Long-term health status and trajectories of seriously injured patients: A population-based longitudinal study

Association between acute pre-injury alcohol use and 12-month health outcomes for survivors of major trauma: A registry-based study

INTRODUCTION

Alcohol is commonly detected in patients presenting to hospital after major trauma and is a key preventable risk factor for injury. While it has been suggested that alcohol intoxication at the time of injury results in worse acute patient outcomes, there is currently limited knowledge on the impact of alcohol on health outcomes following hospital discharge. The aim of this study was to examine the relationship between acute pre-injury alcohol exposure and the self-reported health outcomes of survivors of major trauma 12-months post-injury.

METHODS

Data from the Victorian State Trauma Registry (January 1, 2018 to December 31, 2020) were used to identify major trauma patients who: (1) were aged ≥18 years; (2) survived to 12-months post-injury; and (3) had blood alcohol data available in the registry. Logistic regression analyses were used to examine differences in self-reported health status (EQ-5D) and return to work at 12-months post-injury by blood alcohol concentration (BAC) at the time of presentation to hospital. Analyses were adjusted for potential confounders including a range of demographic, hospital and injury characteristics.

RESULTS

A total of 2957 patients met inclusion criteria, of which 857 (29.0 %) had a BAC >0 and 690 (23.3 %) had a BAC ≥0.05 g/100 mL. After adjusting for potential confounders, having any alcohol detected (i.e., BAC >0) was associated with lower odds of reporting problems on the EQ-5D mobility (aOR = 0.72, 95 %CI = 0.53 to 0.99) and usual activities dimensions (aOR = 0.79, 95 %CI = 0.63 to 0.99). Having a BAC ≥0.05 g/100 mL was only associated with lower adjusted odds of reporting problems on the usual activities dimension (aOR = 0.69, 95 %CI = 0.55 to 0.88) of the EQ-5D. Alcohol detection was not associated with the self-care, pain/discomfort or anxiety/depression dimensions of the EQ-5D, or with return to work in adjusted analyses.

CONCLUSION

Acute pre-injury alcohol exposure was not associated with increased reporting of problems on the EQ-5D or with return to work at 12-months post-injury. Further research is needed to understand why patients with alcohol detections were sometimes associated with paradoxically better 12-month post-injury outcomes relative to patients without alcohol detections.

Stepped collaborative care for pain and posttraumatic stress disorder after major trauma: a randomized controlled feasibility trial

PURPOSE

To examine feasibility and acceptability of providing stepped collaborative care case management targeting posttraumatic stress disorder (PTSD) and pain symptoms after major traumatic injury.

MATERIALS AND METHODS

Participants were major trauma survivors in Victoria, Australia, at risk of persistent pain or PTSD with high baseline symptoms. Participants were block-randomized, stratified by compensation-status, to the usual care (n = 15) or intervention (n = 17) group (46% of eligible patients). The intervention was adapted from existing stepped collaborative care interventions with input from interdisciplinary experts and people with lived experience in trauma and disability. The proactive case management intervention targeted PTSD and pain management for 6-months using motivational interviewing, cognitive behavioral therapy strategies, and collaborative care. Qualitative interviews explored intervention acceptability.

RESULTS

Intervention participants received a median of 7 h case manager contact and reported that they valued the supportive and non-judgmental listening, and timely access to effective strategies, resources, and treatments post-injury from the case manager. Participants reported few disadvantages from participation, and positive impacts on symptoms and recovery outcomes consistent with the reduction in PTSD and pain symptoms measured at 1-, 3- and 6-months.

CONCLUSIONS

Stepped collaborative care was low-cost, feasible, and acceptable to people at risk of PTSD or pain after major trauma.IMPLICATIONS FOR REHABILITATIONAfter hospitalization for injury, people can experience difficulty accessing timely support to manage posttraumatic stress, pain and other concerns.Stepped case management-based interventions that provide individualized support and collaborative care have reduced posttraumatic stress symptom severity for patients admitted to American trauma centers.We showed that this model of care could be adapted to target pain and mental health in the trauma system in Victoria, Australia.The intervention was low cost, acceptable and highly valued by most participants who perceived that it helped them use strategies to better manage post-traumatic symptoms, and to access clinicians and treatments relevant to their needs.

Dollars and Sense: The Financial Argument for Dedicated Posttrauma Center Care

OBJECTIVE

To demonstrate that the creation of a Center for Trauma Survivorship (CTS) is not cost-prohibitive but is a revenue generator for the institution.

BACKGROUND

A dedicated CTS has been demonstrated to increase adherence with follow-up visits and improve overall aftercare in severely injured patients discharged from the trauma center. A potential impediment to the creation of similar centers is its assumed prohibitive cost.

METHODS

This pre and post-cohort study examines the financial impact of patients treated by the CTS. Patients in the PRE cohort were those treated in the year before CTS inception. Eligibility criteria are trauma patients admitted who are ≥18 years of age and have a New Injury Severity Score ≥16 or intensive care unit stay ≥2 days. Financial data were obtained from the hospital's billing and cost accounting systems for a 1-year time period after discharge.

RESULTS

There were 176 patients in the PRE and 256 in the CTS cohort. The CTS cohort generated 1623 subsequent visits versus 748 in the PRE cohort. CTS patients underwent more follow-up surgery in their first year of recovery as compared with the PRE cohort (98 vs 26 procedures). Each CTS patient was responsible for a $7752 increase in net revenue with a positive contribution margin of $4558 compared with those in the PRE group.

CONCLUSIONS

A dedicated CTS increases subsequent visits and necessary procedures and is a positive revenue source for the trauma center. The presumptive financial burden of a CTS is incorrect and the creation of dedicated centers will improve patients' outcomes and the institution's bottom line.

Development and validation of early prediction models for new-onset functional impairment of patients with trauma at hospital discharge

BACKGROUND

Early identification of individuals at risk of functional impairment after trauma is crucial for the timely clinical decision-making and intervention to improve reintegration into the society. This study aimed to develop and validate models for predicting new-onset functional impairment after trauma using predictors that are routinely collected within 2 days of hospital admission.

METHODS

In this multicenter retrospective cohort study of acute care hospitals in Japan, we identified adult patients with trauma with independence in carrying out activities of daily living before hospitalization, treated in the intensive or high-dependency care unit, and survived for at least 2 days between April 2008 and September 2023. The primary outcome was functional impairment defined as Barthel Index ≤60 at hospital discharge. In the internal validation data set (between April 2008 and August 2022), using the routinely collected 129 candidate predictors within 2 days of admission, we trained and tuned the four conventional and machine learning models with repeated random subsampling cross-validation. We measured the performance of these models in the temporal validation data set (between September 2022 and September 2023). We also computed the importance of each predictor variable in our model.

RESULTS

We identified 8,529 eligible patients. Functional impairment at discharge was observed in 41% of the patients (n = 3,506/8,529). In the temporal validation data set, all four models showed moderate discrimination ability, with areas under the curve above 0.79, and extreme gradient boosting showing the best performance (0.83). In the variable importance analyses, age was the most important predictor, followed by consciousness, severity score, cervical spinal cord injury, mild dementia, and serum albumin level at admission.

CONCLUSION

We successfully developed early prediction models for patients with trauma with new-onset functional impairment at discharge that achieved high predictive performance using routinely collected data within 2 days of hospital admission.

LEVEL OF EVIDENCE

Prognostic/Epidemiological; Level II.

Collaborative Care for Injured Older Adults: The Trauma Medical Home Randomized Clinical Trial

Importance

Older adults with recent injuries can have impaired long-term biopsychosocial function and may benefit from interventions adapted to their needs.

Objective

To determine if a collaborative care intervention, Trauma Medical Home (TMH), improved the biopsychosocial function of older patients in the year after injury.

Design, Setting, and Participants

This was a single-blinded, randomized clinical trial conducted at 4 level I trauma centers in Indianapolis, Indiana, and Madison, Wisconsin. Between October 2017 and October 2021, patients aged 50 years and older with an Injury Severity Score (ISS) of 9 or greater and without traumatic brain or spinal cord injury were enrolled. Exclusions were significant brain injury or a spinal cord injury with a persistent neurologic deficit at the time of enrollment, extensive burns, pregnancy, incarceration, neurodegenerative disease, visual or auditory impairment that would preclude study participation, a life expectancy of less than 1 year, significant alcohol or drug use history, and acute stroke during admission. Of 10 276 patients screened, 430 were randomized and 299 completed 12-month follow-up. Data were analyzed from March to July 2023.

Intervention

Intervention patients received 6 months of TMH delivered by a nurse care coordinator guided by an interdisciplinary team (trauma surgeon, pulmonary critical care and geriatrician physicians, nurses, and psychologist) in partnership with primary care. The care coordinator used standard protocols to monitor and treat biopsychosocial symptoms.

Main Outcomes and Measures

Primary outcomes were Medical Outcome Study Short Form-36 (SF-36) score and Short Physical Performance Battery (SPPB) score at 12 months. Secondary outcomes were Patient Health Questionnaire-9 (PHQ-9) score, the Generalized Anxiety Disorder scale-7 (GAD-7) score, and health care utilization.

Results

A total of 429 participants (228 [53.1%] female; mean [SD] age, 69.3 [10.8] years; mean [SD] ISS, 12.3 [4.6]) completed baseline assessments and were randomized. Follow-up was 76% (n = 324) at 6 months and 70% (n = 299) at 12 months. There were no differences between the TMH and usual care groups at 12 months in SF-36 Physical Component Summary score (mean [SD], 40.42 [12.82] vs 39.18 [12.43]), SF-36 Mental Component Summary score (mean [SD], 53.92 [10.02] vs 53.21 [10.82]), or SPPB score (mean [SD], 8.00 [3.60] vs 8.28 [3.88]). Secondary outcomes were also no different. Planned subgroup analysis revealed patients with baseline symptoms of anxiety or depression (high GAD-7 and PHQ-9 scores) experienced improvement in the Mental Component Summary score when randomized to the TMH intervention.

Conclusions and Relevance

The TMH intervention did not significantly influence quality of life, depressive and anxiety symptoms, or physical function of older adults with injury at 12 months. Subgroup analysis showed positive impact in patients with a high burden of anxiety and depression symptoms at enrollment. Collaborative care interventions may improve long-term outcomes of select patients, but further research is needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03108820.

Firearm Injury, It's Not Just Physical: The Adverse Impact on Patient-Reported Socioeconomic, Mental Health, and Quality-of-Life Outcomes

Background: The burden of firearm injury (FI) extends beyond hospitalization; however, literature focuses mostly on short-term physical outcomes. This study aimed to assess changes in patient-reported outcomes following firearm-related trauma. We hypothesized long-term patient-reported socioeconomic, mental health, and quality-of-life (QoL) outcomes are worse post-FI compared to pre-FI.Methods: This was a retrospective study where a phone survey was conducted with FI survivors admitted between January 2017 and August 2022 at a level 1 trauma center. Survey questions assessed demographics, socioeconomics, and mental and physical health pre-FI vs ≥ 6 months post-FI; the McNemar test was used for comparisons. The PROMIS-29 + 2v2.1 NIH validated instrument was used to assess long-term QoL. Standardized NIH PROMIS T-scores were calculated using the HealthMeasures Scoring Service.Results: Of 204 eligible FI survivors, 71 were successfully contacted and 38 surveyed. Respondents were male (86.8%), Black (76%), and aged 18-29 (55.3%), and 68.4% had high school level education. Post-FI, patients were more likely to be unemployed (55.2% vs 13.2%, P < .001) and report increased mental health needs (84.2% vs 21%, P < .001) compared to pre-FI. Most (73.7%) also reported lasting physical disability. Similarly, the PROMIS instrument demonstrated largely worse health-related QoL scores post-FI, particularly high anxiety/fear (T-score 60.2, SE 3.1, CI 54.6-66.3, Table 2), pain resulting in life interference (T-score 60.0, SE 2.3, CI 55.7-63.9), and worse physical function (T-score 42.5, SE 3.0, CI 38.2-46.9).Conclusions: Firearm injury survivors had more unemployment and worse mental health post-FI compared to pre-FI. Firearm injury survivors also reported significantly worse health-related QoL metrics including pain, anxiety, and physical function 6 months following their trauma. These long-term patient-reported outcomes are a framework to build future outpatient resources.Level of Evidence: IV.

Implementation of health-related quality of life in the German TraumaRegister DGU® - first results of a pilot study

BACKGROUND

Approximately 30,000 people are affected by severe injuries in Germany each year. Continuous progress in prehospital and hospital care has significantly reduced the mortality of polytrauma patients. With increasing survival rates, the functional outcome, health-related quality (hrQoL) of life and ability to work are now gaining importance. Aim of the study is, the presentation of the response behavior of seriously injured patients on the one hand and the examination of the factors influencing the quality of life and ability to work 12 months after major trauma on the other hand. Building on these initial results, a standard outcome tool shall be integrated in the established TraumaRegister DGU® in the future.

METHODS

In 2018, patients [Injury Severity Score (ISS) ≥ 16; age:18-75 years] underwent multicenter one-year posttraumatic follow-up in six study hospitals. In addition to assessing hrQoL by using the Short-Form Health Survey (SF-12), five additional questions (treatment satisfaction; ability to work; trauma-related medical treatment; relevant physical disability, hrQoL as compared with the prior to injury status) were applied.

RESULTS

Of the 1,162 patients contacted, 594 responded and were included in the analysis. The post-injury hrQoL does not show statistically significant differences between the sexes. Regarding age, however, the younger the patient at injury, the better the SF-12 physical sum score. Furthermore, the physically perceived quality of life decreases statistically significantly in relation to the severity of the trauma as measured by the ISS, whereas the mentally perceived quality of life shows no differences in terms of injury severity. A large proportion of severely injured patients were very satisfied (42.2%) or satisfied (39.9%) with the treatment outcome. It should be emphasized that patients with a high injury severity (ISS > 50) were on average more often very satisfied with the treatment outcome (46.7%). A total of 429 patients provided information on their ability to work 12 months post-injury. Here, 194 (45.2%) patients had a full employment, and 58 (13.5%) patients were had a restricted employment.

CONCLUSION

The present results show the importance of a structured assessment of the postinjury hrQoL and the ability to work after polytrauma. Further studies on the detection of influenceable risk factors on hrQoL and ability to work in the intersectoral course of treatment should follow to enable the best possible outcome of polytrauma survivors.

Methodologies to measure access to care post-discharge in adults with serious injury-related disability: a scoping review

PURPOSE

This scoping review examined the methodologies used to measure access to care in serious injury-related disability populations, for whom access to care post-discharge has significant implications for patient outcomes and rehabilitation trajectories.

METHODS

Four electronic databases were searched for literature published between 1 January 2000 and 15 February 2022. Relevant articles needed to relate to access to care in adult community-dwelling trauma and rehabilitation populations.

RESULTS

The initial search identified 679 articles. Following de-duplication, the title/abstract screening was completed on 533 articles, and 56 full-text articles were reviewed. Thirty-eight articles met the eligibility criteria and were included in this review. Of the 38 studies included, there was large heterogeneity in the methodologies used to measure access to care. Two articles used multidimensional measures of access to care.

CONCLUSIONS

There is an urgent need to establish the use of multidimensional measures as standard practice in access-to-care research. Failure to account for the multidimensional nature of access to care limits the full realisation of access for people with serious injury-related disability and prevents the implementation of processes that could improve access to health, rehabilitation, and support services and enhance the quality of care for individuals with a serious injury-related disability.

Long-term functional outcomes in polytrauma: a fundamentally new approach is needed in prediction

PURPOSE

Modern trauma care has reduced mortality but poor long-term outcomes with low follow-up rates are common with limited recommendations for improvements. The aim of this study was to describe the impact of severe injury on the health-related quality of life, specifically characterise the non-responder population and to identify modifiable predictors of poorer outcomes.

METHODS

Five-year (2012-2016) prospective cohort study was performed at a level 1 trauma centre. Baseline Short-Form Health Survey (SF36) was collected at admission, and at 6 and 12 months postinjury together with demographics, injury mechanism and severity, psychosocial wellbeing, and return to work capacity.

RESULTS

Of the 306 consecutive patients [age 52 ± 17 years, male 72%, ISS 21 (17, 29), mortality 5%], 195 (64%) completed questionnaires at baseline, and at 12 months. Preinjury physical health scores were above the general population (53.1 vs. 50.3, p < 0.001) and mental health component was consistent with the population norms (51.7 vs. 52.9, p = 0.065). One year following injury, both physical health (13.2, 95% CI 14.8, 11.6) and mental health scores (6.0, 95% CI 8.1, 3.8) were significantly below age- and sex-adjusted preinjury baselines. Non-responders had similar ISS but with a lower admission GCS, and were more likely to be younger, and without comorbidities, employment, or university education.

CONCLUSION

Contrary to their better than population norm preinjury health status, polytrauma patients remain functionally impaired at least 1 year after injury. The identified high risk for non-responding group needs more focused efforts for follow-up. A fundamentally different approach is required in polytrauma research which identify modifiable predictors of poor long-term outcomes.

Medication utilization in traumatic brain injury patients-insights from a population-based matched cohort study

Introduction

Traumatic brain injury (TBI) is associated with health problems across multiple domains and TBI patients are reported to have high rates of medication use. However, prior evidence is thin due to methodological limitations. Our aim was thus to examine the use of a wide spectrum of medications prescribed to address pain and somatic conditions in a population-based cohort of TBI patients, and to compare this to a sex- and age-matched cohort. We also examined how patient factors such as sex, age, and TBI severity were associated with medication use.

Methods

We assessed Swedish nationwide registers to include all individuals treated for TBI in hospitals or specialist outpatient care between 2006 and 2012. We examined dispensed prescriptions for eight different non-psychotropic medication classes for the 12 months before, and 12 months after, the TBI. We applied a fixed-effects model to compare TBI patients with the matched population cohort. We also stratified TBI patients by sex, age, TBI severity and carried out comparisons using a generalized linear model.

Results

We identified 239,425 individuals with an incident TBI and 239,425 matched individuals. TBI patients were more likely to use any medication [Odds ratio (OR) = 2.03, 95% Confidence Interval (CI) = 2.00-2.05], to present with polypharmacy (OR = 1.96, 95% CI = 1.90-2.02), and to use each of the eight medication classes before their TBI, as compared to the matched population cohort. Following the TBI, TBI patients were more likely to use any medication (OR = 1.83, 95% CI = 1.80-1.86), to present with polypharmacy (OR = 1.74, 95% CI = 1.67-1.80), and to use all medication classes, although differences were attenuated. However, differences increased for antibiotics/antivirals (OR = 2.02, 95% CI = 1.99-2.05) and NSAIDs/antirheumatics (OR = 1.62, 95% CI = 1.59-1.65) post-TBI. We also found that females and older patients were more likely to use medications after their TBI than males and younger patients, respectively. Patients with more severe TBIs demonstrated increased use of antibiotics/ antivirals and NSAIDs/antirheumatics than those with less severe TBIs.

Discussion

Taken together, our results point to poor overall health in TBI patients, suggesting that medical follow-up should be routine, particularly in females with TBI, and include a review of medication use to address potential polypharmacy.

[Frequency of Chronic Pain after Work-Related Trauma: A Preliminary Status Survey during Workers' Compensation Rehabilitation in a Tertiary Clinic]

BACKGROUND

Chronic pain after trauma and surgery is a long-term complication. Its relevance for patients within the workers' compensation rehabilitation process has not been adequately investigated.

OBJECTIVES

Initial evaluation of frequency of chronic pain after occupational accidents.

METHODS

In 2017, surgical inpatients (18-65 y) treated in a tertiary hospital were asked about chronic pain arising from an occupational trauma recognized by statutory occupation insurance (interval 2.8±6.9 years), regardless of care received, first at the time of hospitalization and then by telephone interview 6 months later. The focus was on patients with a work-related trauma (A) within the past month or (B) >6 months.

PRIMARY OUTCOME

frequency of work trauma-related chronic pain (>6 months) at the initial interview (point prevalence), secondary outcomes: frequency of chronicity at 6 months (A) and persistence of chronic pain (B). Tertiary outcomes: ability to work, occupational injury classification, burden based on pain intensity, localization, and medication, functional deficits due to the existence of chronic pain, and comorbidity.

RESULTS

Out of 415 patients included in the survey, 85% (160/188) reported accident-related chronic pain (predominantly moderate to highly severe in intensity, localized at joints and bones). 90% (131/145) also reported this pain six months later. 67% (64/96) reported chronic pain for the first time. Patients with chronic pain at follow-up (281/369) were less likely to return to work (p=0.003), required analgesics in 60%, were more often comorbid (p<0.002) and had greater functional deficits (p<0.002).

CONCLUSION

Despite the preliminary nature of the data, chronic pain seems to be common after occupational trauma and negatively affects the recovery of work ability in the long term. Based on the present observational data, a further differentiated re-evaluation of prospective data considering therapeutic measures is strongly recommended.

Prevalence and levels of disability post road traffic orthopaedic injuries in Rwanda

Background

Prolonged disability resulting from road traffic injuries (RTIs) contributes significantly to morbidity and disease burden. A good understanding of the prevalence and the level of disability of orthopaedic injuries in developing countries is crucial for improvement; however, such data are currently lacking in Rwanda.

Objectives

To determine the prevalence and levels of disability of 2 years post-road traffic orthopaedic injuries in Rwanda.

Method

A multicentre, cross-sectional study from five Rwandan referral hospitals of 368 adult RTI victims' sustained from accidents in 2019. Between 02 June 2022, and 31 August 2022, two years after the injury, participants completed the World Health Organization Disability Assessment Schedule (WHODAS 2.0) Questionnaire for the degree of impairment and the Upper Extremity Functional Scale and Lower-Extremity Functional Scale forms for limb functional evaluation. Descriptive, inferential statistics Chi-square and multinomial regression models were analysed using R Studio.

Results

The study's mean age of the RTOI victims was 37.5 (±11.26) years, with a sex ratio M: F:3: 1. The prevalence of disability following road traffic orthopedic injury (RTOI) after 2 years was 36.14%, with victims having WHODAS score > 25.0% and 36.31% were still unable to return to their usual activities. Age group, Severe Kampala Trauma Score and lack of rehabilitation contributed to disability. The most affected WHODAS domains were participation in society (33%) and life activities (28%).

Conclusion

The prevalence and levels of disability because of RTOI in Rwanda are high, with mobility and participation in life being more affected than other WHODAS domains. Middle-aged and socio-economically underprivileged persons are the most affected.

Contribution

This study showed that a good rehabilitation approach and economic support for the RTI victims would decrease their disabilities in Rwanda.

A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory

OBJECTIVES

To explore trauma patients' experiences of the long-term recovery pathway during 18 months following hospital discharge.

DESIGN

Longitudinal qualitative study.

SETTING AND PARTICIPANTS

Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge.

METHOD

The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically.

RESULTS

Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress.

CONCLUSIONS AND IMPLICATIONS

The patients' experiences from this study establish knowledge of several challenges in the trauma population's recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients' health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.

Prevalence of Alcohol and Other Drug Use in Patients Presenting to Hospital for Violence-Related Injuries: A Systematic Review

Substance use is a risk factor for being both a perpetrator and a victim of violence. The aim of this systematic review was to report the prevalence of acute pre-injury substance use in patients with violence-related injuries. Systematic searches were used to identify observational studies that included patients aged ≥15 years presenting to hospital after violence-related injuries and used objective toxicology measures to report prevalence of acute pre-injury substance use. Studies were grouped based on injury cause (any violence-related, assault, firearm, and other penetrating injuries including stab and incised wounds) and substance type (any substance, alcohol only, drugs other than alcohol only), and they were summarized using narrative synthesis and meta-analyses. This review included 28 studies. Alcohol was detected in 13%-66% of any violence-related injuries (five studies), 4%-71% of assaults (13 studies), 21%-45% of firearm injuries (six studies; pooled estimate = 41%, 95% CI: 40%-42%, n = 9,190), and 9%-66% of other penetrating injuries (nine studies; pooled estimate = 60%, 95% CI: 56%-64%, n = 6,950). Drugs other than alcohol were detected in 37% of any violence-related injuries (one study), 39% of firearm injuries (one study), 7%-49% of assaults (five studies), and 5%-66% of penetrating injuries (three studies). The prevalence of any substance varied across injury categories: any violence-related injuries = 76%-77% (three studies), assaults = 40%-73% (six studies), firearms = n/a, other penetrating injuries = 26%-45% (four studies; pooled estimate = 30%, 95% CI: 24%-37%, n = 319).Overall, substance use was frequently detected in patients presenting to hospital for violence-related injuries. Quantification of substance use in violence-related injuries provides a benchmark for harm reduction and injury prevention strategies.

Time off work following psychological injury among health and social care workers: a population-based retrospective cohort study in New South Wales, Australia

OBJECTIVE

This study aimed to determine the disability duration and burden of compensated time loss in the health and social care (HSC) sector following psychological injury.

METHODS

A retrospective cohort study was conducted using data from the New South Wales workers' compensation system. The median weeks disability duration and total weeks of working time lost (WWL) per 1000 workers were compared between the HSC sector and all other industries, and between specific occupational groups in the HSC sector, using accelerated failure time models.

RESULTS

HSC workers had a median (IQR) disability duration of 12.4 (3.3-40.0) weeks, which was less than the 15.3 (4.3-48.3) weeks observed in other industries. Within the HSC sector, ambulance officers had the longest disability duration at 31.1 (6.1-104.0) weeks and highest WWL at 15 734 weeks per 1000 workers. Conversely, nurses and midwives had the shortest disability duration at 8.0 (2.0-25.8) weeks, while other healthcare workers had the lowest WWL (17.0). Controlling for other determinants, ambulance officers had the highest likelihood of longer disability duration (time ratio (TR) 2.14; 95% CI 1.64 to 2.78), followed by social workers (TR 1.46; 95% CI 1.20 to 1.79) and administrators and managers (TR 1.41; 95% CI 1.15 to 1.71). Older age, female sex, full-time employment and working in small organisations correlated with extended disability duration.

CONCLUSION

There is considerable variation in the duration and burden of work disability due to psychological injury across occupational groups in the HSC sector. Findings suggest the need for occupation-specific workplace rehabilitation and psychological support to reduce the impact of psychological injury on HSC workers and improve return-to-work outcomes.

Still in Plight: Traumatic Injuries and Their Acute Health Effects in Karachi, Pakistan

Introduction Traumatic injuries are a leading cause of mortality and morbidity, with significant social and economic impacts. Karachi, Pakistan, a densely populated city with a high incidence of traumatic injuries, faces inadequacies in its trauma-care setup, including a lack of resources and unorganized care, which highlights the need for improved trauma management strategies and trauma registries. The purpose of this research is to present a fundamental profile of traumatic injuries in terms of their health-related consequences in Karachi, Pakistan. The objective is to identify the nature, affected body parts, and severity of traumatic injuries to identify areas for effective safety measures and reduce morbidity and mortality. Methodology This descriptive, cross-sectional study was conducted at Jinnah Postgraduate Medical Center (JPMC) in Karachi, Pakistan, from June to August 2021. The study included trauma patients over the age of 18 who presented at the accident and emergency department (ED) of JPMC during the study period. Data were collected using a structured questionnaire, and statistical analysis was performed using IBM SPSS Statistics. The study aimed to identify the demographic and clinical characteristics of trauma patients presenting to the ED. Results This study of 363 trauma patients found road traffic injuries (62.4%) as the most common mechanism of injury, with extremities (48.5%) being the most affected body part. The majority of trauma victims did not receive prehospital care (65.3%), highlighting a need for improved emergency response systems and public awareness. Open wounds (41.0%) were the most common nature of injury, with falls being the leading mechanism of fractures. The severity of injuries was mostly moderate (48.2%). Conclusion This study highlighted the need for targeted prevention strategies to reduce the health-related burden on the population of Karachi, Pakistan. Future research should focus on longitudinally monitoring all injured patients to identify high-risk populations, injury patterns, and preventative outcomes.

A cross-sectional study of the relationship between injuries and quality of life, psychological distress, sleeping problems, and global subjective health in adults from three Norwegian counties

BACKGROUND

Studies examining associations between injuries and outcomes like quality of life and psychological distress are important to understand a broader range of possible consequences of injuries for population health.

AIMS

The aim of this study was to examine associations between self-reported injury and quality of life, psychological distress, sleeping problems, and global subjective health.

METHODS

The sample was drawn from the Norwegian National Population Register. Data were collected among the general adult populations in three Norwegian counties in 2019-2020 (response rate 45.3%, n = 74,030). Exposure variables were being injured during the last 12 months, cause of injury (if more than one, the most serious one), and functional impairment due to injuries. Outcome variables included measures of total quality of life, global quality of life, positive affect, negative affect, positive social relations, social capital (trust, belongingness, feeling safe), psychological distress, sleep problems, loneliness, and global subjective health. Data were analysed with General Linear Modelling in SPSS Complex.

RESULTS

Reporting to have been injured once during the last 12 months was associated with slightly elevated levels of psychological distress, sleeping problems, and loneliness, and lower mean scores on quality-of-life indicators and global subjective health. Reporting being injured twice or more showed more pronounced contrasts to the reference group on the same outcomes, with Cohen's d-values (absolute numbers) ranging from 0.17 to 0.54. For having been victim to violence, d-values ranged from 0.30 to 1.01. Moderate functional impairment due to injuries was associated with less favourable scores on all outcomes (d ranging from 0.15 to 0.71). For strong functional impairment d-values ranged from 0.35 to 1.17.

CONCLUSIONS

Elevated levels of distress and reduced levels of quality of life are particularly associated with multiple injuries, being victim to violence, and functional impairment due to injuries. Prospective, longitudinal studies with high quality instruments and large samples, allowing adjustment for baseline values of outcome variables, and utilization of state-of-the-art statistical techniques, would bring this research closer to examining causality.

Loss of independence after traumatic injury: A patient-centered study

BACKGROUND

Patient-reported outcomes of postdischarge functional status can provide insight into patient recovery experiences not typically reflected in trauma registries. Injuries may be characterized by a long-term loss of independence. We sought to examine factors predictive of patient-reported, postdischarge loss of independence in trauma patients.

METHODS

Trauma patients admitted to 1 of 3 level I trauma centers were contacted by phone between 6 to 12 months after hospital discharge to complete the Revised Trauma Quality of Life survey. Loss of independence was defined as a new need for assistance with at least one activity of daily living or transition to living in an institutional setting. Patients with severe traumatic brain injury or spinal cord injury were excluded. Multivariable logistic regression analyses were performed to identify predictors of loss of independence.

RESULTS

801 patients were included. The median age was 65 (interquartile range: 46-76) years, 46.1% were female, and the median Injury Severity Score was 9 (interquartile range: 9-13). Two hundred seventy-one patients (33.8%) experienced a loss of independence, most commonly requiring assistance walking up stairs. The main predictors of loss of independence were persistent daily pain (odds ratio: 3.83, 95% confidence interval: [2.90-5.04], P < .001), length of hospital stay (odds ratio: 1.04, 95% confidence interval: [1.01-1.09], P = .021) and income below the national median (odds ratio: 1.46, 95% confidence interval: [1.12-1.91], P = .006). Perceived social support (odds ratio: 0.75, 95% confidence interval: [0.66-0.85], P < .001) was protective against loss of independence.

CONCLUSION

Injury is associated with a relatively high rate of long-term loss of independence. Ensuring adequate social support systems for patients postdischarge may help them regain functional independence after injury.

Adult patient and carer experiences of planning for hospital discharge after a major trauma event: a qualitative systematic review

PURPOSE

To identify, evaluate and synthesize qualitative literature on adult patients and carer experiences of planning for discharge from an acute setting after a major trauma event.

METHODS

The JBI approach to meta-aggregation was followed. Qualitative studies exploring patient and carer discharge planning experiences of major trauma were included in the systematic review. A comprehensive search was conducted in five databases, supplemented by grey literature. Eligible studies were appraised for methodological quality by two reviewers and data extracted using standardized JBI tools.

RESULTS

Four synthesized findings emerged using 69 findings from sixteen papers. (i) Patients and carers feel generally unprepared to manage at home after discharge, (ii) early identification of patients' post discharge needs allows for appropriate referrals and supports to be organised prior to discharge, (iii) patients and carers value participation in the discharge planning process to facilitate a considered, organized and timely discharge from hospital (iv) the timely presentation, delivery, language used, format and relevancy of information impacts how patients and carers manage their discharge.

CONCLUSION

This meta-synthesis demonstrates that patients and carers predominantly have poor experiences of discharge planning after major trauma. Adoption of patient centered principles may improve patient and carer experiences of the discharge planning process.

IMPLICATIONS FOR REHABILITATIONPatients and their carers benefit from a client-centred approach where their needs are recognised and their collaboration encouraged in important decisions, and if they are adequately prepared to reintegrate into their community.Patients can benefit from having a trauma pathway healthcare professional to provide support and advocacy services throughout their hospital admission and after discharge.Discharge planning that is organised, prepared and collaborative leads to a more positive patient experience.Discharge information should be individualised and presented in an easily accessible format for patients and carers.

Functional Outcomes at 6 and 12 Months Post-Injury in a Trauma Centre Population with Moderate-to-Severe Traumatic Injuries

This study aims to evaluate the global functional outcomes after moderate-to-severe traumatic injury at 6 and 12 months and to examine the sociodemographic and injury-related factors that predict these outcomes. A prospective cohort study was conducted in which trauma patients of all ages with a New Injury Severity Score > 9 who were discharged alive from two regional trauma centres in Norway over a one-year period (2020) were included. The Glasgow Outcome Scale Extended (GOSE) score was used to analyse the functional outcomes. Regression analyses were performed to investigate the predictors of the GOSE score. Follow-up assessments were obtained from approximately 85% of the 601 included patients at both time points. The mean (SD) GOSE score was 6.1 (1.6) at 6 months and 6.4 (1.6) at 12 months, which corresponds to an upper-moderate disability. One-half of the patients had a persistent disability at 12 months post-injury. The statistically significant predictors of a low GOSE score at both time points were more pre-injury comorbidity, a higher number of injuries, and higher estimated rehabilitation needs, whereas a thorax injury with an Abbreviated Injury Scale ≥ 3 predicted higher GOSE scores. A high Glasgow Coma Scale score at admission predicted a higher GOSE score at 6 months. This study strengthens the evidence base for the functional outcomes and predictors in this population.

Prehospital Tranexamic Acid for Severe Trauma

BACKGROUND

Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain.

METHODS

We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury.

RESULTS

A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups.

CONCLUSIONS

Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).

Association of Trauma With Long-Term Risk of Death and Immune-Mediated or Cancer Disease in Same-Sex Twins

Importance

Immediate consequences of trauma include a rapid and immense activation of the immune system, whereas long-term outcomes include premature death, physical disability, and reduced workability.

Objective

To investigate if moderate to severe trauma is associated with long-term increased risk of death or immune-mediated or cancer disease.

Design, Setting, and Participants

This registry-based, matched, co-twin control cohort study linked the Danish Twin Registry and the Danish National Patient Registry to identify twin pairs in which 1 twin had been exposed to severe trauma and the other twin had not from 1994 to 2018. The co-twin control design allowed for matching on genetic and environmental factors shared within twin pairs.

Exposure

Twin pairs were included if 1 twin had been exposed to moderate to severe trauma and the other twin had not (ie, co-twin). Only twin pairs where both twins were alive 6 months after the trauma event were included.

Main Outcome and Measure

Twin pairs were followed up from 6 months after trauma until 1 twin experienced the primary composite outcome of death or 1 of 24 predefined immune-mediated or cancer diseases or end of follow-up. Cox proportional hazards regression was used for intrapair analyses of the association between trauma and the primary outcome.

Results

A total of 3776 twin pairs were included, and 2290 (61%) were disease free prior to outcome analysis and were eligible for the analysis of the primary outcome. The median (IQR) age was 36.4 (25.7-50.2) years. The median (IQR) follow-up time was 8.6 (3.8-14.5) years. Overall, 1268 twin pairs (55%) reached the primary outcome; the twin exposed to trauma was first to experience the outcome in 724 pairs (32%), whereas the co-twin was first in 544 pairs (24%). The hazard ratio for reaching the composite outcome was 1.33 (95% CI, 1.19-1.49) for twins exposed to trauma. Analyses of death or immune-mediated or cancer disease as separate outcomes provided hazard ratios of 1.91 (95% CI, 1.68-2.18) and 1.28 (95% CI, 1.14-1.44), respectively.

Conclusion and Relevance

In this study, twins exposed to moderate to severe trauma had significantly increased risk of death or immune-mediated or cancer disease several years after trauma compared with their co-twins.

Epidemiology of severe trauma in Navarra for 10 years: out-of-hospital/ in-hospital deaths and survivors

BACKGROUND

Major trauma is a leading cause of death. Due to the difficulties to keep a registry of these cases, few studies include all subjects, because they exclude out-of-hospital deaths. The purpose of this work was to compare the epidemiological profiles of out-of-hospital deaths, in-hospital deaths, and survivors over a 10-year period (2010-2019) of patients who had been treated by Navarre´s Health Service (Spain).

METHODS

Retrospective longitudinal cohort study using data of patients injured by an external physical force of any intentionality and with a New Injury Severity Score above 15. Hangings, drownings, burns, and chokings were excluded. Intergroup differences of demographic and clinical variables were analysed using the Kruskal Wallis test, chi-squared test, or Fisher´s exact test.

RESULTS

Data from 2,610 patients were analysed; 624 died out-of-hospital, 439 in-hospital, and 1,547 survived. Trauma incidences remained moderately stable over the 10-year period analysed, with a slight decrease in out-of-hospital deaths and a slight increase in in-hospital deaths. Patients of the out-of-hospital deaths group were younger (50.9 years) in comparison to in-hospital deaths and survivors. Death victims were predominantly male in all study groups. Intergroup differences regarding prior comorbidities and predominant type of injury were observed.

CONCLUSIONS

There are significant differences among the three study groups. More than half of the deaths occur out-of-hospital and the causative mechanisms differ in each of them. Thus, when designing strategies, preventive measures were considered for each group on a case-by-case basis.

Factors associated with discharge destination from acute care after moderate-to-severe traumatic injuries in Norway: a prospective population-based study

BACKGROUND

Previous studies have demonstrated that the trauma population has needs for rehabilitation services that are best provided in a continuous and coordinated way. The discharge destination after acute care is the second step to ensuring quality of care. There is a lack of knowledge regarding the factors associated with the discharge destination for the overall trauma population. This paper aims to identify sociodemographic, geographical, and injury-related factors associated with discharge destination following acute care at trauma centers for patients with moderate-to-severe traumatic injuries.

METHODS

A multicenter, population-based, prospective study was conducted with patients of all ages with traumatic injury [New Injury Severity Score (NISS) > 9] admitted within 72 h after the injury to regional trauma centers in southeastern and northern Norway over a 1-year period (2020).

RESULTS

In total, 601 patients were included; a majority (76%) sustained severe injuries, and 22% were discharged directly to specialized rehabilitation. Children were primarily discharged home, and most of the patients ≥ 65 years to their local hospital. Depending on the centrality of their residence [Norwegian Centrality Index (NCI) 1-6, where 1 is most central], we found that patients residing in NCI 3-4 and 5-6 areas sustained more severe injuries than patients residing in NCI 1-2 areas. An increase in the NISS, number of injuries, or a spinal injury with an Abbreviated Injury Scale (AIS) ≥ 3 was associated with discharge to local hospitals and specialized rehabilitation than to home. Patients with an AIS ≥ 3 head injury (RRR 6.1, 95% Confidence interval 2.80-13.38) were significantly more likely to be discharged to specialized rehabilitation than patients with a less severe head injury. Age < 18 years was negatively associated with discharge to a local hospital, while NCI 3-4, preinjury comorbidity, and increased severity of injuries in the lower extremities were positively associated.

CONCLUSIONS

Two-thirds of the patients sustained severe traumatic injury, and 22% were discharged directly to specialized rehabilitation. Age, centrality of the residence, preinjury comorbidity, injury severity, length of hospital stay, and the number and specific types of injuries were factors that had the greatest influence on discharge destination.

Health-related quality of life 12 years after injury: prevalence and predictors of outcomes in a cohort of injured Māori

PURPOSE

Studies have found that many people who sustain an injury can experience adverse outcomes for a considerable time thereafter. Māori, the Indigenous peoples of Aotearoa me Te Waipounamu (New Zealand; NZ), are no exception. The Prospective Outcomes of Injury Study (POIS) found that almost three-quarters of Māori participants were experiencing at least one of a range of poor outcomes at two years post-injury. The aim of this paper was to estimate the prevalence, and identify predictors, of adverse health-related quality of life (HRQoL) outcomes in the POIS-10 Māori cohort, 12 years after participants sustained an injury.

METHODS

Interviewers reached 354 individuals who were eligible to participate in a POIS-10 Māori interview, to be conducted a decade after the last phase of POIS interviews (held 24 months post-injury). The outcomes of interest were responses to each of the five EQ-5D-5L dimensions at 12 years post-injury. Potential predictors (i.e., pre-injury sociodemographic and health measures; injury-related factors) were collected from earlier POIS interviews. Additional injury-related information was collected from administrative datasets proximate to the injury event 12 years prior.

RESULTS

Predictors of 12-year HRQoL outcomes varied by EQ-5D-5L dimension. The most common predictors across dimensions were pre-injury chronic conditions and pre-injury living arrangements.

CONCLUSION

An approach to rehabilitation where health services proactively enquire about, and consider the broader aspects of, patient health and wellbeing throughout the injury recovery process, and effectively coordinate their patients' care with other health and social services where necessary, may help improve long-term HRQoL outcomes for injured Māori.

Perspectives of major traumatic injury survivors on accessibility and quality of rehabilitation services in rural Australia

PURPOSE

For the 30% of Australians who live in rural areas, access to rehabilitation services after sustaining a major traumatic injury can be challenging. This study aimed to explore the experience of rural major traumatic injury survivors accessing rehabilitation services.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 21 rural major traumatic injury survivors (M_age = 47.86; SD = 11.35; Range: 21-61) who were an average of seven years post-injury (SD = 3.10; Range: 3.25-13.01). Transcribed interviews were thematically analysed.

RESULTS

Four themes were identified: (1) Managing the transition back to local services, (2) Independence and determination to get better, (3) Rehabilitation is an ongoing process, and (4) Limited service access and quality. While injury-related symptoms persisted for many participants, they expressed strong determination for independence and self-management of their recovery. Barriers to accessing rehabilitation services included poor knowledge of local services, travel burden, financial costs, and a lack of local practitioners experienced in major traumatic injury rehabilitation. Facilitating factors included financial, psychological, community, and informal supports.

CONCLUSIONS

To support recovery, future rural service models should improve consideration of factors resulting from living at a distance to services and harness independence to self-manage.IMPLICATIONS FOR REHABILITATIONRural major traumatic injury survivors need support to navigate numerous barriers to accessing rehabilitation services.Rural participants expressed their preference for greater involvement in planning their transition back home following hospitalisation and help to link with available services in their local area.Specialist training and support for rural rehabilitation practitioners is needed, to effectively treat impairments related to major traumatic injury, particularly psychological and cognitive difficulties.Future service delivery models should incorporate methods to locate rural services; facilitate telehealth access and client self-management; and provide financial and mental health support to both rural survivors of major traumatic injury and their carers.

Perceptions of an Interactive Trauma Recovery Information Booklet

BACKGROUND

Previous research has shown that people with traumatic injuries have unmet information needs with respect to their injuries, management, and recovery. An interactive trauma recovery information booklet was developed and implemented to address these information needs at a major trauma center in Victoria, Australia.

OBJECTIVE

The aim of this quality improvement project was to explore patient and clinician perceptions of a recovery information booklet introduced into a trauma ward.

METHODS

Semistructured interviews with trauma patients, family members, and health professionals were undertaken and thematically analyzed using a framework approach. In total, 34 patients, 10 family members, and 26 health professionals were interviewed.

RESULTS

Overall, the booklet was well accepted by most participants and was perceived to contain useful information. The design, content, pictures, and readability were all positively appraised. Many participants used the booklet to record personalized information and to ask health professionals questions about their injuries and management.

CONCLUSION

Our findings highlight the usefulness and acceptability of a low-cost interactive booklet intervention to facilitate the provision of quality of information and patient-health professional interactions on a trauma ward.

A qualitative study of older adult trauma survivors' experiences in acute care and early recovery

BACKGROUND

Older adults (aged ≥ 65 yr) account for a substantial proportion of hospital admissions for severe injury, yet little is known about their care experiences and views regarding outcomes. We sought to characterize the acute care and early recovery experiences of older adults who had been discharged after traumatic injury, with a long-term goal to inform the selection of patient-centred process and outcome measures in geriatric trauma.

METHODS

From June 2018 to September 2019, we conducted telephone interviews with adults aged 65 years or older who had been discharged after traumatic injury within 6 months from Sunnybrook or London Health Sciences Centres in Ontario, Canada. Using interpretive description and thematic analysis, we drew on social science theories of illness and aging for data interpretation. We analyzed data to the point of theoretical saturation.

RESULTS

We interviewed 25 trauma survivors aged 65-88 years. Most were injured in a fall. Four themes characterized participants' experiences, as follows: "I don't feel like a senior" (i.e., participants disliked being viewed as a senior or as needing senior-specific care); "don't bother telling him anything" (i.e., participants perceived ageist assumptions and treatment in acute care processes); getting back to normal (i.e., participants emphasized their active lifestyles and functional recovery as goals of care); "I have lost control of my life" (i.e., substantial social and personal losses linked to participants' experiences and adaptations to aging generally).

INTERPRETATION

Findings suggest that older adults experience social and personal loss after injury, and underscore how implicit age bias may influence care experiences and outcomes. This can inform improvements in injury care and guide providers in the selection of patient-centred outcome measures.

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

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

Survivorship

This address challenges the trauma community and each trauma center to develop a dedicated outpatient center for trauma survivors, delivering patient-centered, high-quality physical and behavioral health care as well as social support for patients and caregivers.

Relationship between attitudes toward COVID-19 infection, depression and anxiety: a cross-sectional survey in Japan

BACKGROUND

Although negative attitudes are known to develop with experiences of COVID-19 infection, it remains unclear whether such attitudes contribute to depression and anxiety as sequelae of COVID-19. We aimed to investigate the relationships between attitude towards COVID-19 infection and post-COVID-19 depression and anxiety.

METHODS

A cross-sectional survey of COVID-19 recovered patients was conducted from July to September 2021 in Japan. Outcome variables, depression and anxiety were assessed using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7); scores of 10 and above were identified as having symptoms of depression and anxiety, respectively. Exposure variables were whether participants were experiencing the following attitude strongly: threat to life due to COVID-19 infection, helplessness regarding COVID-19 infection, blaming a third party who did not restrain from going outside, blaming themselves for their COVID-19 infection, worry about spreading the infection to others, and self-stigma (Self-Stigma Scale-Short). Modified Poisson regression analyses were performed to analyze the findings.

RESULTS

A total of 6016 responses were included in the analyses. The proportion of depression was 19.88%, and anxiety was 11.47%. The threat of life due to COVID-19 infection, helplessness regarding COVID-19 infection, blaming oneself for their COVID-19 infection, and self-stigma were significantly associated with depression and anxiety after adjusting covariates. Blaming the third party who did not restrain from going outside was associated with anxiety. There was no association between the worry about spreading infection to others and depression or anxiety.

CONCLUSION

Negative attitudes, including self-stigma with the experience of COVID-19 infection, were related to depression and anxiety. Further studies confirming whether countermeasures for preventing or decreasing the negative attitude towards COVID-19 infection mitigate these symptoms are needed.

Thoracic injuries in trauma patients: epidemiology and its influence on mortality

BACKGROUND

Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality.

METHODS

Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality.

RESULTS

A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3).

CONCLUSION

Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

Definitive Taylor Spatial Frame management for the treatment of high-energy open tibial fractures: Clinical and patient-reported outcomes

BACKGROUND

High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided.  We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided.

METHOD

A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant.

RESULTS

Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work.

CONCLUSION

Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures.  We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term health and mobility of older adults following traumatic injury: a qualitative longitudinal study

PURPOSE

The aim of this study was to explore older adults' experiences of and approaches to managing their long-term health and mobility after traumatic injury.

METHODS

A longitudinal qualitative study was undertaken with older adults following traumatic injury in Victoria, Australia. Fifteen participants (≥65 years) were interviewed at three years post-injury (n = 15), and re-interviewed at four (n = 14) and five years (n = 12) post-injury. Using a framework approach, a longitudinal thematic analysis was performed.

RESULTS

Older age at the time of injury was identified by participants as a key factor influencing their recovery. Many participants reported actively attempting to regain their strength and fitness in the first five years following injury. However, their age, injury impacts, other health conditions, and weight gain made it difficult to achieve recovery goals. Many older adults reported a decline in their physical function over time. While these experiences and persistent disability constrained or changed the quality of social relationships, community participation, and independence, several participants described adapting to their functional limitations, and managing their secondary conditions over time.

CONCLUSION

In our cohort, the intertwined combination of ageing, injury, and comorbid conditions negatively affected health and mobility, reinforcing the need for preventative strategies.Implications for rehabilitationOlder adults recovering from traumatic injury may benefit from specialised care pathways that offer long-term and tailored therapies, with programs and services specific to their needs and goals.An integrated service approach by injury insurers, health care, primary care, disability, and aged care could more clearly identify and effectively address the individual needs and goals of older adults with complex conditions.Health and social services that work with people with injuries to develop personalised coping strategies can reduce anxiety related to uncertainty about the future, promote well-being, and support participation in valued activities.

The effect of age on resilience of health-related quality of life among polytrauma patients: a cross-sectional multicenter study

Purpose

The aim of this study was to determine the impact of age on patient-reported health-related quality of life (HRQoL) and the capacity to show resilience—i.e., the ability to adapt to stressful adverse events—after sustaining a polytrauma.

Methods

A cross-sectional multicenter cohort was conducted between 2013 and 2016 that included surviving polytrauma patients (ISS ≥ 16). HRQoL was obtained by the Short Musculoskeletal Function assessment and EuroQol (SMFA and EQ-5D-5L). The effect of age on HRQoL was tested with linear regression analysis. Next, the individual scores were compared with age- and sex-matched normative data to determine whether they showed resilience. Multivariate binary logistic regression was used to assess the effect of age on reaching the normative threshold of the surveys, correcting for several confounders.

Results

A total of 363 patients responded (57%). Overall, patients had a mean EQ-5D-5L score of 0.73. With higher age, scores on the SMFA subscales “upper extremity dysfunction,” “lower extremity dysfunction” and “daily activities” significantly dropped. Only 42% of patients were classified as being resilient, based on the EQ-5D-5L score. Patients aged 60–69 showed the highest resilience (56%), and those aged 80 + showed the lowest resilience (0%).

Conclusion

Sustaining a polytrauma leads to a serious decline in HRQoL. Aging is associated with a decline in the physical components of HRQoL. No clear relationship with age was seen on the non-physical components of quality of life. Octogenarians, and to a lesser extent septuagenarians and tricenarians, showed to be very vulnerable groups, with low rates of resilience after surviving a polytrauma.

Serious Injury in Metropolitan and Regional Victoria: Exploring Travel to Treatment and Utilisation of Post-Discharge Health Services by Injury Type

This study aimed to describe regional variations in service use and distance travelled to post-discharge health services in the first three years following hospital discharge for people with transport-related orthopaedic, brain, and spinal cord injuries. Using linked data from the Victorian State Trauma Registry (VSTR) and Transport Accident Commission (TAC), we identified 1597 people who had sustained transport-related orthopaedic, brain, or spinal cord injuries between 2006 and 2016 that met the study inclusion criteria. The adjusted odds of GP service use for regional participants were 76% higher than for metropolitan participants in the orthopaedic and traumatic brain injury (TBI) groups. People with spinal cord injury (SCI) living in regional areas had 72% lower adjusted odds of accessing mental health, 76% lower adjusted odds of accessing OT services, and 82% lower adjusted odds of accessing physical therapies compared with people living in major cities. People with a TBI living in regional areas on average travelled significantly further to access all post-discharge health services compared with people with TBI in major cities. For visits to medical services, the median trip distance for regional participants was 76.61 km (95%CI: 16.01-132.21) for orthopaedic injuries, 104.05 km (95% CI: 51.55-182.78) for TBI, and 68.70 km (95%CI: 8.34-139.84) for SCI. Disparities in service use and distance travelled to health services exist between metropolitan Melbourne and regional Victoria following serious injury.

Clustering of trauma patients based on longitudinal data and the application of machine learning to predict recovery

Predicting recovery after trauma is important to provide patients a perspective on their estimated future health, to engage in shared decision making and target interventions to relevant patient groups. In the present study, several unsupervised techniques are employed to cluster patients based on longitudinal recovery profiles. Subsequently, these data-driven clusters were assessed on clinical validity by experts and used as targets in supervised machine learning models. We present a formalised analysis of the obtained clusters that incorporates evaluation of (i) statistical and machine learning metrics, (ii) clusters clinical validity with descriptive statistics and medical expertise. Clusters quality assessment revealed that clusters obtained through a Bayesian method (High Dimensional Supervised Classification and Clustering) and a Deep Gaussian Mixture model, in combination with oversampling and a Random Forest for supervised learning of the cluster assignments provided among the most clinically sensible partitioning of patients. Other methods that obtained higher classification accuracy suffered from cluster solutions with large majority classes or clinically less sensible classes. Models that used just physical or a mix of physical and psychological outcomes proved to be among the most sensible, suggesting that clustering on psychological outcomes alone yields recovery profiles that do not conform to known risk factors.

Differences in time-critical interventions and radiological examinations between adult and older trauma patients: A national register-based study

BACKGROUND

Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients hold important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations.

METHODS

Retrospective analysis of the Norwegian Trauma Registry for 2015 through 2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score of 9 or greater were included, dichotomized into age groups 16 years to 64 years and 65 years or older. Prehospital and emergency department clinical management, advanced airway management, chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests.

RESULTS

There were 9543 patients included, of which 28% (n = 2711) were 65 years or older. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.57-0.71), conveyed by air ambulance (OR, 0.65; 95% CI, 0.58-0.73), and transported directly to a trauma center (OR, 0.86; 95% CI, 0.79-0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with New Injury Severity Score of 25 or greater, showing lower rates for older adults (advanced airway management: OR, 0.60; 95% CI, 0.47-0.76; chest decompression: OR, 0.46; 95% CI, 0.25-0.85; x-ray chest: OR, 0.54; 95% CI, 0.39-0.75; x-ray pelvis: OR, 0.69; 95% CI, 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups.

CONCLUSION

Older trauma patients were less likely to receive advanced prehospital care compared with younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Genetic and immune crosstalk between severe burns and blunt trauma: A study of transcriptomic data

Background: Severe burns and blunt trauma can lead to multiple organ dysfunction syndrome, the leading cause of death in intensive care units. In addition to infection, the degree of immune inflammatory response also affects prognosis. However, the characteristics and clinical relevance of the common mechanisms of these major diseases are still underexplored.

Methods: In the present study, we performed microarray data analysis to identify immune-related differentially expressed genes (DEGs) involved in both disease progression in burns and blunt trauma. Six analyses were subsequently performed, including gene enrichment analysis, protein‐protein interaction (PPI) network construction, immune cell infiltration analysis, core gene identification, co-expression network analysis, and clinical correlation analysis.

Results: A total of 117 common immune-related DEGs was selected for subsequent analyses. Functional analysis emphasizes the important role of Th17 cell differentiation, Th1 and Th2 cell differentiation, Cytokine-cytokine receptor interaction and T cell receptor signaling pathway in these two diseases. Finally, eight core DEGs were identified using cytoHubba, including CD8A, IL10, CCL5, CD28, LCK, CCL4, IL2RB, and STAT1. The correlation analysis showed that the identified core DEGs were more or less significantly associated with simultaneous dysregulation of immune cells in blunt trauma and sepsis patients. Of these, the downregulation of CD8A and CD28 had a worse prognosis.

Conclusion: Our analysis lays the groundwork for future studies to elucidate molecular mechanisms shared in burns and blunt trauma. The functional roles of identified core immune-related DEGs and dysregulated immune cell subsets warrant further in-depth study.

The impact of major occupational injuries on professional reintegration. A Portuguese medico-legal contribution

Occupational injuries represent an enormous economic impact for victims, respective families, involved institutions and all the community due to professional outcomes. Thus, it is of the utmost importance that medico-legal personal injury assessment and the posterior follow-up of these victims, may allow their concrete damage repair, considering the victims' needs fulfilment and professional reintegration, whenever possible. The main objective of this study is to reflect on the role that legal medicine can play in promoting the professional reintegration of victims of major occupational accidents through the analysis of occupational injuries cases considering the medico-legal examinations performed. A retrospective study was conducted using medico-legal major occupational injuries cases (Partial Permanent Disability ≥40%). Data were collected from two medico-legal assessment moments: (a) personal injury assessment homologated by a labour court 4.8 years on average after occupational injury; (b) medico-legal follow-up for needs and/or Partial Permanent Disability adjustments performed 18.9 years on average after occupational injury. The final sample includes 103 cases. The results showed that in major occupational accidents, permanent long-term outcomes were principally associated with neurological (62.1%) and orthopaedic (52.4%) sequelae. Permanent professional damage parameters assigned by the labour court included Partial Permanent Disability (23.3%), Permanent Absolute Disability for Regular Work (41.7%) and Permanent Absolute Disability for Any Work (35%). Three-dimensional methodology is helpful in predicting Partial Permanent Disability and Permanent Absolute Disability for Any Work. However, three-dimensional methodology did not reveal correlations with Permanent Absolute Disability for Regular Work, and currently 65% of the victims who were considered able to work by the labour court are not professionally active. Thus, these major cases deserve a more detailed medico-legal approach based on concrete information about the professional reality of each victim, especially cases with an eventual Permanent Absolute Disability for Regular Work. Medico-legal Injury Assessment must be based on concrete aspects of the victim's professional reality and not only on permanent disability tables. This calls for an articulation between all institutions working with the victim of occupational injuries and legal medicine to promote recovery and the necessary measures to assure professional rehabilitation.

Injury severity and increased socioeconomic differences: A population-based cohort study

BACKGROUND

Several studies have documented an inverse gradient between socioeconomic status (SES) and injury mortality, but the evidence is less consistent for injury morbidity. The aim of this study was to investigate the association between SES and injury severity for acute hospitalizations in a nationwide population-based cohort.

METHODS

We conducted a registry-based cohort study of all individuals aged 25-64 years residing in Norway by 1st of January 2008. This cohort was followed from 2008 through 2014 using inpatient registrations for acute hospitalizations due to all-cause injuries. We derived two measures of severity: threat-to-life using the International Classification of Disease-based Injury Severity Score (ICISS), and threat of disability using long-term disability weights from the Injury-VIBES project. Robust Poisson regression models, with adjustment for age, sex, marital status, immigrant status, municipality population size and healthcare region of residence, were used to calculate incidence rate ratios (IRRs) by SES measured as an index of education, income, and occupation.

RESULTS

We identified 177,663 individuals (7% of the population) hospitalized with at least one acute injury in the observation period. Two percent (n = 4,186) had injuries categorized with high threat-to-life, while one quarter (n = 43,530) had injuries with high threat of disability. The overall adjusted IRR of hospitalization among people with low compared to high SES was 1.57 (95% CI 1.55, 1.60). Comparing low to high SES, injuries with low threat-to-life were associated with an IRR of 1.56 (95% CI 1.54, 1.59), while injuries with high threat-to-life had an IRR of 2.25 (95% CI 2.03, 2.51). Comparing low to high SES, injuries with low, medium, and high threat of disability were associated with IRRs of respectively, 1.15 (95% CI 1.11, 1.19), 1.70 (95% CI 1.66, 1.73) and 1.99 (95% CI 1.92, 2.07).

DISCUSSION

We observed an inverse gradient between SES and injury morbidity, with the steepest gradient for the most severe injuries. This suggests a need for targeted preventive measures to reduce the magnitude and burden of severe injuries for patients with low socioeconomic status.

The Social Vulnerability Index and Long-term Outcomes after Traumatic Injury

OBJECTIVE

To evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury.

BACKGROUND

The SVI is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors.

METHODS

Moderate-severely injured adult patients treated at one of three level-1 trauma centers were prospectively followed six to 14 months post-injury. These data were matched at the census tract level with overall SVI percentile rankings. Patients were stratified based on SVI quartiles, with the lowest quartile designated as low SVI, the middle two quartiles as average SVI, and the highest quartile as high SVI. Multivariable adjusted regression models were used to assess whether SVI was associated with long-term outcomes after injury.

RESULTS

A total of 3,153 patients were included [54% male, mean age 61.6 (SD = 21.6)]. The median overall SVI percentile rank was 35th (IQR: 16th-65th). Compared to low SVI patients, high SVI patients were more likely to have new functional limitations (OR, 1.51; 95% CI, 1.19-1.92), to not have returned to work (OR, 2.01; 95% CI, 1.40-2.89), and to screen positive for PTSD (OR, 1.56; 95% CI, 1.12-2.17). Similar results were obtained when comparing average with low SVI patients, with average SVI patients having significantly worse outcomes.

CONCLUSIONS

The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted prevention and intervention efforts.

The Utility of the Shock Index for Predicting Survival, Function and Health Status Outcomes in Major Trauma Patients: A Registry-Based Cohort Study

The shock index (SI; heart rate/systolic blood pressure) has been found to predict mortality in trauma patients. The aims of this study were to establish whether the SI improved the prediction of an existing model for both mortality and longer-term outcomes in major trauma patients. In total, 29,574 adult (>15 years) major trauma patients were included from the Victorian State Trauma Registry with a date of injury from July 2009 to June 2019. Outcomes of interest were survival to hospital discharge and function and health status at 6 months post-injury. Survival and function were analysed using measures of discrimination and calibration, whereas health status was assessed with R2 and MRSE measures. The area under the receiver operating characteristic curve (AUC) of the VSTR survival model improved when the SI was added (AUC 0.797 (0.787–0.807) versus AUC 0.807 (0.797–0.816), p < 0.001). For the prediction of functional outcome 6 months post-injury, the inclusion of the SI increased the AUC marginally (AUC 0.795 (0.786–0.803) versus AUC 0.799 (0.791–0.807), p < 0.001). When predicting in-hospital mortality and health status 6 months post-injury, including the SI resulted in a slightly better fit to the registry-risk adjustment model. In the future, external validation and the exploration of other models to improve prediction outcomes are warranted.

BEYOND PAIN AND DISABILITY: THE LASTING EFFECTS OF TRAUMA ON LIFE AFTER INJURY

BACKGROUND

The impact of traumatic injury likely extends beyond direct physical consequences and lasts well beyond the acute injury phase. Data collection is sparse after hospital discharge, however. In this observational study, we hypothesized that sequelae of injury would last at least 6 months and sought to prospectively determine patient reported physical, emotional, and social outcomes during this post-injury period.

METHODS

We surveyed patients admitted to our Level I trauma center (7/2019-10/2020) regarding baseline functioning and quality of life after injury, using the PROMIS-29 instrument, a primary care PTSD screen (PC-PTSD-5), and questions on substance use, employment, and living situation. Patients were re-surveyed at 6 months. PROMIS-29 scores are reported as t-scores compared to the U.S. population. Differences between groups were analyzed using chi square, signed-rank, and t-tests, with paired tests used for changes over time.

RESULTS

362 patients completed the baseline, 130 of whom completed 6-month follow-up. Those completing the 6-month survey were similar ages (43.3 ± 17.8 vs 44.4 ± 19.0, p = 0.57), mechanism (24.7% vs 28.0% shot or stabbed, p = 0.61), and severities (median ISS 9 vs 9, p = 0.15) as those who only completed the baseline. 55.0% reported being hospitalized for an injury previously. Patients reported decreases in ability to participate in social roles and activities (mean t-score 51.4 vs 55.3, p = 0.011) and increases in anxiety (53.8 vs 50.5, p = 0.011) and depression (51.0 vs 48.7, p = 0.025). 26.2% screened positive for PTSD at 6 months. Employment decreased at 6 months, with 63.9% reporting being "occasionally" employed or unemployed at 6 months, vs 44.6% pre-injury (p < 0.001).

CONCLUSION

The effects of injury extend beyond pain and disability, impacting several realms of life for at least 6 months following trauma. These data support the development of screening and intervention protocols for post-injury patients.

LEVEL OF EVIDENCE

III, prospective observational.

Regional variation in travel to health services following transport-related major trauma

INTRODUCTION

Post-discharge healthcare needs are complex and persistent for people following major trauma. A number of geographic barriers to accessing healthcare exist, particularly for people in regional areas. The aim of this study was to explore regional variation in the distances travelled to access health services and identify patterns of health service use in the first three years following transport-related major trauma.

METHODS

This registry-based cohort study used linked data from the Victorian State Trauma Registry (VSTR) and the Transport Accident Commission (TAC). Victorians who sustained major trauma from a transport-related event between January 1 2006 and December 31 2016, with at least three years of follow-up TAC claims data were included in the study. Geospatial mapping of the median distance travelled to medical and allied health services was conducted for each Victorian Local Government Area.

RESULTS

In the first three years post-discharge, 4,964 people (75.6%) visited a general practitioner, 5058 (77.0%) saw other medical professionals, 2269 (34.6%) accessed mental health services, 2154 (32.8%) saw an occupational therapist and 4404 (67.0%) attended a physical therapy service. Geospatial mapping revealed that people in regional Local Government Area travelled further distances to access health services. Specific clustering of increased travel distances was observed in regional areas of the far west and north-east of Victoria. The number of people using services declined with each subsequent year beyond hospital discharge. However, the number of trips were consistent over time for those still engaged in services.

CONCLUSIONS

Distances travelled to access health services vary across geographic regions and may result in an increased travel burden for those in some regional Local Government Area. Understanding gaps in health services by geographic region can assist to improve service availability. Alternate service delivery methods, such as telehealth, may assist to reduce the associated burden of travel for those in regional areas.

Mobile telephone follow-up assessment of postdischarge death and disability due to trauma in Cameroon: a prospective cohort study

OBJECTIVES

In Cameroon, long-term outcomes after discharge from trauma are largely unknown, limiting our ability to identify opportunities to reduce the burden of injury. In this study, we evaluated injury-related death and disability in Cameroonian trauma patients over a 6-month period after hospital discharge.

DESIGN

Prospective cohort study.

SETTING

Four hospitals in the Littoral and Southwest regions of Cameroon.

PARTICIPANTS

A total of 1914 patients entered the study, 1304 were successfully contacted. Inclusion criteria were patients discharged after being treated for traumatic injury at each of four participating hospitals during a 20-month period. Those who did not possess a cellular phone or were unable to provide a phone number were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Glasgow Outcome Scale-Extended (GOSE) was administered to trauma patients at 2 weeks, 1 month, 3 months and 6 months post discharge. Median GOSE scores for each timepoint were compared and regression analyses were performed to determine associations with death and disability.

RESULTS

Of 71 deaths recorded, 90% occurred by 2 weeks post discharge. At 6 months, 22% of patients still experienced severe disability. Median (IQR) GOSE scores at the four timepoints were 4 (3-7), 5 (4-8), 7 (4-8) and 7 (5-8), respectively, (p<0.01). Older age was associated with greater odds of postdischarge disability (OR: 1.23, 95% CI: 1.07 to 1.41) and mortality (OR: 2.15, 95% CI: 1.52 to 3.04), while higher education was associated with decreased odds of disability (OR: 0.65, 95% CI: 0.58 to 0.73) and mortality (OR: 0.38, 95% CI: 0.31 to 0.47). Open fractures (OR: 1.73, 95% CI: 1.38 to 2.18) and closed fractures (OR: 1.83, 95% CI: 1.42 to 2.36) were associated with greater postdischarge disability, while higher Injury Severity Score (OR: 2.44, 95% CI: 2.13 to 2.79) and neurological injuries (OR: 4.40, 95% CI: 3.25 to 5.96) were associated with greater odds of postdischarge mortality.

CONCLUSION

Mobile follow-up data show significant morbidity and mortality, particularly for orthopaedic and neurologic injuries, up to 6 months following trauma discharge. These results highlight the need for reliable follow-up systems in Cameroon.

The relationship between hospital selection by employer and disabilities in occupational accidents in Korea

Background

In the event of an industrial accident, the appropriate choice of hospital is important for worker health and prognosis. This study investigates whether the choice of hospital by the employer in the case of industrial accidents affects the prognosis of injured employees.

Methods

Data from the 2018 Panel Study of Workers’ Compensation Insurance in Korea were used in an unmatched case-controlled study. The exposure variable is “hospital selection by an employer,” and the outcome variable is ‘worker’s disability.” Odds ratios (ORs) were estimated by modified Poisson regression and adjusted for age, gender, underlying disease, injury severity, and workplace size and stratified by industrial classification. The group at increased risk was analyzed and stratified by age, gender, and area.

Results

In the construction industry, hospital selection by the employer was significantly associated with increased risk of disability (adjusted OR 1.26; 95% confidence interval [CI]: 1.20–1.32) and severe disability (adjusted OR 1.38; 95% CI: 1.08–1.76) among the injured. Female and younger workers not living in the Seoul capital area were more at risk of disability and severe disability than those living in the Seoul capital area.

Conclusions

Hospital selection by employers affects the prognosis of workers injured in an industrial accident. For protecting workers’ health and safety, workplace emergency medical systems should be improved, and the selection of appropriate hospitals to supply treatment should be reviewed.

Long-term outcomes of hospital survivors following an ICU stay: A multi-centre retrospective cohort study

Background

The focus of much Intensive Care research has been on short-term survival, which has demonstrated clear improvements over time. Less work has investigated long-term survival, and its correlates. This study describes long-term survival and identifies factors associated with time to death, in patients who initially survived an Intensive Care admission in Victoria, Australia.

Methods

We conducted a retrospective cohort study of adult patients discharged alive from hospital following admission to all Intensive Care Units (ICUs) in the state of Victoria, Australia between July 2007 and June 2018. Using the Victorian Death Registry, we determined survival of patients beyond hospital discharge. Comparisons between age matched cohorts of the general population were made. Cox regression was employed to investigate factors associated with long-term survival.

Results

A total of 130,775 patients from 23 ICUs were included (median follow-up 3.6 years post-discharge). At 1-year post-discharge, survival was 90% compared to the age-matched cohort of 98%. All sub-groups had worse long-term survival than their age-matched general population cohort, apart from elderly patients admitted following cardiac surgery who had better or equal survival. Multiple demographic, socio-economic, diagnostic, acute and chronic illness factors were associated with long-term survival.

Conclusions

Australian patients admitted to ICU who survive to discharge have worse long-term survival than the general population, except for the elderly admitted to ICU following cardiac surgery. These findings may assist during goal-of-care discussions with patients during an ICU admission.