Management of severe trauma worldwide: implementation of trauma systems in emerging countries: China, Russia and South Africa

Cohort Profile: The China Severe Trauma Cohort (CSTC)

BACKGROUND

We sought to establish a prospective hospital-based cohort, featuring detailed multidimensional data of trauma patients with active follow-ups, which can be a reliable data source for all studies focusing on the effects or underlying mechanistic pathways of environmental and biological factors on multiple interested trauma-related outcomes, particularly the incidence and trajectory of trauma-related psychopathology, in a Chinese population.

METHODS

The China Severe Trauma Cohort (CSTC) enrolled all traumatized individuals aged 12 to 80 years admitted to the Trauma Center of West China Hospital between March 1st, 2020 and July 8th, 2022. The bio-sample and detailed questionnaire data were collected at recruitment, and phone/internet follow-ups were scheduled at 1, 3, 6, and 12 months after the baseline. Long-term health outcomes are planned to be obtained from administrative databases through data linkage.

RESULTS

A total of 2,500 trauma patients were enrolled (response rate = 87.1%) with an average age of 46.01 years, and most of the participants were males (62.6%). The proportions of participants with blood and fecal sample collected at baseline were 93.8% and 66.3%, respectively. As of August 31st, 2022, the follow-up rate was 90.0%, 77.0%, 76.5%, and 89.0% for 1-, 3-, 6-, and 12-month follow-ups, respectively. Fall/wrench (47.6%) and traffic accident (26.2%) were the top causes of current trauma. The most common psychopathology at recruitment was sleep disturbance (39.4%), followed by depression (22.6%), anxiety (18.2%), and acute stress reaction (7.8%), all of which showed recovering trajectories during the follow-up period, particularly the first 3 months after baseline.

CONCLUSION

CSTC provides a platform with multidimensional data to study both short-term and long-term trauma-related health consequences, prompting early identification and intervention for individuals with high risk of health decline after trauma exposures.

Traumatic rib fracture patterns associated with bone mineral density statuses derived from CT images

Background

The impact of decreased bone mineral density (BMD) on traumatic rib fractures remains unknown. We combined computed tomography (CT) and artificial intelligence (AI) to measure BMD and explore its impact on traumatic rib fractures and their patterns.

Methods

The retrospective cohort comprised patients who visited our hospital from 2017-2018; the prospective cohort (control group) was consecutively recruited from the same hospital from February-June 2023. All patients had blunt chest trauma and underwent CT. Volumetric BMD of L1 vertebra was measured by using an AI software. Analyses were done by using BMD categorized as osteoporosis (<80 mg/cm3), osteopenia (80-120 mg/cm3), or normal (>120 mg/cm3). Pearson's χ2, Fisher's exact, or Kruskal-Wallis tests and Bonferroni correction were used for comparisons. Negative binomial, and logistic regression analyses were used to assess the associations and impacts of BMD status. Sensitivity analyses were also performed.

Findings

The retrospective cohort included 2,076 eligible patients, of whom 954 (46%) had normal BMD, 806 (38.8%) had osteopenia, and 316 (15.2%) had osteoporosis. After sex- and age-adjustment, osteoporosis was significantly associated with higher rib fracture rates, and a higher likelihood of fractures in ribs 4-7. Furthermore, both the osteopenia and osteoporosis groups demonstrated a significantly higher number of fractured ribs and fracture sites on ribs, with a higher likelihood of fractures in ribs 1-3, as well as flail chest. The prospective cohort included 205 eligible patients, of whom 92 (44.9%) had normal BMD, 74 (36.1%) had osteopenia, and 39 (19.0%) had osteoporosis. The findings observed within this cohort were in concurrence with those in the retrospective cohort.

Interpretation

Traumatic rib fractures are associated with decreased BMD. CT-AI can help to identify individuals who have decreased BMD and a greater rib fracture rate, along with their fracture patterns.

Tracking the Trauma Epidemic in KwaZulu-Natal, South Africa

BACKGROUND

Trauma remains an important cause of morbidity and mortality in South Africa, but attempts to track the epidemic are often based on mortality data, or derived from individual health facilities. This project is based on the routine collection of trauma data from all public health facilities in the province of KwaZulu-Natal (KZN), between 2012 and 2022.

METHODS

Hospital level data on trauma over the past ten years was drawn from the district health information system (DHIS). Data relating to assaults, gunshots and motor vehicle collisions (MVCs) were recorded in the emergency rooms, whilst data on admissions are recorded in the wards and intensive care units.

RESULTS

There were 1,263,847 emergency room visits for assaults, gunshots and MVCs over the ten-year period and trauma admissions ranged between four and five percent of the total number of hospital admissions annually. There was a dramatic decrease in trauma presentations and admissions over 2020/2021 as a result of the COVID lockdowns. Over the entire period, intentional injury was roughly twice as frequent as non-intentional injury. Intentional trauma had an almost equal ratio of blunt assault to penetrating assault. Gunshot-related assault increased dramatically over the 2021/2022 collecting period.

CONCLUSIONS

The burden of trauma in KZN remains high. The unique feature of this burden is the excessively high rate of intentional trauma in the form of both blunt and penetrating mechanisms. Developing injury-prevention strategies to reduce the burden of interpersonal violence is more difficult than for unintentional trauma.

Temporal Trend and Research Focus of Injury Burden from 1998 to 2022: A Bibliometric Analysis

Background

Injury is one of the leading causes of mortality and disability worldwide. It is a major contributor to the overall burden of disease. This study aimed to analyze the temporal trend, research focus and future direction of research related to injury burden.

Methods

Publications on injury burden published between January 1998 and September 2022 were extracted from the Web of Science Core Collection (WoSCC) through topic advanced search strategy. Microsoft Excel, RStudio, VOSviewer, and CiteSpace were used to extract, integrate, and visualize bibliometric information.

Results

A total of 2916 articles and 783 reviews were identified. The number of publications on injury burden showed a steady upward trend. The United States of America (USA) (n=1628) and the University of Washington (n=1036) were the most productive country and institution. High-income countries started research in this domain earlier, while research in low- and middle-income countries began in recent years. Lancet was the most influential journal. Public, environmental occupational health, general medicine and neurology were the predominant research domains. Based on keyword co-occurrence analysis, the research focus was divided into five clusters: injury epidemiology and prevention, studies related to the global burden of disease (GBD), risk factors for injury, clinical management of injury, and injury outcome assessment and economic burden.

Conclusion

The burden of injury has drawn increasing attention from various perspectives over the years. The research field on injury burden is also becoming more and more extensive. However, there are some gaps among different countries or regions, and more attention needs to be paid to low and middle-income countries.

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation across country income levels: a scoping review

OBJECTIVE

Trauma is a leading cause of mortality and morbidity globally, disproportionately affecting low/middle-income countries (LMICs). Understanding the factors determining implementation success for in-hospital Trauma Quality Improvement Programs (TQIPs) is critical to reducing the global trauma burden. We synthesised topical literature to identify key facilitators and barriers to in-hospital TQIP implementation across country income levels.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Web of Science and Global Index Medicus databases were searched from June 2009 to January 2022.

ELIGIBILITY CRITERIA

Published literature involving any study design, written in English and evaluating any implemented in-hospital quality improvement programme in trauma populations worldwide. Literature that was non-English, unpublished and involved non-hospital TQIPs was excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers completed a three-stage screening process using Covidence, with any discrepancies resolved through a third reviewer. Content analysis using the Consolidated Framework for Implementation Research identified facilitator and barrier themes for in-hospital TQIP implementation.

RESULTS

Twenty-eight studies met the eligibility criteria from 3923 studies identified. The most discussed in-hospital TQIPs in included literature were trauma registries. Facilitators and barriers were similar across all country income levels. The main facilitator themes identified were the prioritisation of staff education and training, strengthening stakeholder dialogue and providing standardised best-practice guidelines. The key barrier theme identified in LMICs was poor data quality, while high-income countries (HICs) had reduced communication across professional hierarchies.

CONCLUSIONS

Stakeholder prioritisation of in-hospital TQIPs, along with increased knowledge and consensus of trauma care best practices, are essential efforts to reduce the global trauma burden. The primary focus of future studies on in-hospital TQIPs in LMICs should target improving registry data quality, while interventions in HICs should target strengthening communication channels between healthcare professionals.

Effects of the establishment of trauma centres on the mortality rate among seriously injured patients: a propensity score matching retrospective study

BACKGROUND

Little evidence suggests that trauma centres are associated with a lower risk of mortality in severely injured patients (Injury Severity Score (ISS) ≥16) with multiple injuries in China. The objective of this study was to determine the association between the establishment of trauma centres and mortality among severely injured patients with multiple injuries and to identify some risk factors associated with mortality.

METHODS

A retrospective single-centre study was performed including trauma patients admitted to the First Affiliated Hospital of Nanchang University (FAHNU) between January 2016 and December 2021. To determine whether the establishment of a trauma centre was an independent predictor of mortality, logistic regression analysis and propensity score matching (PSM) were performed.

RESULTS

Among 431 trauma patients, 172 were enrolled before the trauma centre was built, while 259 were included after the trauma centre was built. A higher frequency of older age and traffic accident injury was found in patients diagnosed after the trauma centre was built. The times for the completion of CT examinations, emergency operations and blood transfusions in the "after trauma centre" group were shorter than those in the "before trauma centre" group. However, the total expenditure of patients was increased. In the overall group, univariate and multivariate logistic regression analyses showed that a higher ISS was an independent predictor for worse mortality (OR = 17.859, 95% CI, 8.207-38.86, P < 0.001), while the establishment of a trauma centre was favourable for patient survival (OR = 0.492), which was also demonstrated by PSM. After determining the cut-off value of time for the completion of CT examination, emergency operation and blood transfusion, we found that the values were within the "golden one hour", and it was better for patients when the time was less than the cut-off value.

CONCLUSION

Our study showed that for severely injured patients, the establishment of a trauma centre was favourable for a lower mortality rate. Furthermore, the completion of a CT examination, emergency surgery and blood transfusion in a timely manner and a lower ISS were associated with a decreased mortality rate.

Epidemiology and the economic burden of traumatic fractures in China: A population-based study

OBJECTIVES

National data on the admission rate, distribution, in-hospital mortality, and economic burden of traumatic fractures in China is unclear. We aimed to conduct a cross-sectional population-based study to determine such above data at the national level in China.

METHODS

A national administrative database was used to review all traumatic fracture hospitalizations in China during 2020, from which a total of 2,025,169 inpatients with traumatic fractures was retrieved. Admission rates and in-hospital mortality rates stratified by age, sex, and region were calculated. The causes of traumatic fracture and economic burden were described.

RESULTS

The admission rate of traumatic fractures of all China population in 2020 was 1.437‰. The admission rate increased with age and varied with genders and causes of injuries. Falls are the leading cause of traumatic fracture hospitalization, followed by road traffic injuries. The most common diagnoses were femoral neck fractures, with a number of 138,377. The in-hospital mortality was 1.209‰. Road traffic injuries led to the highest in-hospital mortality. The median length of stay was 10 days, with the median hospitalization cost of ¥20,900 (about $3,056).

CONCLUSION

Traumatic fractures are concerning conditions with a high admission rate and in-hospital mortality in China, which are mainly caused by falls and road traffic injuries. The government should implement more public health policies to enhance the health of the elderly and improve transportation safety to prevent traumatic fractures.

De un centro de trauma a un sistema de trauma en el suroccidente colombiano

Introducción. El objetivo de este estudio fue evaluar el impacto sobre la mortalidad según el perfil de ingreso a un centro de trauma del suroccidente colombiano, como método para entender las dinámicas de atención del paciente con trauma. Métodos. Se realizó un subanálisis del registro de la Sociedad Panamericana de Trauma asociado a un centro de trauma en el suroccidente colombiano. Se analizaron los pacientes atendidos entre los años 2012 y 2021. Se compararon los pacientes con condición de ingreso directo y aquellos que ingresaron remitidos. Se hicieron análisis de poblaciones de interés como pacientes con trauma severo (ISS > 15) y pacientes con/sin trauma craneoencefálico. Se evaluó el impacto de los pacientes remitidos y su condición al ingreso sobre la mortalidad. Resultados. Se incluyeron 10.814 pacientes. La proporción de pacientes remitidos fue del 54,7 %. Los pacientes que ingresaron remitidos presentaron diferencias respecto a la severidad del trauma y compromiso fisiológico al ingreso comparado con los pacientes con ingreso directo. Los pacientes remitidos tienen mayor riesgo de mortalidad (RR: 2,81; IC95% 2,44-3,22); sin embargo, es el estado fisiológico al ingreso lo que impacta en la mortalidad. Conclusión. Los pacientes remitidos de otras instituciones tienen un mayor riesgo de mortalidad, siendo una inequidad en salud que invita a la articulación de actores institucionales en la atención de trauma. Un centro de trauma debe relacionarse con las instituciones asociadas para crear un sistema de trauma que optimice la atención de los pacientes y la oportunidad.

Prolonged Casualty Care: Extrapolating Civilian Data to the Military Context

BACKGROUND

Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource-limitations, and system configuration to U.S. military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations.

METHODS

We conducted a 6 month analysis of an on-going, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape ('EpiC'). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using chi-squared and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models.

RESULTS

146 of 995 patients experienced PCC. The PCC group, compared to non-PCC, were more critically injured (66% vs 51%), received more critical interventions (36% vs 29%), had a greater proportionate mortality (5% vs 3%), longer hospital stays (3 vs 1 day), and higher SOFA scores (5 vs 3). The odds of 7-day mortality and a SOFA score ≥ 5 were 1.6 (OR: 1.59; 0.68, 3.74) and 3.6 (OR: 3.69; 2.11, 6.42) times higher, respectively, in PCC versus non-PCC patients.

CONCLUSIONS

EpiC enrolled critically injured patients with PCC who received resuscitative interventions. PCC patients had worse outcomes than non-PCC. EpiC will be a useful platform to provide on-going data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care.

LEVEL OF EVIDENCE

III; prospective comparative study.