 110,863 patients with an ISS of 9 or more. There were no changes in unadjusted mortality. The analysis of trends in risk adjusted survival for study hospitals shows a 19% (95% CI 3%-36%) increase in the case mix adjusted odds of survival from severe injury over the 9-year study period. Interrupted time series analysis showed a significant positive change in the slope after the intervention time point of April 2012 (+ 0.08% excess survivors per quarter, p = 0.023), in other words an increase of 0.08 more survivors per 100 patients every quarter. INTERPRETATION A whole system national change was associated with significant improvements in both the care process and outcomes of patients after severe injury. FUNDING This analysis was carried out independently and did not receive funding. The data collection for the national clinical audit was funded by subscriptions from participating hospitals.
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Affiliation(s)
| | - Fiona Lecky
- Centre for Urgent and Emergency Care REsearch (CURE), Health Services Research Section, School of Health and Related Research, University of Sheffield, S1 4DA, UK
| | - Omar Bouamra
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Tom Lawrence
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Antoinette Edwards
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Maralyn Woodford
- Trauma Research and Audit Network, University of Manchester, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Keith Willett
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
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25
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Epidemiology of Pediatric Traumatic Brain Injury in a Dense Urban Area Served by a Helicopter Trauma Service. Pediatr Emerg Care 2018; 34:426-430. [PMID: 29851919 DOI: 10.1097/pec.0000000000000845] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Pediatric traumatic brain injury is the most common cause of death and a major cause of morbidity in children and young adults worldwide. Despite this, our understanding of epidemiological factors relating to this type of injury is incomplete. The objective of this study was to explore a variety of factors relating to these injuries including mechanism, timing of emergency response, prehospital management, radiological diagnosis, neurosurgical care, and final outcomes. METHODS A retrospective review of all pediatric traumas attending a single large, densely populated urban area within a 2-year period was undertaken, and all cases with significant pediatric traumatic brain injury, as defined by a computed tomography scan showing an intracranial injury, were included for further analysis. Various epidemiological and treatment factors were explored. RESULTS One hundred sixteen patients fulfilled the inclusion criteria, and their injuries and management were explored further. A variety of key trends were identified. The most common mechanism of injury was pedestrian struck by car followed by falls from height. Males were injured 5 times more frequently than girls. A helicopter emergency trauma team attended 22% of the patients and intubated 11 in total. The most common intracranial injuries were skull fractures followed by contusions. Nineteen neurosurgical interventions were undertaken. Overall mortality in all patients was 8%. CONCLUSIONS An improved understanding of the epidemiology of pediatric brain injury will provide baselines for future outcome measurement and comparative analysis. This may improve service organization and delivery.
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26
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Sajankila N, He JC, Zosa BM, Allen DL, Claridge JA. Statewide Analysis Shows Collaborative Regional Trauma Network Reduces Regional Mortality. Am Surg 2018. [DOI: 10.1177/000313481808400243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A Regional Trauma Network (RTN), composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems, was established in 2010. This collaborative network used a unified triage protocol and a single transfer center. The impact of this RTN was assessed by evaluating regional mortality changes before and after RTN establishment. Patients in the state trauma registry aged 15 and older from 2006 to 2012 were analyzed; 2006 to 2009 and 2010 to 2012 were designated as pre-RTN and RTN periods, respectively. The region was defined as a county containing L1TC and its adjacent counties. Any counties bordering multiple L1TC-containing counties were excluded from analysis. Mortality was compared for all regions before and after RTN implementation. The following subgroups were also included a priori for the comparison: Injury Severity Score ≥15, age ≥65, and trauma mechanisms. 121,448 patients were analyzed; 66,977 and 54,471 patients were in the pre-RTN and RTN groups, respectively. Mean age was 58; 90 per cent had blunt injuries. The overall mortality was 4.9 per cent. Mortality comparisons over time for all regions are presented. The RTN region was the only region in the state that had mortality reduction in all patient subgroups. After adjusting for age, Injury Severity Score, level of TC that performed treatment, and trauma mechanism, RTN implementation was an independent predictor of survival (odds ratio: 0.876; 95% CI: 0.771–0.995, P = 0.04, c-statistic: 0.84). These findings suggest that regional collaboration and network-wide, uniform triage practices should be key components in the development of regionalized trauma networks.
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Affiliation(s)
- Nitin Sajankila
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio and
| | - Jack C. He
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio and
| | - Brenda M. Zosa
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio and
| | | | - Jeffrey A. Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio and
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27
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Lombardo S, Unurbileg B, Gerelmaa J, Bayarbaatar L, Sarnai E, Price R. Trauma Care in Mongolia: INTACT Evaluation and Recommendations for Improvement. World J Surg 2018; 42:2285-2292. [DOI: 10.1007/s00268-018-4462-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Moore L, Evans D, Yanchar NL, Thakore J, Stelfox HT, Hameed M, Simons R, Kortbeek J, Clément J, Lauzier F, Turgeon AF. Canadian benchmarks for acute injury care. Can J Surg 2017; 60:380-387. [PMID: 28930046 DOI: 10.1503/cjs.002817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Acute care injury outcomes vary substantially across Canadian provinces and trauma centres. Our aim was to develop Canadian benchmarks to monitor mortality and hospital length of stay (LOS) for injury admissions. METHODS Benchmarks were derived using data from the Canadian National Trauma Registry on patients with major trauma admitted to any level I or II trauma centre in Canada and from the following patient subgroups: isolated traumatic brain injury (TBI), isolated thoracoabdominal injury, multisystem blunt injury, age 65 years or older. We assessed predictive validity using measures of discrimination and calibration, and performed sensitivity analyses to assess the impact of replacing analytically complex methods (multiple imputation, shrinkage estimates and flexible modelling) with simple models that can be implemented locally. RESULTS The mortality risk adjustment model had excellent discrimination and calibration (area under the receiver operating characteristic curve 0.886, Hosmer-Lemeshow 36). The LOS risk-adjustment model predicted 29% of the variation in LOS. Overall, observed:expected ratios of mortality and mean LOS generated by an analytically simple model correlated strongly with those generated by analytically complex models (r > 0.95, κ on outliers > 0.90). CONCLUSION We propose Canadian benchmarks that can be used to monitor quality of care in Canadian trauma centres using Excel (see the appendices, available at canjsurg.ca). The program can be implemented using local trauma registries, providing that at least 100 patients are available for analysis.
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Affiliation(s)
- Lynne Moore
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - David Evans
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Natalie L Yanchar
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Jaimini Thakore
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Henry Thomas Stelfox
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Morad Hameed
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Richard Simons
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - John Kortbeek
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Julien Clément
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - François Lauzier
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Alexis F Turgeon
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
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Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Büki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Söderberg J, Stanworth SJ, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K, Adams H, Agnoletti V, Allanson J, Amrein K, Andaluz N, Anke A, Antoni A, van As AB, Audibert G, Azaševac A, Azouvi P, Azzolini ML, Baciu C, Badenes R, Barlow KM, Bartels R, Bauerfeind U, Beauchamp M, Beer D, Beer R, Belda FJ, Bellander BM, Bellier R, Benali H, Benard T, Beqiri V, Beretta L, Bernard F, Bertolini G, Bilotta F, Blaabjerg M, den Boogert H, Boutis K, Bouzat P, Brooks B, Brorsson C, Bullinger M, Burns E, Calappi E, Cameron P, Carise E, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Christie B, Cnossen M, Coles J, Collett J, Della Corte F, Craig W, Csato G, Csomos A, Curry N, Dahyot-Fizelier C, Dawes H, DeMatteo C, Depreitere B, Dewey D, van Dijck J, Đilvesi Đ, Dippel D, Dizdarevic K, Donoghue E, Duek O, Dulière GL, Dzeko A, Eapen G, Emery CA, English S, Esser P, Ezer E, Fabricius M, Feng J, Fergusson D, Figaji A, Fleming J, Foks K, Francony G, Freedman S, Freo U, Frisvold SK, Gagnon I, Galanaud D, Gantner D, Giraud B, Glocker B, Golubovic J, Gómez López PA, Gordon WA, Gradisek P, Gravel J, Griesdale D, Grossi F, Haagsma JA, Håberg AK, Haitsma I, Van Hecke W, Helbok R, Helseth E, van Heugten C, Hoedemaekers C, Höfer S, Horton L, Hui J, Huijben JA, Hutchinson PJ, Jacobs B, van der Jagt M, Jankowski S, Janssens K, Jelaca B, Jones KM, Kamnitsas K, Kaps R, Karan M, Katila A, Kaukonen KM, De Keyser V, Kivisaari R, Kolias AG, Kolumbán B, Kolundžija K, Kondziella D, Koskinen LO, Kovács N, Kramer A, Kutsogiannis D, Kyprianou T, Lagares A, Lamontagne F, Latini R, Lauzier F, Lazar I, Ledig C, Lefering R, Legrand V, Levi L, Lightfoot R, Lozano A, MacDonald S, Major S, Manara A, Manhes P, Maréchal H, Martino C, Masala A, Masson S, Mattern J, McFadyen B, McMahon C, Meade M, Melegh B, Menovsky T, Moore L, Morgado Correia M, Morganti-Kossmann MC, Muehlan H, Mukherjee P, Murray L, van der Naalt J, Negru A, Nelson D, Nieboer D, Noirhomme Q, Nyirádi J, Oddo M, Okonkwo DO, Oldenbeuving AW, Ortolano F, Osmond M, Payen JF, Perlbarg V, Persona P, Pichon N, Piippo-Karjalainen A, Pili-Floury S, Pirinen M, Ple H, Poca MA, Posti J, Van Praag D, Ptito A, Radoi A, Ragauskas A, Raj R, Real RGL, Reed N, Rhodes J, Robertson C, Rocka S, Røe C, Røise O, Roks G, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossi S, Rueckert D, de Ruiter GCW, Sacchi M, Sahakian BJ, Sahuquillo J, Sakowitz O, Salvato G, Sánchez-Porras R, Sándor J, Sangha G, Schäfer N, Schmidt S, Schneider KJ, Schnyer D, Schöhl H, Schoonman GG, Schou RF, Sir Ö, Skandsen T, Smeets D, Sorinola A, Stamatakis E, Stevanovic A, Stevens RD, Sundström N, Taccone FS, Takala R, Tanskanen P, Taylor MS, Telgmann R, Temkin N, Teodorani G, Thomas M, Tolias CM, Trapani T, Turgeon A, Vajkoczy P, Valadka AB, Valeinis E, Vallance S, Vámos Z, Vargiolu A, Vega E, Verheyden J, Vik A, Vilcinis R, Vleggeert-Lankamp C, Vogt L, Volovici V, Voormolen DC, Vulekovic P, Vande Vyvere T, Van Waesberghe J, Wessels L, Wildschut E, Williams G, Winkler MKL, Wolf S, Wood G, Xirouchaki N, Younsi A, Zaaroor M, Zelinkova V, Zemek R, Zumbo F. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16:987-1048. [DOI: 10.1016/s1474-4422(17)30371-x] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
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Magnone S, Ghirardi A, Ceresoli M, Ansaloni L. Trauma patients centralization for the mechanism of trauma: old questions without answers. Eur J Trauma Emerg Surg 2017; 45:431-436. [PMID: 29127439 DOI: 10.1007/s00068-017-0873-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/04/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Centralization of trauma patients has become the standard of care. Unfortunately, overtriage can overcome the capability of Trauma Centres. This study aims to analyse the association of different mechanisms of injury with severe or major trauma defined as Injury Severity Score (ISS) greater than 15 and an estimation of overtriage upon our Trauma Centre. METHODS A retrospective review of our prospective database was undertaken from March 2014 to August 2016. Univariate and multivariable logistic regression models were used to estimate the association between covariates (gender, age, and mechanisms of injury) and the risk of major trauma. RESULTS The trauma team (TT) treated 1575 patients: among the 1359 (86%) were triaged only because of dynamics or mechanism of trauma. Overtriage according to an ISS < 15, was 74.6% on all trauma team activation (TTA) and 83.2% among the TTA prompted by the mechanism of injury. Patients aged 56-70 years had an 87% higher risk of having a major trauma than younger patients (OR 1.87, 95% CI 1.29-2.71) while for patients aged more than 71 years OR was 3.45, 95% CI 2.31-5.15. Car head-on collision (OR 2.50, 95% CI 1.27-4.92), intentional falls (OR 5.61, 95% CI 2.43-12.97), motorbike crash (OR 1.67, 95% CI 1.06-2.65) and pedestrian impact (OR 2.68, 95% CI 1.51-4.74) were significantly associated with a higher risk of major trauma in a multivariate analysis. CONCLUSIONS Significant association with major trauma was demonstrated in the multivariate analysis of different mechanisms of trauma in patients triaged only for dynamics. A revision of our field triage protocol with a prospective validation is needed to improve overtriage that is above the suggested limits.
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Affiliation(s)
- S Magnone
- General Surgery Unit, Ospedale Papa Giovani XXIII, Piazza OMS 1, 24127, Bergamo, Italy.
| | - A Ghirardi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M Ceresoli
- General Surgery Unit, Ospedale Papa Giovani XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - L Ansaloni
- General Surgery Unit, Ospedale Papa Giovani XXIII, Piazza OMS 1, 24127, Bergamo, Italy
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Fakhry SM, Ferguson PL, Johnson EE, Wilson DA. Hospitalization in low-level trauma centres after severe traumatic brain injury: review of a population-based emergency department data base. Brain Inj 2017; 31:1486-1493. [PMID: 28980837 DOI: 10.1080/02699052.2017.1376762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To achieve the best possible recovery, individuals with severe TBI should be treated at Level I/II trauma centres (I/II TC). Increased morbidity and mortality can result when injured patients are admitted to facilities that may not have the appropriate resources or expertise to treat the injury. The purpose of this study was to estimate the proportion of severe TBI visits resulting in hospitalization in lower-level trauma centres (OTH) and evaluate the characteristics associated with such hospitalizations. METHODS The 2012 National Emergency Department Sample (NEDS) data set was analysed. Weighted descriptive analysis and multivariable logistic regression were used to describe the association of hospitalization in OTH with demographic, clinical and hospital characteristics. RESULTS Of visits for severe TBI, 112 208 were admitted to I/II TC and 43 294 admitted to OTH. The adjusted odds of hospitalization in OTH were higher for isolated TBI, falls, women, in those with ≥3 chronic conditions and increasing age. CONCLUSIONS An estimated 19.5% of visits for severe TBI resulted in hospitalization in OTH. These findings show the need to further evaluate the relationship between sex, age and mechanism of injury to inform efforts to appropriately triage individuals with TBI to ensure the best possible recovery.
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Affiliation(s)
- Samir M Fakhry
- a Trauma Service, Division of General Surgery, Department of Surgery , Medical University of South Carolina , Charleston , SC , USA
| | - Pamela L Ferguson
- a Trauma Service, Division of General Surgery, Department of Surgery , Medical University of South Carolina , Charleston , SC , USA
| | - Emily E Johnson
- b College of Nursing , Medical University of South Carolina , Charleston , SC , USA
| | - Dulaney A Wilson
- a Trauma Service, Division of General Surgery, Department of Surgery , Medical University of South Carolina , Charleston , SC , USA.,c Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
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Abstract
The organization of prehospital care for trauma patients began in the military arena. At the urging of multiple stakeholders and providers, these lessons were applied to the civilian setting and emergency medical services were created across the nation. Advances have taken place in the triage, transport, and management of severely injured patients. Many issues remain in the care of trauma patients in the prehospital environment. Collaboration between stakeholders and providers, regionalization of trauma care, and protocol-driven care may be solutions to some of these issues. Further research is necessary to dictate standard of care in this early phase after injury.
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Affiliation(s)
- Joshua Brown
- Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Nitin Sajankila
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Jeffrey A Claridge
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 Metrohealth Drive, Cleveland, OH 44109, USA.
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Chieregato A, Volpi A, Gordini G, Ventura C, Barozzi M, Caspani MLR, Fabbri A, Ferrari AM, Ferri E, Giugni A, Marino M, Martino C, Pizzamiglio M, Ravaldini M, Russo E, Trabucco L, Trombetti S, De Palma R. How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study. BMJ Open 2017; 7:e016415. [PMID: 28965094 PMCID: PMC5640142 DOI: 10.1136/bmjopen-2017-016415] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system. SETTING ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million. PARTICIPANTS 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only. RESULTS A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit. CONCLUSION The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.
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Affiliation(s)
- Arturo Chieregato
- Neurorianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Annalisa Volpi
- 1a Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giovanni Gordini
- Rianimazione ed Emergenza Territoriale 118, Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Chiara Ventura
- Servizio Strutture, Tecnologie e Sistemi Informativi, Direzione Generale Cura della persona, Salute, Welfare - Assessorato alla Sanità - Regione Emilia-Romagna, Bologna, Italy
- Area Governo Clinico, Agenzia Sanitaria e Sociale - Regione Emilia Romagna, Bologna, Italy
| | - Marco Barozzi
- Pronto Soccorso e Coordinamento emergenze traumatologiche, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | | | - Andrea Fabbri
- Pronto Soccorso e Medicina d ’Urgenza, Ospedale di Forlì, Azienda AUSL di Romagna, Forlì, Italy
| | - Anna Maria Ferrari
- Pronto Soccorso e Medicina d’Urgenza, Azienda Ospedaliera Arcispedale Santa Maria Nuova–IRCCS, Reggio Emilia, Italy
| | - Enrico Ferri
- Rianimazione ed Emergenza Territoriale 118, Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Aimone Giugni
- Rianimazione ed Emergenza Territoriale 118, Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Massimiliano Marino
- Governo Clinico - Direzione Sanitaria, Azienda USL Reggio Emilia, Reggio Emilia, Italy
| | - Costanza Martino
- Anestesia e Rianimazione, Ospedale di Cesena, AUSL di Romagna, Emilia-Romagna, Italy
| | | | - Maurizio Ravaldini
- Anestesia e Rianimazione, Ospedale di Cesena, AUSL di Romagna, Emilia-Romagna, Italy
| | - Emanuele Russo
- Anestesia e Rianimazione, Ospedale di Cesena, AUSL di Romagna, Emilia-Romagna, Italy
| | - Laura Trabucco
- Pronto Soccorso e Medicina d’Urgenza, Azienda Ospedaliera Arcispedale Santa Maria Nuova–IRCCS, Reggio Emilia, Italy
| | - Susanna Trombetti
- Area Governo Clinico, Agenzia Sanitaria e Sociale - Regione Emilia Romagna, Bologna, Italy
- UOC Cure Primarie e Specialistica S. Lazzaro-Dipartimento Cure Primarie, AUSL di Bologna, Bologna, Italy
| | - Rossana De Palma
- Area Governo Clinico, Agenzia Sanitaria e Sociale - Regione Emilia Romagna, Bologna, Italy
- Servizio Assistenza Ospedaliera, Direzione Generale Cura della Persona, Salute e Welfare - Assessorato alla Sanità - Regione Emilia Romagna, Bologna, Italy
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Schechtman D, He JC, Zosa BM, Allen D, Claridge JA. Trauma system regionalization improves mortality in patients requiring trauma laparotomy. J Trauma Acute Care Surg 2017; 82:58-64. [PMID: 28005711 DOI: 10.1097/ta.0000000000001302] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION This study evaluates the impact of a regional trauma network (RTN) on patient survival, intensive care unit (ICU) length of stay, and hospital length of stay in patients who required trauma laparotomy. METHODS Patients who required trauma laparotomy from January 2008 to December 2013 were analyzed. Patients admitted during 2008-2009 and 2011-2013 were designated as pre-RTN and RTN groups, respectively. The primary outcome was mortality. RESULTS A total of 569 patients were analyzed, 231 patients were pre-RTN, and 338 were in the RTN group. Overall, mean age was 35.7 ± 17.1 and median Injury Severity Score was 16 (25th-75th percentile: 9-26). The two groups were similar with regard to age, Injury Severity Score, Abbreviated Injury Scale abdomen, sex, and mechanism. Overall, there was a 35% relative reduction in mortality from the pre-RTN to RTN group (p = 0.035), and 30% more patients were triaged to a Level 1 trauma center in the RTN group (p < 0.001). Logistic regression showed that being in the RTN group was an independent predictor for survival (p = 0.026) with odds ratio of 0.53 (95% confidence interval, 0.30-0.93). Patients with penetrating trauma had a nonsignificant decrease in mortality and a reduction of 1 day of ICU stay (p = 0.001). Patients with blunt trauma had a significant reduction in mortality from 38% in the pre-RTN group to 23% in the RTN group (p = 0.017). CONCLUSION This study focused on the unique patient population that required trauma laparotomies. It showed that trauma system regionalization led to a significant increase in the number of patients triaged to a Level 1 trauma center and reduction of ICU length of stay. More importantly, it demonstrated the benefit of regionalization by showing a significant reduction of hospital mortality in this critically injured patient population. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- David Schechtman
- From the Case Western Reserve University School of Medicine (D.S.), Cleveland, Ohio; Department of Surgery (J.C.H., B.M.Z., J.A.C.), MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; and The Northern Ohio Trauma System (D.A., J.A.C.), Cleveland, Ohio
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Spence RT, Scott JW, Haider A, Navsaria PH, Nicol AJ. Comparative assessment of in-hospital trauma mortality at a South African trauma center and matched patients treated in the United States. Surgery 2017; 162:620-627. [PMID: 28688519 DOI: 10.1016/j.surg.2017.04.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/21/2017] [Accepted: 04/22/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The unacceptably high rate of death and disability due to injury in Sub-Saharan Africa is alarming. The objective of this work was to compare mortality rates between severely injured trauma patients at a high-volume trauma center in South Africa with matched patients in the United States. METHODS Clinical databases from the Groote Schuur Hospital for patients treated in Cape Town, South Africa and the American College of Surgeon's National Trauma Databank for patients treated at large academic trauma centers in the United States were used. Coarsened exact matching identified the most comparable patient populations based on sex, age, intent, injury type, injury mechanism, Injury Severity Score, Glasgow Coma Score, and systolic blood pressure. Conditional logistic regression generated odds ratios for mortality among the entire sample and clinically relevant subgroups. RESULTS Coarsened exact matching matched 97.9% of the Groote Schuur Hospital patient sample, resulting in 3,206 matched-pairs between the Groote Schuur Hospital and National Trauma Databank cohorts. Conditional logistic regression revealed an odds ratio of mortality of 1.67 (95% confidence interval, 1.10-2.52) for patients at Groote Schuur Hospital compared with matched patients from the National Trauma Databank. Subset analyses revealed significantly increased odds of mortality among patients with blunt injuries (odds ratio 3.40, 95% confidence interval, 1.68-6.88) and patients with a Glasgow Coma Score of 8 or lower (odds ratio 4.33, 95% confidence interval, 2.10-8.95). No statistically significant difference was identified among patients with penetrating injuries or with a Glasgow Coma Score >8 (P value .90 and .39, respectively). CONCLUSION International comparisons of interhospital variation in risk-adjusted outcomes following trauma can identify opportunities for quality improvement and have the potential to measure the impact of any corrective strategy implemented.
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Affiliation(s)
- Richard T Spence
- Department of Surgery, Groote Schuur Trauma Center, University of Cape Town, Cape Town, South Africa.
| | - John W Scott
- Center for Surgery and Public Health, Bringham and Woman's Hospital, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | - Adil Haider
- Center for Surgery and Public Health, Bringham and Woman's Hospital, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | - Pradeep H Navsaria
- Department of Surgery, Groote Schuur Trauma Center, University of Cape Town, Cape Town, South Africa
| | - Andrew J Nicol
- Department of Surgery, Groote Schuur Trauma Center, University of Cape Town, Cape Town, South Africa
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Big children or little adults? A statewide analysis of adolescent isolated severe traumatic brain injury outcomes at pediatric versus adult trauma centers. J Trauma Acute Care Surg 2017; 82:368-373. [PMID: 27805998 DOI: 10.1097/ta.0000000000001291] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The appropriate managing center for adolescent trauma patients is debated. We sought to determine whether outcome differences existed for adolescent severe traumatic brain injury (sTBI) patients treated at pediatric versus adult trauma centers. We hypothesized that no difference in mortality, functional status at discharge (FSD), or overall complication rate would be observed between center types. METHODS All adolescent trauma patients (aged 15-17 years) presenting with isolated sTBI (head Abbreviated Injury Scale [AIS] score ≥3; all other AIS body region scores ≤2) to accredited Levels I to II trauma centers in Pennsylvania from 2003 to 2015 were extracted from the Pennsylvania Trauma Outcome Study database. Dead on arrival, transfer, and penetrating trauma patients were excluded from analysis. Adult trauma centers were defined as non-pediatirc (PED) (n = 24), whereas standalone pediatric hospitals and adult centers with pediatric affiliation were considered Pediatric (n = 9). Multilevel mixed effects logistic regression models and a generalized linear mixed models assessed the adjusted impact of center type on mortality, overall complications, and FSD. Significance was defined as a p value less than 0.05. RESULTS A total of 1,109 isolated sTBI patients aged 15 to 17 years presented over the 13-year study period (non-PED, 685; PED, 424). In adjusted analysis controlling for age, shock index, head AIS, Glasgow Coma Scale motor, trauma center level of managing facility, case volume of managing facility, and injury year, no significant difference in mortality (adjusted odds ratio, 0.82; 95% confidence interval [CI], 0.23-2.86; p = 0.754), FSD (coefficient, -0.85; 95% CI, -2.03 to 0.28; p = 0.136), or total complication rate (adjusted odds ratio, 1.21; 95% CI, 0.43-3.39; p = 0.714) was observed between center types. CONCLUSION Although the optimal treatment facility for adolescent patients is frequently debated, patients aged 15 to 17 years presenting with isolated sTBI may experience similar outcomes when managed at pediatric and adult trauma centers. LEVEL OF EVIDENCE Epidemiologic study, level III; therapeutic study, level IV.
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Abstract
BACKGROUND The Northern Ohio Trauma System (NOTS), established in 2010, is a collaborative regional trauma system composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems. Mortalities between counties in NOTS and other Ohio counties were compared to assess NOTS performance. METHODS State trauma registry was analyzed for patients 15 years or older from 2006 to 2012. Mortality change over time was assessed by comparing all counties before and after NOTS establishment. Two analyses were done in the post-NOTS period: (1) a county analysis, comparing Cuyahoga County, the county containing NOTS level I TC (L1TC), with other counties containing L1TCs and (2) a regional analysis, comparing Cuyahoga and its adjacent counties (i.e., the NOTS region) with other L1TC containing regions. The following subgroups were included a priori: Injury Severity Score 15 or greater, age 65 years or older, and trauma mechanism. RESULTS A total of 178,143 patients were analyzed. Cuyahoga was the only county that had a decrease in mortality for both the overall group and all subgroups over time (all p < 0.05). Both the county and regional analyses showed that the overall NOTS patients were 1 to 4 years older (p < 0.05), had similar or higher Injury Severity Score (p < 0.05), and were treated more often at lower-level TCs (p < 0.001). County analysis demonstrated that Cuyahoga County had approximately 1% lower mortality in geriatrics patients compared with non-NOTS counties. Regional analysis showed lower mortality in the NOTS region for the overall patient group, as well as geriatric and blunt injuries subgroups. CONCLUSIONS Cuyahoga was the only county in Ohio that had significant mortality reduction for all patient groups over time. Trauma system regionalization was associated with greater utilization of lower-level TCs and lower patient mortality. These findings suggest that a collaborative regional trauma system may be more important than the number of L1TC in an area. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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He JC, Schechtman D, Allen DL, Cremona JJ, Claridge JA. Despite Trauma Center Closures, Trauma System Regionalization Reduces Mortality and Time to Definitive Care in Severely Injured Patients. Am Surg 2017. [DOI: 10.1177/000313481708300623] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Northern Ohio Trauma System (NOTS), consisting of multiple hospital systems, was established in 2010 to improve trauma outcomes. This study assessed its impact on mortality and time to definitive care, focusing especially on the severely injured patients. NOTS trauma registry was queried for all trauma activations from 2008 to 2013. The years between 2008–2009 and 2011–2013 were designated as pre- and post-NOTS, respectively. Data from 2010 was excluded as a transitional year. Two trauma centers (TCs) closed in 2010. Predetermined patient subgroups were analyzed. A total of 27,843 patients were examined. Mean age was 46 and 64 per cent were male. Median Injury Severity Score (ISS) was five, and 87 per cent sustained blunt injuries. Of these, 10,641 patients were pre-NOTS and 17,202 were post-NOTS. Comparing the two groups, mortality decreased from 5 to 4 per cent post-NOTS (P < 0.001); median time to definitive care increased by 12 minutes post-NOTS. Multivariate logistic regression showed that NOTS implementation was an independent predictor for survival (P = 0.008), whereas time to definitive care was not. Subgroup analyses demonstrated mortality reductions post-NOTS for all subgroups except patients with penetrating injuries, where mortality remained the same despite an increase in ISS. Patients with ISS ≥15 had a 23 per cent relative reduction in mortality, and their median time to definitive care decreased by 12 minutes. Implementation of a collaborative, regional trauma system was associated with mortality reduction and shortened time to definitive care in the severely injured patients. These findings highlight the importance of collaboration in the future development of regional trauma systems.
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Affiliation(s)
- Jack C. He
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Northern Ohio Trauma System, Cleveland, Ohio
| | - David Schechtman
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Jeffrey A. Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Northern Ohio Trauma System, Cleveland, Ohio
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Nouh T. Nonoperative Management of Trauma. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2017; 5:91-92. [PMID: 30787764 PMCID: PMC6298378 DOI: 10.4103/sjmms.sjmms_34_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Thamer Nouh
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Oliver GJ, Walter DP, Redmond AD. Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades. Injury 2017; 48:978-984. [PMID: 28363752 DOI: 10.1016/j.injury.2017.01.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 12/26/2016] [Accepted: 01/20/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND & OBJECTIVES In 1994, Hussain and Redmond revealed that up to 39% of prehospital deaths from accidental injury might have been preventable had basic first aid care been given. Since then there have been significant advances in trauma systems and care. The exclusion of prehospital deaths from the analysis of trauma registries, giv en the high rate of those, is a major limitation in prehospital research on preventable death. We have repeated the 1994 study to identify any changes over the years and potential developments to improve patient outcomes. METHODS We examined the full Coroner's inquest files for prehospital deaths from trauma and accidental injury over a three-year period in Cheshire. Injuries were scored using the Abbreviated-Injury-Scale (AIS-1990) and Injury Severity Score (ISS), and probability of survival estimated using Bull's probits to match the original protocol. RESULTS One hundred and thirty-four deaths met our inclusion criteria; 79% were male, average age at death was 53.6 years. Sixty-two were found dead (FD), fifty-eight died at scene (DAS) and fourteen were dead on arrival at hospital (DOA). The predominant mechanism of injury was fall (39%). The median ISS was 29 with 58 deaths (43%) having probability of survival of >50%. Post-mortem evidence of head injury was present in 102 (76%) deaths. A bystander was on scene or present immediately after injury in 45% of cases and prior to the Emergency Medical Services (EMS) in 96%. In 93% of cases a bystander made the call for assistance, in those DAS or DOA, bystander intervention of any kind was 43%. CONCLUSIONS The number of potentially preventable prehospital deaths remains high and unchanged. First aid intervention of any kind is infrequent. There is a potentially missed window of opportunity for bystander intervention prior to the arrival of the ambulance service, with simple first-aid manoeuvres to open the airway, preventing hypoxic brain injury and cardiac arrest.
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Affiliation(s)
- G J Oliver
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK.
| | - D P Walter
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK
| | - A D Redmond
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK
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Vali Y, Rashidian A, Jalili M, Omidvari A, Jeddian A. Effectiveness of regionalization of trauma care services: a systematic review. Public Health 2017; 146:92-107. [DOI: 10.1016/j.puhe.2016.12.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 08/15/2016] [Accepted: 12/08/2016] [Indexed: 02/03/2023]
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Moore L, Champion H, O’Reilly G, Leppaniemi A, Cameron P, Palmer C, Abu-Zidan FM, Gabbe B, Gaarder C, Yanchar N, Stelfox HT, Coimbra R, Kortbeek J, Noonan V, Gunning A, Leenan L, Gordon M, Khajanchi M, Shemilt M, Porgo V, Turgeon AF. Impact of trauma system structure on injury outcomes: a systematic review protocol. Syst Rev 2017; 6:12. [PMID: 28109306 PMCID: PMC5251247 DOI: 10.1186/s13643-017-0408-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/06/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Injury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization. METHODS We will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool. DISCUSSION We expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts. SYSTEMATIC REVIEW REGISTRATION This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041336 .
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie–Urgence-Soins intensifs (Trauma–Emergency–Critical Care Medicine), CHU de Québec–Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4 Canada
| | | | - Gerard O’Reilly
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ari Leppaniemi
- Department of Surgery, Helsinki University, Helsinki, Finland
| | - Peter Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Monash University, Melbourne, Australia
| | - Cameron Palmer
- Trauma Service, Royal Children’s Hospital, Melbourne, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Natalie Yanchar
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, California USA
| | - John Kortbeek
- Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alberta Canada
| | - Vanessa Noonan
- Rick Hansen Institute, Vancouver, BC Canada
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Amy Gunning
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke Leenan
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Malcolm Gordon
- Department of Emergency Medicine, University of Glasgow, Glasgow, UK
| | | | - Michèle Shemilt
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie–Urgence-Soins intensifs (Trauma–Emergency–Critical Care Medicine), CHU de Québec–Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4 Canada
| | - Valérie Porgo
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
| | - Alexis F. Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
| | - on behalf of the International Injury Care Improvement Initiative
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie–Urgence-Soins intensifs (Trauma–Emergency–Critical Care Medicine), CHU de Québec–Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4 Canada
- U Health Sciences, Baltimore, Maryland USA
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Surgery, Helsinki University, Helsinki, Finland
- Emergency and Trauma Centre, The Alfred Hospital, Monash University, Melbourne, Australia
- Trauma Service, Royal Children’s Hospital, Melbourne, Australia
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia Canada
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, California USA
- Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alberta Canada
- Rick Hansen Institute, Vancouver, BC Canada
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Emergency Medicine, University of Glasgow, Glasgow, UK
- Seth G.S. Medical College and KEM Hospital, Mumbai, India
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Mobile health technology transforms injury severity scoring in South Africa. J Surg Res 2016; 204:384-392. [PMID: 27565074 DOI: 10.1016/j.jss.2016.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/12/2016] [Accepted: 05/11/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND The burden of data collection associated with injury severity scoring has limited its application in areas of the world with the highest incidence of trauma. MATERIAL AND METHODS Since January 2014, electronic records (electronic Trauma Health Records [eTHRs]) replaced all handwritten records at the Groote Schuur Hospital Trauma Unit in South Africa. Data fields required for Glasgow Coma Scale, Revised Trauma Score, Kampala Trauma Score, Injury Severity Score (ISS), and Trauma Score-Injury Severity Score calculations are now prospectively collected. Fifteen months after implementation of eTHR, the injury severity scores were compared as predictors of mortality on three accounts: (1) ability to discriminate (area under receiver operating curve, ROC); (2) ability to calibrate (observed versus expected ratio, O/E); and (3) feasibility of data collection (rate of missing data). RESULTS A total of 7460 admissions were recorded by eTHR from April 1, 2014 to July 7, 2015, including 770 severely injured patients (ISS > 15) and 950 operations. The mean age was 33.3 y (range 13-94), 77.6% were male, and the mechanism of injury was penetrating in 39.3% of cases. The cohort experienced a mortality rate of 2.5%. Patient reserve predictors required by the scores were 98.7% complete, physiological injury predictors were 95.1% complete, and anatomic injury predictors were 86.9% complete. The discrimination and calibration of Trauma Score-Injury Severity Score was superior for all admissions (ROC 0.9591 and O/E 1.01) and operatively managed patients (ROC 0.8427 and O/E 0.79). In the severely injured cohort, the discriminatory ability of Revised Trauma Score was superior (ROC 0.8315), but no score provided adequate calibration. CONCLUSIONS Emerging mobile health technology enables reliable and sustainable injury severity scoring in a high-volume trauma center in South Africa.
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Abstract
OBJECTIVE To describe the long-term outcomes of major trauma patients and factors associated with the rate of recovery. BACKGROUND As injury-related mortality decreases, there is increased focus on improving the quality of survival and reducing nonfatal injury burden. METHODS Adult major trauma survivors to discharge, injured between July 2007 and June 2012 in Victoria, Australia, were followed up at 6, 12, and 24 months after injury to measure function (Glasgow Outcome Scale-Extended) and return to work/study. Random-effects regression models were fitted to identify predictors of outcome and differences in the rate of change in each outcome between patient subgroups. RESULTS Among the 8844 survivors, 8128 (92%) were followed up. Also, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% (adjusted odds ratio 1.27, 95% confidence interval [CI] 1.19-1.36) higher compared with 6 months, and 9% (adjusted odds ratio 1.09, 95% CI, 1.02-1.17) higher at 24 months compared with 12 months. The adjusted relative risk (RR) of returning to work was 14% higher at 12 months compared with 6 months (adjusted RR 1.14, 95% CI, 1.12-1.16) and 8% (adjusted RR 1.08, 95% CI, 1.06-1.10) higher at 24 months compared with 12 months. CONCLUSIONS Improvement in outcomes over the study period was observed, although ongoing disability was common at 24 months. Recovery trajectories differed by patient characteristics, providing valuable information for informing prognostication and service planning, and improving our understanding of the burden of nonfatal injury.
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Gregson BA, Rowan EN, Francis R, McNamee P, Boyers D, Mitchell P, McColl E, Chambers IR, Unterberg A, Mendelow AD. Surgical Trial In Traumatic intraCerebral Haemorrhage (STITCH): a randomised controlled trial of Early Surgery compared with Initial Conservative Treatment. Health Technol Assess 2016; 19:1-138. [PMID: 26346805 DOI: 10.3310/hta19700] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND While it is accepted practice to remove extradural (EDH) and subdural haematomas (SDH) following traumatic brain injury, the role of surgery in parenchymal traumatic intracerebral haemorrhage (TICH) is controversial. There is no evidence to support Early Surgery in this condition. OBJECTIVES There have been a number of trials investigating surgery for spontaneous intracerebral haemorrhage but none for TICH. This study aimed to establish whether or not a policy of Early Surgery for TICH improves outcome compared with a policy of Initial Conservative Treatment. DESIGN This was an international multicentre pragmatic parallel group trial. Patients were randomised via an independent telephone/web-based randomisation service. SETTING Neurosurgical units in 59 hospitals in 20 countries registered to take part in the study. PARTICIPANTS The study planned to recruit 840 adult patients. Patients had to be within 48 hours of head injury with no more than two intracerebral haematomas greater than 10 ml. They did not have a SDH or EDH that required evacuation or any severe comorbidity that would mean they could not achieve a favourable outcome if they made a complete recovery from their head injury. INTERVENTIONS Patients were randomised to Early Surgery within 12 hours or to Initial Conservative Treatment with delayed evacuation if it became clinically appropriate. MAIN OUTCOME MEASURES The Extended Glasgow Outcome Scale (GOSE) was measured at 6 months via a postal questionnaire. The primary outcome was the traditional dichotomised split into favourable outcome (good recovery or moderate disability) and unfavourable outcome (severe disability, vegetative, dead). Secondary outcomes included mortality and an ordinal assessment of Glasgow Outcome Scale and Rankin Scale. RESULTS Patient recruitment began in December 2009 but was halted by the funding body because of low UK recruitment in September 2012. In total, 170 patients were randomised from 31 centres in 13 countries: 83 to Early Surgery and 87 to Initial Conservative Treatment. Six-month outcomes were obtained for 99% of 168 eligible patients (82 Early Surgery and 85 Initial Conservative Treatment patients). Patients in the Early Surgery group were 10.5% more likely to have a favourable outcome (absolute benefit), but this difference did not quite reach statistical significance because of the reduced sample size. Fifty-two (63%) had a favourable outcome with Early Surgery, compared with 45 (53%) with Initial Conservative Treatment [odds ratio 0.65; 95% confidence interval (CI) 0.35 to 1.21; p = 0.17]. Mortality was significantly higher in the Initial Conservative Treatment group (33% vs. 15%; absolute difference 18.3%; 95% CI 5.7% to 30.9%; p = 0.006). The Rankin Scale and GOSE were significantly improved with Early Surgery using a trend analysis (p = 0.047 and p = 0.043 respectively). CONCLUSIONS This is the first ever trial of surgery for TICH and indicates that Early Surgery may be a valuable tool in the treatment of TICH, especially if the Glasgow Coma Score is between 9 and 12, as was also found in Surgical Trial In spontaneous intraCerebral Haemorrhage (STICH) and Surgical Trial In spontaneous lobar intraCerebral Haemorrhage (STICH II). Further research is clearly warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN 19321911. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 70. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Barbara A Gregson
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Elise N Rowan
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Richard Francis
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Patrick Mitchell
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Iain R Chambers
- South Tees Hospitals Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, D-69120 Heidelberg, Germany
| | - A David Mendelow
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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Galvagno Jr SM, Sikorski R, Hirshon JM, Floccare D, Stephens C, Beecher D, Thomas S. Helicopter emergency medical services for adults with major trauma. Cochrane Database Syst Rev 2015; 2015:CD009228. [PMID: 26671262 PMCID: PMC8627175 DOI: 10.1002/14651858.cd009228.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured people derive the greatest benefit. OBJECTIVES To determine if helicopter emergency medical services (HEMS) transport, compared with ground emergency medical services (GEMS) transport, is associated with improved morbidity and mortality for adults with major trauma. SEARCH METHODS We ran the most recent search on 29 April 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE (OvidSP), EMBASE Classic + EMBASE (OvidSP), CINAHL Plus (EBSCOhost), four other sources, and clinical trials registers. We screened reference lists. SELECTION CRITERIA Eligible trials included randomized controlled trials (RCTs) and nonrandomized intervention studies. We also evaluated nonrandomized studies (NRS), including controlled trials and cohort studies. Each study was required to have a GEMS comparison group. An Injury Severity Score (ISS) of at least 15 or an equivalent marker for injury severity was required. We included adults age 16 years or older. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and assessed the risk of bias of included studies. We applied the Downs and Black quality assessment tool for NRS. We analyzed the results in a narrative review, and with studies grouped by methodology and injury type. We constructed 'Summary of findings' tables in accordance with the GRADE Working Group criteria. MAIN RESULTS This review includes 38 studies, of which 34 studies examined survival following transportation by HEMS compared with GEMS for adults with major trauma. Four studies were of inter-facility transfer to a higher level trauma center by HEMS compared with GEMS. All studies were NRS; we found no RCTs. The primary outcome was survival at hospital discharge. We calculated unadjusted mortality using data from 282,258 people from 28 of the 38 studies included in the primary analysis. Overall, there was considerable heterogeneity and we could not determine an accurate estimate of overall effect.Based on the unadjusted mortality data from six trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS. Twenty-one studies used multivariate regression to adjust for confounding. Results varied, some studies found a benefit of HEMS while others did not. Trauma-Related Injury Severity Score (TRISS)-based analysis methods were used in 14 studies; studies showed survival benefits in both the HEMS and GEMS groups as compared with MTOS. We found no studies evaluating the secondary outcome, morbidity, as assessed by quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). Four studies suggested a small to moderate benefit when HEMS was used to transfer people to higher level trauma centers. Road traffic and helicopter crashes are adverse effects which can occur with either method of transport. Data regarding safety were not available in any of the included studies. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria. AUTHORS' CONCLUSIONS Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, we could not determine an accurate composite estimate of the benefit of HEMS. Although some of the 19 multivariate regression studies indicated improved survival associated with HEMS, others did not. This was also the case for the TRISS-based studies. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their nonrandomized design. The question of which elements of HEMS may be beneficial has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximize the potential utility of results. Large, multicenter studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.
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Affiliation(s)
- Samuel M Galvagno Jr
- University of Maryland School of Medicine, Division of Trauma Anesthesiology, Program in Trauma, R Adams Cowley Shock Trauma CenterDepartment of AnesthesiologyBaltimoreMDUSA21201
| | - Robert Sikorski
- University of Maryland School of Medicine, Division of Trauma Anesthesiology, Program in Trauma, R Adams Cowley Shock Trauma CenterDepartment of AnesthesiologyBaltimoreMDUSA21201
| | - Jon M Hirshon
- University of Maryland School of MedicineDepartment of Emergency MedicinePaca‐Pratt Building110 S. Paca Street, 4S‐127BaltimoreMarylandUSA21201‐1559
| | - Douglas Floccare
- Maryland Institute for Emergency Medical Services Systems653 W Pratt StreetBaltimoreMDUSA21201
| | - Christopher Stephens
- R. Adams Cowley Shock Trauma Center, University of MarylandTrauma AnaesthesiologyDepartment of AnesthesiologyBaltimoreMDUSA21201
| | - Deirdre Beecher
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupKeppel StreetLondonUKWC1E 7HT
| | - Stephen Thomas
- Hamad General Hospital & Weill Cornell Medical College in QatarDepartment of Emergency MedicineDohaQatar
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Lecky F. Twenty-five years of the trauma audit and research network: a continuing evolution to drive improvement. Emerg Med J 2015; 32:906-8. [DOI: 10.1136/emermed-2015-205460] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system. J Trauma Acute Care Surg 2015; 79:372-7. [PMID: 26307868 DOI: 10.1097/ta.0000000000000762] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We previously demonstrated that regionalization of trauma (RT) significantly reduced in-hospital mortality from 19% to 14% in patients with severe traumatic brain injury (sTBI). However, functional and long-term outcomes had not been assessed. We hypothesized that RT would be associated with improved functional and long-term outcomes in sTBI patients. METHODS All TBI patients older than 14 years with a head Abbreviated Injury Scale (AIS) score of 3 or greater were identified from the RT database and matched to the state death index and the regional TBI rehabilitation (TBIr) database. Data from 2008 through 2012 were analyzed before and after RT in 2010. For patients discharged to the TBIr unit, overall Functional Independence Measure (FIM) scores and FIM score gains were compared before and after RT. RESULTS A total of 3,496 patients with sTBI were identified in the RT database, 1,359 in the pre-RT and 2,137 in the post-RT period. The mortality rate after discharge decreased significantly after RT from 21% to 16% (p < 0.0001) at 30 days and from 24% to 20% (p = 0.004) at 6 months. Multivariable logistic regression demonstrated RT to be an independent predictor against mortality at 30 days (odds ratio, 0.74; 95% confidence interval, 0.60-0.91; C statistic, 0.84) and 6 months (odds ratio, 0.82; 95% confidence interval, 0.67-0.99; C statistic, 0.82). Discharges to the TBIr unit increased from 117 (9%) in the pre-RT to 297 (14%) in the post-RT period (p < 0.0001), while discharges to home and non-TBIr units remained similar. Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score for all discharged patients remained similar. FIM admission scores were similar in the pre-RT (median, 54; interquartile range [IQR], 30-65) and post-RT period (median, 48; IQR, 31-61) (p = 0.2) and remained similar at discharge in the pre-RT (median, 92; IQR, 75-102) and post-RT period (median, 89; IQR, 73-100) (p = 0.1). TBIr patients showed similar FIM score gains in the pre-RT (median, 37; IQR, 26-46) and post-RT period (median, 36; IQR, 24-49) (p = 0.6). CONCLUSION RT was associated with reduced long-term mortality, increased TBIr admissions, and similar FIM score improvements for patients with sTBI. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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Restructuring an evolving Irish trauma system: What can we learn from Europe and Australia? Surgeon 2015; 14:44-51. [PMID: 26344740 DOI: 10.1016/j.surge.2015.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/23/2015] [Accepted: 08/13/2015] [Indexed: 11/21/2022]
Abstract
AIM Major trauma is a leading cause of mortality and disability. Internationally, major trauma centres and comprehensive trauma networks are associated with improved outcomes. This study aimed to examine selected international trauma systems in Europe and Australia to identify common themes that may aid reconfiguration of the Irish trauma service. METHODS An electronic search strategy was utilised using Medline, and a search of the grey literature using Google and Google Scholar. Search terms included "trauma systems", "trauma care", "major trauma centre" and "trauma network". Relevant articles were reviewed and data summarised in a narrative format. RESULTS Republic of Ireland currently lacks designated major trauma centres and surrounding trauma networks. Lessons from international models and data from the on-going national trauma audit may guide reconfiguration. Well-functioning trauma systems internationally bear striking similarities, and involve a hub and spoke model. This model has a central major trauma centre, surrounded by a co-ordinated trauma network with trauma units. Concentration of major trauma into high volume centres is key, but these centres must be adequately resourced to deliver a high quality service. Investment in and co-ordination of prehospital care is essential to overcome geographical impediments to centralising trauma care. Funding of rehabilitation infrastructure and resources is also an integral part of a well-functioning trauma system. Trauma outcome data is key to informing trauma system design, with dissemination of this data and public engagement critical for change. CONCLUSION International models of trauma care provide valuable lessons for countries currently in process of reconfiguring trauma services.
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