Geriatric Trauma - A Rising Tide. Assessing Patient Safety Challenges in a Vulnerable Population Using Norwegian Trauma Registry Data and Focus Group Interviews: Protocol for a Mixed Methods Study

Care pathways and factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe traumatic brain injury: a population-based study from the Norwegian trauma registry

BACKGROUND

Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals.

METHODS

A population-based cohort study from the national Norwegian Trauma Registry (2015-2020) of adult patients (≥ 16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head ≥ 3, AIS Body < 3 and maximum 1 AIS Body = 2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability.

RESULTS

The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P < 0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P < 0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤ 13: 55% vs. 27, P < 0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients < 77 years, and increasing NISSs until the effect was inverted at higher scores. Decreased transfer probability was significantly associated with increasing age and comorbidity, and distance between the acute care trauma hospital and the nearest neurotrauma center, except for extreme NISSs.

CONCLUSIONS

Acute care trauma hospitals managed a substantial burden of isolated moderate-to-severe TBI patients primarily and definitively, highlighting the importance of high-quality neurotrauma care in non-neurosurgical hospitals. The transfer probability declined with increasing age and comorbidity, suggesting that older patients were carefully selected for transfer to specialized care.

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.

Differences in characteristics between patients ≥ 65 and < 65 years of age with orthopaedic injuries after severe trauma

Aim

Many trauma patients have associated orthopaedic injuries at admission. The existing literature regarding orthopaedic trauma often focuses on single injuries, but there is a paucity of information that gives an overview of this group of patients. Our aim was to describe the differences in characteristics between polytrauma patients ≥ 65 and < 65 years of age suffering orthopaedic injuries.

Methods

Patients registered in the Norwegian Trauma Registry (NTR) with an injury severity score (ISS) > 15 and orthopaedic injuries, who were admitted to Haukeland University Hospital in 2016–2018, were included. Data retrieved from the patients’ hospital records and NTR were analysed. The patients were divided into two groups based on age.

Results

The study comprised 175 patients, of which 128 (73%) and 47 (27%) were aged < 65 (Group 1) and ≥ 65 years (Group 2), respectively. The ISS and the new injury severity score (NISS) were similar in both groups. The dominating injury mechanism was traffic-related and thoracic injury was the most common location of main injury in both groups. The groups suffered a similar number of orthopaedic injuries. A significantly higher proportion of Group 1 underwent operative treatment for their orthopaedic injuries than in Group 2 (74% vs. 53%). The mortality in Group 2 was significantly higher than that in Group 1 (15% vs. 3%). In Group 2 most deaths were related to traffic injuries (71%). High energy falls and traffic-related incidents caused the same number of deaths in Group 1. In Group 1 abdominal injuries resulted in most deaths, while head injuries was the primary reason for deaths in Group 2.

Conclusions

Although the ISS and NISS were similar, mortality was significantly higher among patients aged ≥ 65 years compared to patients < 65 years of age. The younger age group underwent more frequently surgery for orthopaedic injuries than the elderly. There may be multiple reasons for this difference, but our study does not have sufficient data to draw any conclusions. Future studies may provide a deeper understanding of what causes treatment variation between age groups, which would hopefully help to further develop strategies to improve outcome for the elderly polytrauma patient.

Trauma Care Training in Vietnam: Narrative Scoping Review

BACKGROUND

The model of trauma in Vietnam has changed significantly over the last decade and requires reforming medical education to deal with new circumstances. Our aim is to evaluate this transition regarding the new target by analyzing trauma and the medical training system as a whole.

OBJECTIVE

This study aimed to establish if medical training in the developing country of Vietnam has adapted to the new disease pattern of road trauma emerging in its economy.

METHODS

A review was performed of Vietnamese medical school, Ministry of Health, and Ministry of Education and Training literature on trauma education. The review process and final review paper were prepared following the guidelines on scoping reviews and using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart.

RESULTS

The current trauma training at the undergraduate level is minimal and involves less than 5% of the total credit. At the postgraduate level, only the specialties of surgery and anesthesia have a significant and increasing trauma training component ranging from 8% to 22% in the content. Trauma training, which focuses on practical skills, accounts for 31% and 32% of the training time of orientation courses for young doctors in "basic surgery" and "basic anesthesia," respectively. Other relevant short course trainings, such as continuing medical education, in trauma are available, but they vary in topics, facilitators, participants, and formats.

CONCLUSIONS

Medical training in Vietnam has not adapted to the new emerging disease pattern of road trauma. In the interim, the implementation of short courses, such as basic trauma life support and primary trauma care, can be considered as an appropriate method to compensate for the insufficient competency-related trauma care among health care workers while waiting for the effectiveness of medical training reformation.

Incidence, Mechanisms of Injury and Mortality of Severe Traumatic Brain Injury: An Observational Population-Based Cohort Study from New Zealand and Norway

BACKGROUND

Comparing trauma registry data from different countries can help to identify possible differences in epidemiology, which may help to improve the care of trauma patients.

METHODS

This study directly compares the incidence, mechanisms of injuries and mortality of severe TBI based on population-based data from the two national trauma registries from New Zealand and Norway. All patients prospectively registered with severe TBI in either of the national registries for the 4-year study period were included. Patient and injury variables were described and age-adjusted incidence and mortality rates were calculated.

RESULTS

A total of 1378 trauma patients were identified of whom 751 (54.5%) from New Zealand and 627 (45.5%) from Norway. The patient cohort from New Zealand was significantly younger (median 32 versus 53 years; p < 0.001) and more patients from New Zealand were injured in road traffic crashes (37% versus 13%; p < 0.001). The age-adjusted incidence rate of severe TBI was 3.8 per 100,000 in New Zealand and 2.9 per 100,000 in Norway. The age-adjusted mortality rates were 1.5 per 100,000 in New Zealand and 1.2 per 100,000 in Norway. The fatality rates were 38.5% in New Zealand and 34.2% in Norway (p = 0.112).

CONCLUSIONS

Road traffic crashes in younger patients were more common in New Zealand whereas falls in elderly patients were the main cause for severe TBI in Norway. The age-adjusted incidence and mortality rates of severe TBI among trauma patients are similar in New Zealand and Norway. The fatality rates of severe TBI are still considerable with more than one third of patients dying.

Epidemiology of geriatric trauma patients in Norway: A nationwide analysis of Norwegian Trauma Registry data, 2015-2018. A retrospective cohort study

INTRODUCTION

Geriatric patients have a high risk of poor outcomes after trauma and is a rapid-increasing group within the trauma population. Given the need to ensure that the trauma system is targeted, efficient, accessible, safe and responsive to all age groups the aim of the present study was to explore the epidemiology and characteristics of the Norwegian geriatric trauma population and assess differences between age groups within a national trauma system.

MATERIALS AND METHODS

This retrospective analysis is based on data from the Norwegian Trauma Registry (2015-2018). Injury severity was scaled using the Abbreviated Injury Scale (AIS), and the New Injury Severity Score (NISS). Trauma patients 16 years or older with NISS ≥9 were included, dichotomized into age groups 16-64 years (Group 1, G1) and ≥65 years (Group 2, G2). The groups were compared with respect to differences in demographics, injury characteristics, management and outcome. Descriptive statistics and relevant parametric and non-parametric tests were used.

RESULTS

Geriatric patients proved to be at risk of sustaining severe injuries. Low-energy falls predominated in G2, and the AIS body regions 'Head' and 'Pelvis and lower extremities' were most frequently injured. Crude 30-day mortality was higher in G2 compared to G1 (G1: 2.9 vs. G2: 13.6%, P<0.01) and the trauma team activation (TTA) rate was lower (G1: 90 vs. G2: 73%, P<0.01). A lower proportion of geriatric patients were treated by a physician prehospitally (G1: 30 vs. G2: 18%, [NISS 15-24], P<0.01) and transported by air-ambulance (G1: 24 vs. G2: 14%, [NISS 15-24], P<0.01). Median time from alarm to hospital admission was longer for geriatric patients (G1: 71 vs. G2: 78 min [NISS 15-24], P<0.01), except for the most severely injured patients (NISS≥25).

CONCLUSION

In this nationwide study comparing adult and geriatric trauma patients, geriatric patients were found to have a higher mortality, receive less frequently advanced prehospital treatment and transportation, and a lower TTA rate. This is surprising in the setting of a Nordic country with free access to publicly funded emergency services, a nationally implemented trauma system with requirements to pre- and in-hospital services and a national trauma registry with high individual level coverage from all trauma-receiving hospitals. Further exploration and a deeper understanding of these differences is warranted.