Complications to evaluate adult trauma care: An expert consensus study

Blunt Cerebrovascular Injury Complications in Aging Adults: A National Trauma Database Study

INTRODUCTION

Blunt cerebrovascular injury (BCVI) is defined as a nonpenetrating injury to the carotid or vertebral arteries which can be highly morbid. Because BCVI is rare, most studies have been devoted to triaging trauma patients for BCVI identification, with little data available regarding the complications these patients experience after initial evaluation. Here, we analyze the association of complications during admission for BCVI patients.

METHODS

The National Trauma Databank was queried from 2007 to 2014 for adults ≥65 y old. Demographics, incidence of BCVI, and injury data were evaluated using univariate analysis. Rates of inpatient complications due to acutely acquired infections and strokes were evaluated using univariate and multivariable analysis.

RESULTS

We identified 666,815 non-BCVI and 552 BCVI patients. Patients with a BCVI were typically male, White, younger (65-75-y-old), had three or more comorbidities, and had Medicare insurance. BCVI patients had a mild head injury upon arrival at the emergency department and experienced a motor vehicle accident/fall. The median length of stay in the intensive care unit, days spent on a ventilator, and presence of polytrauma were higher among BCVI patients. BCVI patients had increased odds of experiencing a stroke and pneumonia as complications while admitted compared to their non-BCVI counterparts.

CONCLUSIONS

Postinjury, patients who suffered a BCVI had higher odds of stroke and pneumonia than patients who did not experience a BCVI. Additional studies are needed to determine the modifiable risk factors associated with BCVIs among aging adults.

Epidemiology, injury pattern and outcome of older trauma patients: A 15-year study of level-I trauma centers

BACKGROUND

Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients.

METHODS

A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes.

RESULTS

A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36-77] to 67[46-82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively).

CONCLUSIONS

Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality.

Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement

BACKGROUND

Prevention of hospital-acquired conditions (HACs) is a focus of trauma center quality improvement. The relative contributions of various HACs to postinjury hospital outcomes are unclear. We sought to quantify and compare the impacts of six HACs on early clinical outcomes and resource utilization in hospitalized trauma patients.

METHODS

Adult patients from the 2013 to 2016 American College of Surgeons Trauma Quality Improvement Program Participant Use Data Files who required 5 days or longer of hospitalization and had an Injury Severity Score of 9 or greater were included. Multiple imputation with chained equations was used for observations with missing data. The frequencies of six HACs and five adverse outcomes were determined. Multivariable Poisson regression with log link and robust error variance was used to produce relative risk estimates, adjusting for patient-, hospital-, and injury-related factors. Risk-adjusted population attributable fractions estimates were derived for each HAC-outcome pair, with the adjusted population attributable fraction estimate for a given HAC-outcome pair representing the estimated percentage decrease in adverse outcome that would be expected if exposure to the HAC had been prevented.

RESULTS

A total of 529,856 patients requiring 5 days or longer of hospitalization were included. The incidences of HACs were as follows: pneumonia, 5.2%; urinary tract infection, 3.4%; venous thromboembolism, 3.3%; surgical site infection, 1.3%; pressure ulcer, 1.3%; and central line-associated blood stream infection, 0.2%. Pneumonia demonstrated the strongest association with in-hospital outcomes and resource utilization. Prevention of pneumonia in our cohort would have resulted in estimated reductions of the following: 22.1% for end organ dysfunction, 7.8% for mortality, 8.7% for prolonged hospitalization, 7.1% for prolonged intensive care unit stay, and 6.8% for need for mechanical ventilation. The impact of other HACs was comparatively small.

CONCLUSION

We describe a method for comparing the contributions of HACs to outcomes of hospitalized trauma patients. Our findings suggest that trauma program improvement efforts should prioritize pneumonia prevention.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

PREVALÊNCIA E FATORES ASSOCIADOS À DOENÇA CRÍTICA CRÔNICA EM HOSPITALIZADOS POR TRAUMA EM TERAPIA INTENSIVA

RESUMO Objetivo identificar a prevalência de doença crítica crônica e fatores associados em pacientes hospitalizados por trauma em Unidade de Terapia Intensiva. Método estudo de caso-controle, com dados de prontuários de adultos hospitalizados por trauma em uma Unidade de Terapia Intensiva, entre 2013 e 2019. Os dados foram coletados do livro de admissão de pacientes, do prontuário eletrônico e das fichas do Serviço de Controle de Infecção Hospitalar. A variável dependente foi a ocorrência de doença crítica crônica e as variáveis independentes relacionavam-se às características sociodemográficas, comorbidades, trauma, atendimento pré-hospitalar, índices prognósticos, procedimentos e complicações. Realizou-se análise de regressão logística múltipla, que estimou o Ods Ratio (OR) e respectivos intervalos de confiança (IC). Resultados a doença crítica crônica ocorreu em 150 pacientes (24,2%), dos 619 estudados. Os fatores associados à DCC foram disfunção orgânica (OR=1,09) e complicações gastrointestinais (OR=2,71). Os pacientes com doença crítica crônica, além de demandarem por procedimentos cirúrgicos, desenvolveram disfunções orgânicas em diferentes sistemas, apresentando altas pontuações nos índices de prognósticos, ou seja, um pior prognóstico, além de desenvolverem complicações. Conclusão a identificação das complicações gastrointestinais e o aumento da disfunção orgânica como fatores associados ao paciente crítico crônico tornam-se úteis para compor perfil clínico de pacientes e para planejar a assistência intensiva ao traumatizado, contribuindo, assim, para a prevenção e o manejo desses pacientes pelo enfermeiro.

PREVALENCE AND FACTORS ASSOCIATED WITH CHRONIC CRITICAL DISEASE IN HOSPITALIZED FOR TRAUMA IN INTENSIVE CARE

ABSTRACT Objective to identify the prevalence of chronic critical disease and associated factors in patients hospitalized for trauma in the Intensive Care Unit. Method case-control study, with data from medical records of adults hospitalized for trauma in an Intensive Care Unit, between 2013 and 2019. Data were collected from the patient admission book, the electroni cmedical records and the records of the Hospital Infection Control Service. The dependent variable was the occurrence of chronic critical disease, and the independent variables were related to sociodemographic characteristics, comorbidities, trauma, pre-hospital care, prognostic indices, procedures and complications. Multiple logistic regression analysis was performed, which estimated the Ods Ratio (OR) and respective confidence intervals (CI). Results chronic critical disease occurred in 150 patients (24.2%), of the 619 patients studied. The factors associated with CCD were organic dysfunction (OR=1.09) and gastrointestinal complications (OR=2.71). Patients with chronic critical disease, in addition to proseeding for surgical procedures, developed organic dysfunctions in different systems, presenting high scores in prognostic indexes, i.e., a worse prognosis, in addition to developing complications. Conclusion the identification of gastrointestinal complications and the increase in organic dysfunction as factors associated with chronic critical patients become useful to compose the clinical profile of patients and to plan intensive care for the traumatized patients, thus contributing to the prevention and management of these patients by nurses.

Trauma system accreditation and patient outcomes in British Columbia: an interrupted time series analysis

OBJECTIVE

We aim to assess the impact of several accreditation cycles of trauma centers on patient outcomes, specifically in-hospital mortality, complications and hospital length of stay.

DESIGN

Interrupted time series.

SETTING

British Columbia, Canada.

PARTICIPANTS

Trauma patients admitted to all level I and level II trauma centers between January 2008 and March 2018.

EXPOSURE

Accreditation.

MAIN OUTCOMES AND MEASURES

We first computed quarterly estimates of the proportions of in-hospital mortality, complications and survival to discharge standardized for change in patient case-mix using prognostic scores and the Aalen-Johansen estimator of the cumulative incidence function. Piecewise regressions were then used to estimate the change in levels and trends for patient outcomes following accreditation.

RESULTS

For in-hospital mortality and major complications, the impact of accreditation seems to be associated with short- and long-term reductions after the first cycle and only short-term reductions for subsequent cycles. However, the 95% confidence intervals for these estimates were wide, and we lacked the precision to consistently conclude that accreditation is beneficial.

CONCLUSIONS

Applying a quasi-experimental design to time series accounting for changes in patient case-mix, our results suggest that accreditation might reduce in-hospital mortality and major complications. However, there was uncertainty around the estimates of accreditation. Further studies looking at clinical processes of care and other outcomes such as patient or health staff satisfaction are needed.

The Economic and Clinical Impact of an Early Mobility Program in the Trauma Intensive Care Unit: A Quality Improvement Project

Traumatic injury survivors often face a difficult recovery. Surgical and invasive procedures, prolonged monitoring in the intensive care unit (ICU), and constant preventive vigilance by medical staff guide standards of care to promote positive outcomes. Recently, patients with traumatic injuries have benefited from early mobilization, a multidisciplinary approach to increasing participation in upright activity and walking. The purpose of this project was to determine the impact of an early mobility program in the trauma ICU on length of stay (LOS), ventilator days, cost, functional milestones, and rehabilitation utilization. A quality improvement project compared outcomes and cost before and after the implementation of an early mobility program. The trauma team assigned daily mobility levels to trauma ICU patients. Nursing and rehabilitation staff collaborated to set daily goals and provide mobility-based interventions. Forty-four patients were included in the preintervention group and 43 patients in the early mobility group. Physical therapy and occupational therapy were initiated earlier in the early mobilization group (p = .044 and p = .026, respectively). Improvements in LOS, duration of mechanical ventilation, time to out-of-bed activity and walking, and discharge disposition were not significant. There were no adverse events related to the early mobility initiative. Activity intolerance resulted in termination of 7.1% of mobility sessions. The development and initiation of a trauma-specific early mobility program proved to be safe and reduce patient care costs. In addition, the program facilitated earlier initiation of physician and occupational therapies. Although not statistically significant, retrospective data abstraction provides evidence of fewer ICU and total hospital days, earlier extubations, and greater proactive participation in functional activities.

Inter-hospital variation in surgical intensity for trauma admissions: A multicentre cohort study

BACKGROUND

Guidelines for injury care are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. We aimed to assess inter-hospital variation in surgical intensity for injury admissions and evaluate the correlation between hospital surgical intensity and mortality/complications.

METHODS

We included adults admitted for major trauma between 2006 and 2016 in a Canadian provincial trauma system. Analyses were stratified for orthopaedic (n = 16 887), neurological (n = 12 888) and torso injuries (n = 9816). Surgical intensity was quantified with the number of surgical procedures <72 hours. Inter-hospital variation was assessed with the intra-class correlation coefficient (ICC). We assessed the correlation between the risk-adjusted mean number of surgical procedures and risk-adjusted incidence of mortality and complications using Pearson correlation coefficients (r).

RESULTS

Moderate inter-hospital variation was observed for orthopaedic surgery (ICC = 14.0%) whereas variation was low for torso surgery (ICC = 2.7%) and neurosurgery (ICC = 0.8%). Surgical intensity was negatively correlated with hospital mortality for torso injury (r = -.32, P = .02) and neurotrauma (r = -.65, P = .08). A strong positive correlation was observed with hospital complications for orthopaedic injuries (r = .36, P = .006) whereas the opposite was observed for neurotrauma (r = -.71, P = .05).

CONCLUSIONS

Results should be interpreted with caution as they may be a result of residual confounding. However, they may suggest that there are opportunities for quality improvement in surgical care for injury admissions, particularly for orthopaedic injuries. Moving forward, we should aim to prospectively evaluate adherence to guidelines on non-operative management and their impact on mortality and morbidity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment

PURPOSE

Venous thromboembolisms (VTE) are a major concern after acute survival from trauma. Variations in treatment protocols for trauma patients exist worldwide. This study analyzes the differences in the number of VTE events and the associated complications of thromboprophylaxis between two level I trauma populations utilizing varying treatment protocols.

METHODS

International multicenter trauma registry-based study was performed at the University Medical Center Utrecht (UMCU) in The Netherlands (early commencement chemical prophylaxis), and Harborview Medical Center (HMC) in the United States (restrictive early chemical prophylaxis). All severely injured patients (ISS ≥ 16), aged ≥ 18 years, and admitted in 2013 were included. Primary outcomes were VTE [deep venous thrombosis (DVT) (no screening), pulmonary embolism (PE)], and hemorrhagic complications.

RESULTS

In UMCU, 279 patients were included and in HMC, 974 patients. Overall, 75% of the admitted trauma patients in UMCU and 81% in HMC (p < 0.001) received thromboprophylaxis, of which 100% in and 75% at, respectively, UMCU and HMC consisted of chemical prophylaxis. From these patients, 72% at UMCU and 47% at HMC (p < 0.001) were treated within 48 h after arrival. At UMCU, 4 patients (1.4%) (PE = 3, DVT = 1) and HMC 37 patients (3.8%) (PE = 22, DVT = 16; p = 0.06) developed a VTE. At UMCU, a greater percent of patients with VTE had traumatic brain injuries (TBI). Most VTE occurred despite adequate prophylaxis being given (75% UMCU and 81% HMC). Hemorrhagic complications occurred in, respectively, 4 (1.4%) and 10 (1%) patients in UMCU and HMC (p = 0.570). After adjustment for age, ISS, HLOS, and injury type, no significant difference was demonstrated in UMCU compared to HMC for the development of VTE, OR 2.397, p = 0.102 and hemorrhagic complications, OR 0. 586, p = 0.383.

CONCLUSIONS

A more early commencement protocol resulted in almost twice as much chemical prophylaxis being started within the first 48 h in comparison with a more delayed initiation of treatment. Interestingly, most episodes of VTE developed while receiving recommended prophylaxis. Early chemical thromboprophylaxis did not significantly increase the bleeding complications and it appears to be safe to start early.

Consensus Core Point-of-care Ultrasound Applications for Pediatric Emergency Medicine Training

BACKGROUND

Pediatric emergency medicine (PEM) physicians have variably incorporated point-of-care ultrasound (POCUS) into their practice. Prior guidelines describe the scope of POCUS practice for PEM physicians; however, consensus does not yet exist about which applications should be prioritized and taught as fundamental skills for PEM trainees. Members of the PEM POCUS Network (P2Network) conducted a consensus-building process to determine which applications to incorporate into PEM fellowship training.

METHODS

A multinational group of experts in PEM POCUS was recruited from the P2Network and greater PEM POCUS community if they met the following criteria: performed over 1,000 POCUS scans and had at least 3 years of experience teaching POCUS to PEM fellows, were a local academic POCUS leader, or completed a formal PEM POCUS fellowship. Experts rated 60 possible PEM POCUS applications for their importance to include as part of a PEM fellowship curriculum using a modified Delphi consensus-building technique.

RESULTS

In round 1, 66 of 92 (72%) participants responded to an e-mail survey of which 48 met expert criteria and completed the survey. Consensus was reached to include 18 items in a PEM fellowship curriculum and to exclude two items. The 40 remaining items and seven additional items were considered in round 2. Thirty-seven of 48 (77%) experts completed round 2 reaching consensus to include three more items and exclude five. The remaining 39 items did not reach consensus for inclusion or exclusion.

CONCLUSION

Experts reached consensus on 21 core POCUS applications to include in PEM fellowship curricula.

Complications, burden and in-hospital death among hospital treated injury patients in Victoria, Australia: a data linkage study

Background

A wide range of outcome measures can be calculated for hospital-treated injury patients. These include mortality, use of critical care services, complications, length of stay, treatment costs, readmission and nursing care after discharge. Each address different aspects and phases of injury recovery and can yield vastly different results. This study aims to: (1) measure and report this range of outcomes in hospital-treated injury patients in a defined population; and (2) describe the associations between injury characteristics, socio-demographics and comorbidities and the various outcomes.

Methods

A retrospective analysis was conducted of injury-related hospital admissions from July 2012 to June 2014 (152,835 patients) in Victoria, Australia. The admission records were linked within the dataset, enabling follow-up, to assess the outcomes of in-hospital death, burden, complications and 30-day readmissions. Associations between factors and outcomes were determined using univariate regression analysis.

Results

The proportion of patients who died in hospital was 0.9%, while 26.8% needed post-discharge care. On average patients had 2.4 complications (confidence interval (CI) 2.4–2.5) related to their initial injury, the mean cost of treating a patient was Australian dollars 7013 (CI 6929–7096) and the median length of stay was one day (inter quartile range 1–3). Intensive-care-unit-stay was recorded in 3% of the patients. All-cause 30-day readmissions occurred in 12.3%, non-planned 30-day readmissions in 7.9%, while potentially avoidable 30-day readmissions were observed in 3.2% of the patients. Increasing age was associated with all outcomes. The need for care post-discharge from hospital was highest among children and the oldest age group (85 years and over). Injury severity was associated with all adverse outcomes. Increasing number of comorbidities increased the likelihood of all outcomes. Overall, outcomes are shown to differ by age, gender, comorbidities, body region injured, injury type and injury severity, and to a lesser extent by socio-economic areas.

Conclusions

Outcomes and risk factors differ depending on the outcome measured, and the method used for measuring the outcome. Similar outcomes measured in different ways produces varying results. Data linkage has provided a valuable platform for a comprehensive overview of outcomes, which can help design and target secondary and tertiary preventive measures.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7080-y) contains supplementary material, which is available to authorized users.

Hospital and Intensive Care Unit Length of Stay for Injury Admissions: A Pan-Canadian Cohort Study

OBJECTIVE

To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations.

BACKGROUND

Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care.

METHODS

We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces.

RESULTS

Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%.

CONCLUSIONS

We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.

Complications following hospital admission for traumatic brain injury: A multicenter cohort study

PURPOSE

To evaluate the incidence, determinants and impact on outcome of in-hospital complications in adults with traumatic brain injury (TBI).

MATERIALS AND METHODS

We conducted a multicenter cohort study of TBI patients admitted between 2007 and 2012 in an inclusive Canadian trauma system. Risk ratios of complications, odds ratios of mortality and geometric mean ratios of length of stay (LOS) were calculated using generalized linear models with adjustment for prognostic indicators and hospital cluster effects.

RESULTS

Of 12,887 patients, 3.2% had at least one neurological complication and 22.6% a non-neurological complication. Mechanical ventilation, head injury severity, blood transfusion and neurosurgical intervention had the strongest correlation with neurological complications. Mechanical ventilation, the Glasgow Coma Scale, blood transfusion and concomitant injuries had the strongest correlation with non-neurological complications. Neurological and non-neurological complications were associated with a 85% and 53% increase in the odds of mortality, and a 60% and two-fold increases in LOS, respectively.

CONCLUSIONS

More than 20% of patients with TBI developed a complication. Many of these complications were associated with increased mortality and LOS. Results highlight the importance of prevention strategies adapted to treatment decisions and underline the need to improve knowledge on the underuse and overuse of clinical interventions.

Impact of trauma centre designation level on outcomes following hemorrhagic shock: a multicentre cohort study

BACKGROUND

Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS).

METHODS

We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999-2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS.

RESULTS

Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [CI]) of mortality for level III and IV centres were 1.71 (1.03-2.85) and 2.25 (1.08-4.73), respectively. Surgical delays did not vary across designation levels, but mean LOS and complications were lower in level II-IV centres than level I centres.

CONCLUSION

Level I/II centres may offer a survival advantage over level III/IV centres for patients requiring emergency intervention for hemorrhagic shock. Further research with larger sample sizes is required to confirm these results and to identify optimal transport time thresholds for bypassing level III/IV centres in favour of level I/II centres.

Transfusion of red blood cells in patients with traumatic brain injuries admitted to Canadian trauma health centres: a multicentre cohort study

BACKGROUND

Optimisation of healthcare practices in patients sustaining a traumatic brain injury is of major concern given the high incidence of death and long-term disabilities. Considering the brain's susceptibility to ischaemia, strategies to optimise oxygenation to brain are needed. While red blood cell (RBC) transfusion is one such strategy, specific RBC strategies are debated. We aimed to evaluate RBC transfusion frequency, determinants of transfusions and associated clinical outcomes.

METHODS

We conducted a retrospective multicentre cohort study using data from the National Trauma Registry of Canada. Patients admitted with moderate or severe traumatic brain injury to participating hospitals between April 2005 and March 2013 were eligible. Patient information on blood products, comorbidities, interventions and complications from the Discharge Abstract Database were linked to the National Trauma Registry data. Relative weights analyses evaluated the contribution of each determinant. We conducted multivariate robust Poisson regression to evaluate the association between potential determinants, mortality, complications, hospital-to-home discharge and RBC transfusion. We also used proportional hazard models to evaluate length of stay for time to discharge from ICU and hospital.

RESULTS

Among the 7062 patients with traumatic brain injury, 1991 patients received at least one RBC transfusion during their hospital stay. Female sex, anaemia, coagulopathy, sepsis, bleeding, hypovolemic shock, other comorbid illnesses, serious extracerebral trauma injuries were all significantly associated with RBC transfusion. Serious extracerebral injuries altogether explained 61% of the observed variation in RBC transfusion. Mortality (risk ratio (RR) 1.23 (95% CI 1.13 to 1.33)), trauma complications (RR 1.38 (95% CI 1.32 to 1.44)) and discharge elsewhere than home (RR 1.88 (95% CI 1.75 to 2.04)) were increased in patients who received RBC transfusion. Discharge from ICU and hospital were also delayed in transfused patients.

CONCLUSIONS

RBC transfusion is common in patients with traumatic brain injury and associated with unfavourable outcomes. Trauma severity is an important determinant of RBC transfusion. Prospective studies are needed to further evaluate optimal transfusion strategies in traumatic brain injury.

Do Patients with Pre-Existing Psychiatric Illness Have an Increased Risk of Infection after Injury?

BACKGROUND

Trauma remains a leading cause of death and long term-morbidity. We have shown that patients who sustain traumatic injuries are at increased risk for the development of infectious complications. Psychiatric illnesses (PIs) are also noted to occur frequently among the general population. The presence of a PI has been shown to be a risk factor for the development of infections. Despite the prevalence of both traumatic injuries and psychiatric diseases, there are little data relating the impact of PI on the outcome of patients with trauma. We hypothesize that the presence of a PI will be associated with an increased risk of an infection developing after injury.

PATIENTS AND METHODS

This is a five year retrospective chart review of all admitted patients with trauma age 18 years and older. Patients with and without a major psychiatric illness were compared. Demographic data, mechanism of injury and Injury Severity Score (ISS) were reviewed. Co-morbidities included diabetes mellitus, obesity, pre-injury steroid use, and International Classification of Diseases, 9th edition, based psychiatric illness. All infections were diagnosed by microbiologic criteria (urinary tract infection [UTI], ventilator-associated pneumonia) or Centers for Disease Control and Prevention criteria for clinically evident infections (surgical site infection).

RESULTS

Of the 11,147 admitted trauma patients, 14.5% had a pre-injury PI diagnosis. The PI patients were older (61.5 ± 0.5 vs. 54.3; p < 0.001), more often female (56% vs. 39.1%; p < 0.001), and had no difference in blunt mechanism rates (88.4% vs. 89.9%; p = 0.06) or median ISS (9 vs. 9; p = 0.06). There was no difference between PI and non-PI patients in pre-injury diabetes mellitus (13.4% vs. 12.7%; p = 0.4), steroid use (2.5% vs. 1.9%; p = 0.1), but patients with PI were more likely to be obese (15.7% vs. 13.6%; p = 0.03). Patients with PI were more likely to have an infection develop (10.4% vs. 7.5%; p < 0.001). The most common infection in both groups was UTI (6.9% vs. 4.2%; p < 0.001). Compared with non-PI patients, adjusting for age, gender, ISS, diabetes mellitus, and obesity, patients with PI were more likely to have an infection develop (odds ratio 1.3, 95% confidence interval = 1.1-1.5) Conclusions: Patients with an underlying PI are at increased risk of having a UTI after traumatic injury. This study identifies a previously unknown independent risk factor for UTIs in patients with trauma. This stresses the need for increased awareness and attention to this vulnerable population.

Validation of Complications Selected by Consensus to Evaluate the Acute Phase of Adult Trauma Care: A Multicenter Cohort Study

OBJECTIVE

Evaluate the predictive validity of complications derived using expert consensus methodology to monitor the quality of trauma care. Secondary objectives were to assess the predictive validity of complications not selected by consensus and identify determinants of complications.

BACKGROUND

A list of complications to monitor the quality of trauma care has recently been derived using Delphi consensus methodology. However, the predictive validity of consensus complications has not yet been demonstrated.

METHODS

We conducted a multicenter cohort study of adults admitted to the 57 adult trauma centers of a Canadian integrated trauma system (2007-2012; n = 84,216). Multiple generalized linear models were used to assess the influence of complications on mortality and acute care length of stay (LOS) and to identify determinants of consensus complications.

RESULTS

The presence of at least 1 consensus complication was associated with a 2.7-fold [95% confidence interval (CI): 2.45-2.90] and 2.2-fold (95% CI: 2.11-2.19) increase in the odds of mortality and mean LOS, respectively. Nonselected complications were associated with no increase in mortality (odds ratio = 0.90, 95% CI: 0.80-1.01) and a 60% increase in LOS (geometric mean ratio = 1.60, 95% CI: 1.57-1.62). Patient-related factors and factors related to treatment explained 66% and 34% of the variation in complication rates, respectively.

CONCLUSIONS

In addition to the face and content validity ensured by consensus methodology, this study suggests that consensus complications have good predictive validity. Monitoring these complications as part of quality improvement activities would provide an opportunity to improve outcome and resource use for injury admissions.

Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system

BACKGROUND

According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains.

METHODS

Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients.

RESULTS

Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS).

CONCLUSION

Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes.

LEVEL OF EVIDENCE

Prognostic study, level III.