Rethinking the tiered trauma team response: A case-series study in a regional trauma centre

OBJECTIVE

To reduce perceived unnecessary resource use, we modified our tiered trauma response. If a patient was not physiologically compromised, surgical registrar attendance was not mandated. We investigated the effect of this change on missed injury, unplanned representation to ED, diagnostic imaging rates and staff satisfaction.

METHODS

A retrospective case series study assessing the 3-month period before and after the intervention was conducted. Logistic regression analyses were used to examine the association between ordering of computerised tomography (CT) and ED length of stay (LOS), injury severity (ISS), age, surgical review and admission. A staff survey was conducted to investigate staff perceptions of the practice change. Free text data were analysed using inductive content analysis.

RESULTS

There were 105 patients in the control and 166 in the intervention group and their mean (SD) ISS was the same (ISS [SD] = 4 [±4] [P = 0.608]). A higher proportion of the control group were admitted (56.3% vs 42.2% [P = 0.032]) and they had a shorter ED LOS (274 min [202-456] vs 326 min [225-560], P = 0.044). The rate of missed injury was unchanged. A surgical review resulted in a 26-fold increase in receipt of a whole-body CT scan (odds ratio = 26.89, 95% confidence interval = 3.31-218.17). Just over half of survey respondents felt the change was safe (54.4%), and more surgical (90%) than ED staff (69%) reported the change as positive.

CONCLUSION

The removal of the surgical registrar from the initial trauma standby response did not result in any adverse events, reduced admissions, pathology and imaging, but resulted in an increased ED LOS and time to surgical review.

Stress-Induced (Not Diabetic) Hyperglycemia is Associated With Mortality in Geriatric Trauma Patients

INTRODUCTION

Stress-induced hyperglycemia (SIH) is associated with worse outcomes among trauma patients. It is also known that injured geriatric patients have higher mortality when compared to younger patients. We sought to investigate the association of all levels of SIH with mortality among geriatric trauma patients at a level 1 academic trauma center. We hypothesized that SIH in the geriatric trauma population would be associated with increased mortality.

METHODS

A retrospective review of all geriatric patients admitted to our level 1 trauma center over a 3-year period (January 2018-December 2020) was performed using the institutional trauma database. Data collected included demographics, injury severity score (ISS), emergency department (ED) blood glucose level, ED systolic blood pressure (SBP), and mortality. Patients were divided into 4 groups based on emergency room blood glucose level, as follows: normoglycemic (<120 mg/dL), mild hyperglycemia (120-150 mg/dL), moderate hyperglycemia (151-199 mg/dL), and severe hyperglycemia (≥200 mg/dL). Multivariable logistic regression analysis was performed to evaluate the association of SIH and in-hospital mortality adjusting for ISS, age, comorbidities, and ED SBP.

RESULTS

A total of 4432 geriatric trauma patients were admitted during the study period, of which 3358 patients (75.8%) were not diabetic. There were 2206 females (65.7%), 2993 were White (89.2%), with a mean age of 81.5 y. There were 114 deaths (3.4%). Univariate results showed that there was a statistically significant association between mortality and glucose groups (P < 0.01). The number of deaths in the four glucose groups were, as follows: 30 (2.0%), 32 (3.8%), 20 (6.2%), and 10 (12.2%), respectively. Multivariable logistic regression analysis results showed that compared to the normoglycemic group, the risk of death was higher in the mild, moderate, and severe glucose groups, as follows: mild group (OR 1.80, 95% confidence interval [CI] 1.04-3.13, P 0.04), moderate group (OR 2.53, 95% CI 1.34-4.80, P < 0.01), and severe group (OR 5.04, 95% CI 2.18-11.67, P < 0.01).

CONCLUSIONS

Mild, moderate, and severe SIH are statistically significant predictors of death among geriatric trauma patients independently of ISS, age, comorbidities, and SBP.

Experiences of medical practitioners in the Australian Defence Force on live tissue trauma training

INTRODUCTION

Care of battle casualties is a central role of military medical practitioners. Historically, certain trauma procedural skills have been learnt through live tissue training. However, faced with opposition from community members and academics, who argue equivalence of non-animal alternatives, this is now being phased out. This study explores Australian military medical practitioners' experiences of and attitudes towards live tissue training.

METHOD

We performed a phenomenologically driven qualitative exploration of individuals' experiences of live tissue trauma training. 32 medical officers volunteered for the study. In-depth interviews were conducted with 15 practitioners (60% Army, 20% Air Force, 20% Navy; 33% surgical, 53% critical care, 13% general practice). Qualitative data were subjected to content analysis, with key themes identified using manual and computer-assisted coding.

RESULTS

Live tissue training was valued by military medical practitioners, particularly because of the realistic feel of tissues and physiological responsiveness to treatment. Learner-perceived value of live tissue training was higher for complex skills and those requiring delicate tissue handling. 100% of surgeons and critical care doctors regarded live tissue as the only suitable model for learning repair of penetrating cardiac injury. Live tissue training was felt to enhance self-efficacy, particularly for rarely applied skills. Though conscious of the social and ethical context of live tissue training, >90% of participants reported positive emotional responses to live tissue training.

CONCLUSION

In contrast to published research, live tissue training was thought by participants to possess characteristics that are not yet replicable using alternative learning aids. The experienced positive values of live tissue training should inform the decision to move towards non-animal alternatives.

Outcomes in traumatic cardiac arrest patients who underwent advanced life support

OBJECTIVE

Survival following a traumatic cardiac arrest (TCA) remains poor despite research focused on specific management and guideline adaptation. Previous research has identified factors including age, arresting rhythm, injury severity and distance from hospital to be associated with prehospital TCA outcomes. The present study aimed to review the local incidence of TCA to inform local practice within a mature trauma system.

METHODS

A retrospective trauma database review from 2008 to 2021 was conducted at the Royal Brisbane and Women's Hospital. Patients were categorised by prehospital and in-hospital arrest, prehospital return of spontaneous circulation (ROSC), and year in relation to TCA management protocol changes. Descriptive comparative analysis was performed with the primary outcome of interest being survival to hospital discharge.

RESULTS

Survival to hospital discharge was similar in patients in whom TCA occurred in the prehospital environment and hospital (24 vs 29%). Mechanism of injury, response to intervention and location of cardiac arrest were important outcome associations. Patients with a positive focused assessment with sonography in trauma scan were less likely to achieve ROSC but more likely to survive to discharge. The frequency of prehospital interventions remained similar after the guideline changes; with more patients arriving to the hospital with improved haemodynamic parameters and increased survival.

CONCLUSIONS

These results support the identification and immediate management of TCA. No patients survived if they did not achieve ROSC by hospital arrival, questioning the role for aggressive management beyond the ED in this cohort. Future research will focus on the identification of patients with potentially positive survival outcomes and further define futile intervention factors.

Impact of comorbidities on survival following major injury across different types of road users

BACKGROUND

While comorbidities and types of road users are known to influence survival in people hospitalised with injury, few studies have examined the association between comorbidities and survival in people injured in road traffic crashes. Further, few studies have examined outcomes across different types of road users with different types of pre-existing comorbidities. This study aims to examine differences in survival within 30 days of admission among different road user types with and without different pre-existing comorbidities.

METHOD

Retrospective cohort study using data for all major road trauma cases were extracted from the NSW Trauma Registry Minimum Dataset (1 January 2013 - 31 July 2019) and linked to the NSW Admitted Patient Data Collection, and the NSW Registry of Births, Deaths and Marriages - death dataset. Pre-existing comorbidities and road user types were identified by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and Charlson Comorbidity Index in the Trauma Registry, hospital admission, and death datasets. Logistic regression was used to assess the associations between six types of road users (pedestrian, pedal cycle, two- and three-wheel motorcycle, car and pick-up truck, heavy vehicle and bus, and other types of vehicle) and death within 30 days of hospital admission while controlling for comorbidities. All models used 'car and pick-up truck driver/passenger' as the road user reference group and adjusted for demographic variables, injury severity, and level of impaired consciousness.

RESULTS

Within 6253 traffic injury person-records (all aged ≥15 years old, ISS>12), and in final models, injured road users with major trauma who had a history of cardiovascular diseases (including stroke), diabetes mellitus, and higher Charlson Comorbidity Index score, were more likely to die, than those without pre-existing comorbidities. Furthermore, in final models, pedestrians were more likely to die than car occupants (OR: 1.68 - 1.77, 95CI%: 1.26 - 2.29 depending on comorbidity type).

CONCLUSIONS

This study highlights the need to prioritize enhanced management of trauma patients with comorbidities, given the increasing prevalence of chronic medical conditions globally, together with actions to prevent pedestrian crashes in strategies to reach Vision Zero.

Disadvantaged by More Than Distance: A Systematic Literature Review of Injury in Rural Australia

Rural populations experience injury-related mortality and morbidity rates 1.5 times greater than metropolitan residents. Motivated by a call for stronger epidemiological evidence around rural injuries to inform prevention, a systematic review of peer-reviewed literature published between January 2010 and March 2021 was undertaken to explore the epidemiology of rural injury and associated risk factors in Australia. A subsequent aim was to explore definitions of rurality used in injury prevention studies. There were 151 papers included in the review, utilizing 23 unique definitions to describe rurality. People living in rural areas were more likely to be injured, for injuries to be more severe, and for injuries to have greater resulting morbidity than people in metropolitan areas. The increase in severity reflects the mechanism of rural injury, with rural injury events more likely to involve a higher energy exchange. Risk-taking behavior and alcohol consumption were significant risk factors for rural injury, along with rural cluster demographics such as age, sex, high socio-economic disadvantage, and health-related comorbidities. As injury in rural populations is multifactorial and nonhomogeneous, a wide variety of evidence-based strategies are needed. This requires funding, political leadership for policy formation and development, and implementation of evidence-based prevention interventions.

The effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis

BACKGROUND

Traumatic injury remains the leading cause of death, with more than five million deaths every year. Little is known about the comparative effectiveness in reducing mortality of trauma care systems at different stages of development. The objective of this study was to review the literature and examine differences in mortality associated with different stages of trauma system development.

METHOD

A systematic review of peer-reviewed population-based studies retrieved from MEDLINE, EMBASE, and CINAHL. Additional studies were identified from references of articles, through database searching, and author lists. Articles written in English and published between 2000 and 2020 were included. Selection of studies, data extraction, and quality assessment of the included studies were performed by two independent reviewers. The results were reported as odds ratio (OR) with 95 % confidence intervals (CI).

RESULTS

A total of 52 studies with a combined 1,106,431 traumatic injury patients were included for quantitative analysis. The overall mortality rate was 6.77% (n = 74,930). When patients were treated in a non-trauma centre compared to a trauma centre, the pooled statistical odds of mortality were reduced (OR 0.74 [95% CI 0.69-0.79]; p < 0.001). When patients were treated in a non-trauma system compared to a trauma system the odds of mortality rates increased (OR 1.17 [95% CI 1.10-1.24]; p < 0.001). When patients were treated in a post-implementation/initial system compared to a mature system, odds of mortality were significantly higher (OR 1.46 [95% CI 1.37-1.55]; p < 0.001).

CONCLUSION

The present study highlights that the survival of traumatic injured patients varies according to the stage of trauma system development in which the patient was treated. The analysis indicates a significant reduction in mortality following the introduction of the trauma system which is further enhanced as the system matures. These results provide evidence to support efforts to, firstly, implement trauma systems in countries currently without and, secondly, to enhance existing systems by investing in system development.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019142842 .

Characteristics and Outcomes of Critically Ill Trauma Patients in Australia and New Zealand (2005-2017)

OBJECTIVES

To compare the characteristics of adults admitted to the ICU in Australia and New Zealand after trauma with nonelective, nontrauma admissions. To describe trends in hospital mortality and rates of discharge home among these two groups.

DESIGN

Retrospective review (2005-2017) of the Australia and New Zealand Intensive Care Society's Center for Outcome and Resource Evaluation Adult Patient Database.

SETTING

Adult ICUs in Australia and New Zealand.

PATIENTS

Adult (≥17 yr), nonelective, ICU admissions.

INTERVENTION

Observational study.

MEASUREMENTS AND MAIN RESULTS

We compared 77,002 trauma with 741,829 nonelective, nontrauma patients. Trauma patients were younger (49.0 ± 21.6 vs 60.6 ± 18.7 yr; p < 0.0001), predominantly male (73.1% vs 53.9%; p < 0.0001), and more frequently treated in tertiary hospitals (74.7% vs 45.8%; p < 0.0001). The mean age of trauma patients increased over time but was virtually static for nonelective, nontrauma patients (0.72 ± 0.02 yr/yr vs 0.03 ± 0.01 yr/yr; p < 0.0001). Illness severity increased for trauma but fell for nonelective, nontrauma patients (mean Australia and New Zealand risk of death: 0.10% ± 0.02%/yr vs -0.21% ± 0.01%/yr; p < 0.0001). Trauma patients had a lower hospital mortality than nonelective, nontrauma patients (10.0% vs 15.8%; p < 0.0001). Both groups showed an annual decline in the illness severity adjusted odds ratio (odds ratio) of hospital mortality, but this was slower among trauma patients (trauma: odds ratio 0.976/yr [0.968-0.984/yr; p < 0.0001]; nonelective, nontrauma: odds ratio 0.957/yr [0.955-0.959/yr; p < 0.0001]; interaction p < 0.0001). Trauma patients had lower rates of discharge home than nonelective, nontrauma patients (56.7% vs 64.6%; p < 0.0001). There was an annual decline in illness severity adjusted odds ratio of discharge home among trauma patients, whereas nonelective, nontrauma patients displayed an annual increase (trauma: odds ratio 0.986/yr [0.981-0.990/yr; p < 0.0001]; nonelective, nontrauma: odds ratio 1.014/yr [1.012-1.016/yr; p < 0.0001]; interaction: p < 0.0001).

CONCLUSIONS

The age and illness severity of adult ICU trauma patients in Australia and New Zealand has increased over time. Hospital mortality is lower for trauma than other nonelective ICU patients but has fallen more slowly. Trauma patients have become less likely to be discharged home than other nonelective ICU patients.

Vascular injury-related in-hospital mortality in Ontario between 1991 and 2009

OBJECTIVE

Trauma-related vascular injuries are major contributors to morbidity and mortality worldwide. We conducted a retrospective, population-based, cross-sectional study to examine temporal trends and factors associated with traumatic vascular injury-related in-hospital mortality in Ontario, Canada from 1991 to 2009.

METHODS

We obtained data on Ontario hospital admissions for traumatic vascular injury, including injury mechanism and body region; and patient age, sex, socioeconomic status, and residence from the Canadian Institute for Health Information Discharge Abstract Database and Registered Persons Database from fiscal years 1991 to 2009. We performed time series analysis of vascular injury-related in-hospital mortality rates and multivariable logistic regression analysis to identify significant mortality-associated factors.

RESULTS

The overall in-hospital mortality rate for trauma-related vascular injury was 5.5%. A slight but non-significant decline in mortality occurred over time. The likelihood of vascular injury-related in-hospital mortality was significantly higher for patients involved in transport-related accidents (odds ratio [OR[=2.21, 95% confidence interval [CI], 1.76-2.76), age ≥65 years (OR = 4.34, 95% CI, 2.25-8.38), or with thoracic (OR = 2.24, 95% CI, 1.56-3.20) or abdominal (OR = 2.45, 95% CI, 1.75-3.42) injuries.

CONCLUSIONS

In-hospital mortality from traumatic vascular injury in Ontario was low and stable from 1991 to 2009.

Clinical Features and Required Aids of Transferred Severe Trauma Patients

Background

It is crucial to identify the pivotal factors for transferring patients with major trauma. We aim to delineate the clinical features and required aids of severe trauma patients and identify the differences between those who were admitted directly to a trauma center and those transferred from other hospitals.

Methods

We retrospectively reviewed all hospitalized trauma patients discharged from the ward in Chi-Mei Medical Center from January 1, 2017 to December 31, 2018. Of 5,846 patients, we identified 1,061 patients with Injury Severity Score >15, of which 92 patients were transferred from two branch hospitals (branch group), 172 patients were transferred from other hospitals (other group), and 797 patients were admitted directly through the emergency department (control group). We compared the clinical variables between control and the other two groups.

Results

The branch group included a high proportion of pediatric patients (control: 1.8%, other: 2.3%, and branch: 6.5%). The branch group demonstrated higher requirements for life-saving interventions and arterial embolization (branch vs. control, life-saving interventions: 26.1% vs. 17.6%, p = 0.046; arterial embolization: 9.8% vs. 3.5%, p = 0.004). However, no statistically significant differences were observed between the control group and other group in terms of requirements of life-saving interventions. The prognoses were similar between the groups.

Conclusions

Our trauma center can provide pediatric trauma care and timely life-saving interventions to help severe trauma patients transferred from other hospitals. The branch hospitals benefit mostly from the aid. Better network connection and information sharing between hospitals might play crucial roles in the management of transferred severe trauma patients.

Emergency trauma care in rural and remote settings: Challenges and patient outcomes

INTRODUCTION

Trauma is a global public health concern, with higher mortality rates acknowledged in rural and remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary objective of this integrative literature review was to examine the challenges associated with providing emergency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective was to explore strategies to improve trauma patient outcomes.

METHODS

An integrative review approach was used to inform the methods of this study. A systematic search of databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other search methods included hand searching journal references.

RESULTS

2157 articles were identified for screening and 87 additional papers were located by hand searching. Of these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique challenges in the provision of emergency trauma care such as large distances, delays transferring patients to definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors, weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural and remote populations often experience higher mortality rates in comparison to urban populations although this may be different for specific mechanisms of injury or population subsets. While an increased risk of death was associated with an increase in remoteness, research also found it costs substantially less to provide care to rural patients in their rural environment than their urban counterparts. Other factors found to influence mortality rates were severity of injury and differences in characteristics between rural and urban populations. Trauma systems vary around the world and must address local issues that may be affected by distance, geography, seasonal population variations, specific population risk factors, trauma network operationalisation, referral and retrieval and involvement of hospitals and services which have no trauma designation.

CONCLUSIONS

The challenges acknowledged for rural and remote trauma patients may be lessened and mortality rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma systems that are responsive to local needs and resources. Additional research to determine which of these challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve this.

Factors influencing vehicle passenger fatality have changed over 10 years: a nationwide hospital-based study

Traffic injury trends have changed with safety developments. To establish effective preventive measures against traffic fatalities, the factors influencing fatalities must be understood. The present study evaluated data from a national medical database to determine the changes in these factors over time, as this has not been previously investigated. This observational study retrospectively analysed data from the Japanese Trauma Data Bank. Vehicle passengers involved in collisions from 2004–2008 and 2016–2017 were included. Data were compared between the two study periods, and between fatal and non-fatal patients within each period. Multivariate logistic regression analyses were performed to determine the factors influencing fatalities. In 2016–2017, patients were older and had lower fatality rates. In 2004–2008, fatalities were more likely to involve older male front-seat passengers with low d-BP, BT, and GCS values, and high AIS of the neck and abdomen. However, in 2016–2017, fatalities were more likely to involve older males with low GCS, high AIS of the abdomen, and positive focused assessment with sonography for trauma results. Our study identified independent factors influencing vehicle passenger fatalities, which will likely continue to evolve with the aging of the population and changing manners of injury.

Five-Year Forecasting Deaths Caused by Traffic Accidents in Fars Province of Iran

Objective:

The aim of study was to conduct a time-based analysis to utilize the obtained knowledge for forecasting the trend of accidents in the future.

Methods:

The present study, which was conducted as a cross-sectional research, investigated deaths from traffic accidents in Fars Province during a five-year period from 2013 to 2018. The pseudo-regression model of Spline was used to predict the increase in mortality rate by 2021.

Results:

The forecasted values indicated a decline in deaths from traffic accidents by 2021. A total of 8020 records of accidents leading to death were included in the study. The mean mortality rate from traffic accidents in the province was approximately estimated to be 33.7 per 100,000 populations. More than half of the people who died (52.36%) were in a car, 25.57% were motorcycle riders, and 19.93% were pedestrians. The highest rate of deaths was observed in the age group of 16 to 25 years old (21.5%). The data indicated a reduction in the rate of death among car riders and pedestrians and an increase in the number of deaths among motorcycle riders. The trend of deaths occurred outside the city had been increasing while the trend of deaths occurred inside the city had been decreasing.

Conclusion:

The present regulations are only able to reduce a small number of deaths each year. In order to achieve a downward trend in mortality with a steeper pace, it is necessary to design and implement more intelligent standards, not merely the stricter ones.

Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical, system and human factors peer-review tool

BACKGROUND

There is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents.

METHODS

Medical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of ≥9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus.

RESULTS

A total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2-12) years, the median ISS was 25 (IQR 16-30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%).

CONCLUSION

The peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.

Biomarkers of autonomic regulation for predicting psychological distress and functional recovery following road traffic injuries: protocol for a prospective cohort study

INTRODUCTION

Psychological distress is a prevalent condition often overlooked following a motor vehicle crash (MVC), particularly when injuries are not severe. The aim of this study is to examine whether biomarkers of autonomic regulation alone or in combination with other factors assessed shortly after MVC could predict risk of elevated psychological distress and poor functional recovery in the long term, and clarify links between mental and physical health consequences of traffic injury.

METHODS AND ANALYSIS

This is a controlled longitudinal cohort study, with follow-up occurring at 3, 6 and 12 months. Participants include up to 120 mild to moderately injured MVC survivors who consecutively present to the emergency departments of two hospitals in Sydney and who agree to participate, and a group of up to 120 non-MVC controls, recruited with matched demographic characteristics, for comparison. WHO International Classification of Functioning is used as the framework for study assessment. The primary outcomes are the development of psychological distress (depressive mood and anxiety, post-traumatic stress symptoms, driving phobia, adjustment disorder) and biomarkers of autonomic regulation. Secondary outcomes include indicators of physical health (presence of pain/fatigue, physical functioning) and functional recovery (quality of life, return to function, participation) as well as measures of emotional and cognitive functioning. For each outcome, risk will be described by the frequency of occurrence over the 12 months, and pathways determined via latent class mixture growth modelling. Regression models will be used to identify best predictors/biomarkers and to study associations between mental and physical health.

ETHICS AND DISSEMINATION

Ethical approvals were obtained from the Sydney Local Health District and the research sites Ethics Committees. Study findings will be disseminated to health professionals, related policy makers and the community through peer-reviewed journals, conference presentations and health forums.

TRIAL REGISTRATION NUMBER

ACTRN12616001445460.

Improving emergency department trauma care in Fiji: Implementing and assessing the trauma call system

OBJECTIVE

The trauma team process was recently implemented at the Colonial War Memorial (CWM) Hospital, Suva. This study audits the trauma call procedure at the hospital over a period of 12 months.

METHOD

Retrospective descriptive study of trauma calls from August 2015 to July 2016 at CWM Hospital. Data relating to patient demographics, time of presentation, time to team assembly and time to computed tomography (CT) scan were extracted from the ED trauma call database. Disposition from the ED and status at hospital discharge was extracted from the hospital patient information system.

RESULTS

There were 38 trauma calls for 46 patients. Seventy-two per cent were male. Eighty-two per cent occurred when the CT radiographer was off site (16.00-08.00 h), including 47% that occurred between midnight and 08.00 h. Fifty-two per cent of patients were intubated, 43% went to ICU, 26% went directly to the operating theatre, and 37% died. Benchmarks for time to trauma team assembly and time to CT scan were met in 50% of cases.

CONCLUSION

This was a severely injured cohort of patients with a high mortality rate. The rate of missed calls was not assessed in this study. Time to CT scan could be improved with an onsite radiographer. Time to team assembly could be improved with trauma team training and early notification from pre-hospital providers. There is a need to continue to monitor and refine the trauma call process and to extend data capture to measure injury severity and outcomes.

External benchmarking of trauma services in New South Wales: Risk-adjusted mortality after moderate to severe injury from 2012 to 2016

BACKGROUND

Trauma centres and systems have been associated with improved morbidity and mortality after injury. However, variability in outcomes across centres within a given system have been demonstrated. Performance improvement initiatives, that utilize external benchmarking as the backbone, have demonstrated system-wide improvements in outcomes. This data driven approach has been lacking in Australia to date. Recent improvement in local data quality may provide the opportunity to engage in data driven performance improvement. Our objective was to generate risk-adjusted outcomes for the purpose of external benchmarking of trauma services in New South Wales (NSW) based on existing data standards.

METHODS

Retrospective cohort study of the NSW Trauma Registry. We included adults (>16 years), with an Injury Severity Score >12, that received definitive care at either Major Trauma Services (MTS) or Regional Trauma Services (RTS) between 2012-2016. Hierarchical logistic regression models were then used to generate risk-adjusted outcomes. Our outcome measure was in-hospital death. Demographics, vital signs, transfer status, survival risk ratios, and injury characteristics were included as fixed-effects. Median odds ratios (MOR) and centre-specific odds ratios with 95% confidence intervals were generated. Centre-level variables were explored as sources of variability in outcomes.

RESULTS

14,452 patients received definitive care at one of seven MTS (n = 12,547) or ten RTS (n = 1905). Unadjusted mortality was lower at MTS (9.4%) compared to RTS (11.2%). After adjusting for case-mix, the MOR was 1.33, suggesting that the odds of death was 1.33-fold greater if a patient was admitted to a randomly selected centre with worse as opposed to better risk-adjusted mortality. Definitive care at an MTS was associated with a 41% lower likelihood of death compared to definitive care at an RTS (OR 0.59 95%CI 0.35-0.97). Similar findings were present in the elderly and isolated severe brain injury subgroups.

CONCLUSIONS

The NSW trauma system exhibited variability in risk-adjusted outcomes that did not appear to be explained by case-mix. A better understanding of the drivers of the described variation in outcomes is crucial to design targeted locally-relevant quality improvement interventions.

Epidemiology of trauma patients attended by ambulance paramedics in Perth, Western Australia

OBJECTIVE

The aim of the study was to describe the epidemiology of trauma in adult patients attended by ambulance paramedics in Perth, Western Australia.

METHODS

A retrospective cohort study of trauma patients aged ≥16 years attended by St John Ambulance Western Australia (SJA-WA) paramedics in greater metropolitan Perth between 2013 and 2016 using the SJA-WA database and WA death data. Incidence and 30 day mortality rates were calculated. Patients who died prehospital (immediate deaths), on the day of injury (early deaths), within 30 days (late deaths) and those who survived longer than 30 days (survivors) were compared for age, sex, mechanism of injury and acuity level. Prehospital interventions were also reported.

RESULTS

Overall, 97 724 cases were included. A statistically significant increase in the incidence rate occurred over the study period (from 1466 to 1623 per 100 000 population year P ≤ 0.001). There were 2183 deaths within 30 days (n = 2183/97 724, 2.2%). Motor vehicle accidents were responsible for most immediate and early deaths (n = 98/203, 48.3% and n = 72/156, 46.2%, respectively). The majority of transported patients were low acuity (acuity levels 3 to 5, n = 60 594/79 887, 75.8%) and high-acuity patients accounted for 2.7% (n = 2176/79 997). Analgesia administration was the most frequently performed intervention (n = 32 333/80 643, 40.1%), followed by insertion of intravenous catheters (n = 25 060/80 643, 31.1%). Advanced life support interventions such as endotracheal intubation were performed in <1% of patients.

CONCLUSION

The trauma incidence rate increased over time and the majority of patients had low-acuity injuries. Focusing research, training and resources solely on high-acuity patients will not cater for the needs of the majority of patients.

Ten-year inhospital mortality trends for patients with trauma in Japan: a multicentre observational study

OBJECTIVES

Trauma is one of the main causes of death in Japan, and treatments and prognoses of these injuries are constantly changing. We therefore aimed to investigate a 10-year trend (2004-2013) in inhospital mortality among patients with trauma in Japan.

DESIGN

Multicentre observational study.

SETTING

Japanese nationwide trauma registry (the Japan Trauma Data Bank) data.

PARTICIPANTS

All patients with trauma whose Injury Severity Score (ISS) were 3 and above, who were aged 15 years or older, and whose mechanisms of injury (MOI) were blunt and penetrating between 2004 and 2013 (n=90 833).

OUTCOME MEASURES

A 10-year trend in inhospital mortality.

RESULTS

Inhospital mortality for all patients with trauma significantly decreased over the study decade in our Cochran-Armitage test (P<0.001). Similarly, inhospital mortality for patients with ISS 16 or more and patients who scored 50% or better on the Trauma and Injury Severity Score (TRISS) probability of survival scale significantly decreased (P<0.001). In addition, the OR for inhospital mortality of these three patient groups decreased yearly after adjusting for age, gender, MOI, ISS, Glasgow Coma Scale, systolic blood pressure and respiratory rate on hospital arrival in multivariable logistic regression analyses. Furthermore, inhospital mortality for patient with blunt trauma significantly decreased in injury mechanism-stratified Mantel-extension testing (P<0.001). Finally, multivariable logistic regression analyses showed that the OR for inhospital mortality of patients with ISS 16 and over decreased each year after adding and adjusting for means of transportation and usage of whole-body CT.

CONCLUSION

Inhospital mortality for patients with trauma in Japan significantly decreased during the study decade after adjusting for patient characteristics, injury severity and the response environment after injury.

The experience and understanding of pain management in recently discharged adult trauma patients: A qualitative study

INTRODUCTION

Pain following injury is often intense, prolonged and debilitating. If poorly managed, this acute pain has the potential to delay rehabilitation and lead to chronic pain. Recent quantitative Australian research recommends implementing further information and interventions to improve trauma patient outcomes, however, to ensure effectiveness, exploration of the patient perspective is imperative to ensure the success of future pain management strategies. This study aimed to gain understanding about the experience of pain management using prescribed analgesic regimens of recently discharged adult trauma patients.

METHOD

Semi-structured interviews were used to explore the experiences and understandings of trauma patients in managing pain using prescribed analgesic regimens during the initial post-hospital discharge period. Twelve participants were purposively selected over a 6-month period at a level one trauma outpatient clinic based on questionnaire responses indicating pain related concerns. Qualitative data were thematically analysed.

RESULTS

The overarching finding was that injuries and inadequate pain management incapacitate the patient at home. Four main themes were developed: injury pain is unique and debilitating; patients are uninformed at hospital discharge; patients have low confidence with pain management at home; and patients make independent decisions about pain management. Patients felt they were not given adequate information at hospital discharge to support them to make effective decisions about their pain management practices at home.

CONCLUSION

There is a need for more inclusive and improved hospital discharge processes that includes patient and family education around pain management following injury. To achieve this, clinician education, support and training is essential.

Incidence, Intensity, and Impact of Pain in Recently Discharged Adult Trauma Patients: An Exploratory Study

The long-term implications of pain following injury are well known; however, the immediate posthospitalization incidence and impact of pain is less understood. Inadequate pain relief during this time can delay return to work, leading to psychological stress and chronic pain. This exploratory study aimed to identify the incidence, intensity, and impact of injury-related pain in recently discharged adult trauma patients. During July to December 2014, 82 recently discharged adult trauma patients completed a questionnaire about their injury-related pain experience approximately 2 weeks posthospital discharge from a Level 1 trauma center. The questionnaire was developed using the Brief Pain Inventory, assessing severity, and impact of pain through a score from 0 to 10. The average age of participants was 52 years, the median Injury Severity Score was 6, and almost all (n = 80, 98%) experienced a blunt injury. The majority of participants reported pain since discharge (n = 80, 98%), with 65 (81%) still experiencing pain on the day of data collection. Normal work was most affected by pain, with an average score of 6.6 of 10, closely followed by effect on general activity (6.1 of 10) and enjoyment of life (5.7 of 10). The highest pain severity was reported by those with injuries from road trauma, with low Injury Severity Scores, who were female, and did not speak English at home. Pain in the recently discharged adult trauma patient is common, intense and interferes with quality of life. Identification of barriers to effective pain management and interventions to address these barriers are required.

Does prehospital management by doctors affect outcome in major trauma? A systematic review

BACKGROUND

There is substantial variation worldwide in prehospital management of trauma and the role of doctors is controversial. The objective of this review was to determine whether prehospital management by doctors affects outcomes in major trauma, including the prespecified subgroup of severe traumatic brain injuries when compared with management by other advanced life support providers.

METHODS

EMBASE, MEDLINE(R), PubMed, SciELO, Trip, Web of Science, and Zetoc were searched for published articles. HSRProj, OpenGrey, and the World Health Organization International Clinical Trials Registry Platform were searched for unpublished data. Relevant reference lists were hand-searched. There were no limits on publication year, but articles were limited to the English language. Authors were contacted for further information as required. Quality was assessed using the Downs and Black criteria. Mortality was the primary outcome, and disability was the secondary outcome of interest. Studies were subjected to a descriptive analysis alone without a meta-analysis due to significant study heterogeneity. All searches, quality assessment, data abstraction, and data analysis was performed by two reviewers independently.

RESULTS

Two thousand thirty-seven articles were identified, 49 full-text articles assessed and eight studies included. The included studies consisted of one randomized controlled trial with 375 participants and seven observational studies with over 4,451 participants. All included studies were at a moderate to high risk of bias. Six of the eight included studies showed an improved outcome with prehospital management by doctors, five in terms of mortality and one in terms of disability. Two studies found no significant difference.

CONCLUSION

There appears to be an association between prehospital management by doctors and improved survival in major trauma. There may also be an association with improved survival and better functional outcomes in severe traumatic brain injury. Further high-quality evidence is needed to confirm these findings.

LEVEL OF EVIDENCE

Systematic review, level III.

Deaths caused by injury among people of working age (18-64) are decreasing, while those among older people (64+) are increasing

Background

Injury is an important cause of death in all age groups worldwide, and contributes to many losses of human and economic resources. Currently, we know a few data about mortality from injury, particularly among the working population. The aim of the present study was to examine death from injury over a period of 14 years (1999–2012) using the Swedish Cause of Death Registry (CDR) and the National Patient Registry, which have complete national coverage.

Method

CDR was used to identify injury-related deaths among adults (18 years or over) during the years 1999–2012. ICD-10 diagnoses from V01 to X39 were included. The significance of changes over time was analyzed by linear regression.

Results

The incidence of prehospital death decreased significantly (coefficient −0.22, r² = 0.30; p = 0.041) during the study period, while that of deaths in hospital increased significantly (coefficient 0.20, r² = 0.75; p < 0.001). Mortality/100,000 person-years in the working age group (18–64 years) decreased significantly (coefficient −0.40, r² = 0.37; p = 0.020), mainly as a result of decrease in traffic-related deaths (coefficient −0.34, r² = 0.85; p < 0.001). The incidence of deaths from injury among elderly (65 years and older) patients increased because of the increase in falls (coefficient 1.71, r² = 0.84; p < 0.001) and poisoning (coefficient 0.13, r² = 0.69; p < 0.001).

Conclusion

The epidemiology of injury in Sweden has changed during recent years in that mortality from injury has declined in the working age group and increased among those people 64 years old and over.

Falls in older people: comparing older and younger fallers in a developing country

Purpose

While falls are common in older people, causing significant mortality and morbidity, this phenomenon has not been extensively studied in the Caribbean. This study aimed to compare falls in older and younger people in this setting.

Methods

We conducted a prospective observational study of older trauma patients in Trinidad, comparing older and younger patients sustaining falls.

Results

1432 adult trauma patients were included (1141 aged 18–64 years and 291 aged 65 years and older). Older fallers were more likely to be female (66.7 vs 47.2%; p < 0.001), suffer from multiple pre-existing diseases (24.7 vs 2.4%; p < 0.001) and take multiple medications (16.1 vs 0.8%; p < 0.001). They also sustained more severe injuries and presented with higher acuity than younger fallers. Admission rates were higher among older fallers (29.9 vs 13.1%; p < 0.001).

Conclusions

In our study, older patients who fell were a distinct group from younger falls victims, with unique demographic, clinical and injury related characteristics. Their increased risk of injury within the home, coupled with their propensity for more severe injuries made them a high risk patient group. More research is needed to better understand this patient group and plan specific preventive interventions.

Electronic supplementary material

The online version of this article (doi:10.1007/s00068-017-0818-2) contains supplementary material, which is available to authorized users.

Metformin ameliorates gender-and age-dependent hemodynamic instability and myocardial injury in murine hemorrhagic shock

Severity of multiple organ failure is significantly impacted by age and gender in patients with hemorrhagic shock. However, the molecular mechanisms underlying the enhanced organ injury are not fully understood. AMP-activated protein kinase (AMPK) is a pivotal orchestrator of metabolic responses during stress. We investigated whether hemorrhage-induced myocardial injury is age and gender dependent and whether treatment with metformin, an AMPK activator, affords cardioprotective effects. C57/BL6 young (3-5months) and mature (9-12months) male and female mice were subjected to hemorrhagic shock by blood withdrawing followed by resuscitation with blood and Lactated Ringer's solution. Vehicle-treated young and mature mice of both genders had a similar elevation of plasma inflammatory cytokines at 3h after resuscitation. However, vehicle-treated male mature mice experienced hemodynamic instability and higher myocardial damage than young male mice, as evaluated by echocardiography, histology and cardiovascular injury biomarkers. There was also a gender-dependent difference in cardiovascular injury in the mature group as vehicle-treated male mice exhibited more severe organ injury than female mice. At molecular analysis, vehicle-treated mature mice of both genders exhibited a marked downregulation of AMPKα activation and nuclear translocation of peroxisome proliferator-activated receptor γ co-activator α when compared with young mice. Treatment with metformin improved cardiovascular function and survival in mature animals of both genders. However, specific cardioprotective effects of metformin were gender-dependent. Metformin did not affect hemodynamic or inflammatory responses in young animals. Thus, our data suggest that targeting metabolic recovery with metformin may be a potential treatment approach in severe hemorrhage in adult population.

Age-related trends in injury and injury severity presenting to emergency departments in New South Wales Australia: Implications for major injury surveillance and trauma systems

OBJECTIVES

To describe population based trends and clinical characteristics of injury related presentations to Emergency Departments (EDs).

DESIGN AND SETTING

A retrospective, descriptive analysis of de-identified linked ED data across New South Wales, Australia over five calendar years, from 2010 to 2014.

PARTICIPANTS

Patients were included in this analysis if they presented to an Emergency Department and had an injury related diagnosis. Injury severity was categorised into critical (triage category 1-2 and admitted to ICU or operating theatre, or died in ED), serious (admitted as an in-patient, excluding above critical injuries) and minor injuries (discharged from ED).

MAIN OUTCOME MEASURES

The outcomes of interest were rates of injury related presentations to EDs by age groups and injury severity.

RESULTS

A total of 2.09 million injury related ED presentations were analysed. Minor injuries comprised 85.0%, and 14.1% and 1.0% were serious and critical injuries respectively. There was a 15.8% per annum increase in the rate of critical injuries per 1000 population in those 80 years and over, with the most common diagnosis being head injuries. Around 40% of those with critical injuries presented directly to a major trauma centre.

CONCLUSION

Critical injuries in the elderly have risen dramatically in recent years. A minority of critical injuries present directly to major trauma centres. Trauma service provision models need revision to ensure appropriate patient care. Injury surveillance is needed to understand the external causes of injury presenting to hospital.

Complications and in-hospital mortality in trauma patients treated in intensive care units in the United States, 2013

BACKGROUND

Traumatic injury is a leading cause of morbidity and mortality worldwide, but epidemiologic data about trauma patients who require intensive care unit (ICU) admission are scant. This study aimed to describe the annual incidence of ICU admission for adult trauma patients, including an assessment of risk factors for hospital complications and mortality in this population.

METHODS

This was a retrospective study of adults hospitalized at Level 1 and Level 2 trauma centers after trauma and recorded in the National Trauma Data Bank in 2013. Multiple logistic regression analyses were performed to determine predictors of hospital complications and hospital mortality for those who required ICU admission.

RESULTS

There were an estimated total of 1.03 million ICU admissions for trauma at Level 1 and Level 2 trauma centers in the United States in 2013, yielding an annual incidence of 3.3 per 1000 population. The annual incidence was highest in men (4.6 versus 1.9 per 100,000 for women), those aged 80 years or older (7.8 versus 3.6-4.3 per 100,000 in other age groups), and residents in the Western US Census region (3.9 versus 2.7 to 3.6 per 100,000 in other regions). The most common complications in patients admitted to the ICU were pneumonia (10.9 %), urinary tract infection (4.7 %), and acute respiratory distress syndrome (4.4 %). Hospital mortality was significantly higher for ICU patients who developed one or more complications (16.9 % versus 10.7 % for those who did not develop any complications, p < 0.001).

CONCLUSIONS

Admission to the ICU after traumatic injury is common, and almost a quarter of these patients experience hospital complications. Hospital complications are associated with significantly increased risk of mortality.

Factors affecting mortality in older trauma patients-A systematic review and meta-analysis

INTRODUCTION

Major trauma in older people is a significant health burden in the developed world. The aging of the population has resulted in larger numbers of older patients suffering serious injury. Older trauma patients are at greater risk of death from major trauma, but the reasons for this are less well understood. The aim of this review was to identify the factors affecting mortality in older patients suffering major injury.

MATERIALS AND METHODS

A systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with meta-analysis. Multi-centre cohort studies of existing trauma registries that reported risk-adjusted mortality (adjusted odds ratios, AOR) in their outcomes and which analysed patients aged 65 and older as a separate cohort were included in the review.

RESULTS

3609 papers were identified from the electronic databases, and 28 from manual searches. Of these, 15 papers fulfilled the inclusion criteria. Demographic variables (age and gender), pre-existing conditions (comorbidities and medication), and injury-related factors (injury severity, pattern and mechanism) were found to affect mortality. The 'oldest old', aged 75 and older, had higher mortality rates than younger patients, aged 65-74 years. Older men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37-1.66). Three papers reported a higher risk of death in patients with pre-existing conditions. Two studies reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05-1.66). Higher mortality was seen in patients with lower Glasgow coma scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26-6.60).

CONCLUSIONS

Multiple factors contribute to mortality risk in older trauma patients. The relation between these factors and mortality is complex, and a fuller understanding of the contribution of each factor is needed to develop a better predictive model for trauma outcomes in older people. More research is required to identify patient and process factors affecting mortality in older patients.

Benefits of Initial Limited Crystalloid Resuscitation in Severely Injured Trauma Patients at Emergency Department

Background

Whether initial limited crystalloid resuscitation (LCR) benefits to all severely injured trauma patients receiving blood transfusions at emergency department (ED) is uncertain. We aimed to determine the role of LCR and its associations with packed red blood cell (PRBC) transfusion during initial resuscitation.

Methods

Trauma patients receiving blood transfusions were reviewed from 2004 to 2013. Patients with LCR (L group, defined as < 2,000 mL) and excessive crystalloid resuscitation (E group, defined as ≥ 2,000 mL) were compared separately in terms of basic demographic, clinical variables, and hospital outcomes. Logistic regression, R-square (R²), and Spearman rho correlation were used for analysis.

Results

A total of 633 patients were included. The mortality was 51% in L group and 45% in E group (P = 0.11). No statistically significant difference was found in terms of basic demographics, vital signs upon arrival at ED, or injury severity between the groups. The volume of blood transfused strongly correlated with the volume of crystalloid infused in E group (R² = 0.955). Crystalloid to PRBC (C/PRBC) ratio was 0.8 in L group and 1.3 in E group (P < 0.01). The correlations between C/PRBC and ED versus ICU versus hospital length of stay (LOS) via Spearman rho were 0.25, 0.22, and 0.22, respectively.

Conclusions

Similar outcomes were observed in trauma patients receiving blood transfusions regardless of the crystalloid infusion volume. More crystalloid infusions were associated with more blood transfusions. The C/PRBC did not demonstrate predictive value regarding mortality but might predict LOS in severely injured trauma patients.

Incremental cost-effectiveness of trauma service improvements for road trauma casualties: experience of an Australian major trauma centre

Objective The aim of the present study was to estimate the cost-effectiveness of trauma service funding enhancements at an inner city major trauma centre. Methods The present study was a cost-effectiveness analysis using retrospective trauma registry data of all major trauma patients (injury severity score >15) presenting after road trauma between 2001 and 2012. The primary outcome was cost per life year gained associated with the intervention period (2007-12) compared with the pre-intervention period (2001-06). Incremental costs were represented by all trauma-related funding enhancements undertaken between 2007 and 2010. Risk adjustment for years of life lost was conducted using zero-inflated negative binomial regression modelling. All costs were expressed in 2012 Australian dollar values. Results In all, 876 patients were identified during the study period. The incremental cost of trauma enhancements between 2007 and 2012 totalled $7.91million, of which $2.86million (36%) was attributable to road trauma patients. After adjustment for important covariates, the odds of in-hospital mortality reduced by around half (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.27, 0.82; P=0.01). The incremental cost-effectiveness ratio was A$7600 per life year gained (95% CI A$5524, $19333). Conclusion Trauma service funding enhancements that enabled a quality improvement program at a single major trauma centre were found to be cost-effective based on current international and Australian standards. What is known about this topic? Trauma quality improvement programs have been implemented across most designated trauma hospitals in an effort to improve hospital care processes and outcomes for injured patients. These involve a combination of education and training, the use of audit and key performance indicators. What does this paper add? A trauma quality improvement program initiated at an Australian Major Trauma Centre was found to be cost-effective over 12 years with respect to years of life saved in road trauma patients. What are the implications for practitioners? The results suggest that adequate resourcing of trauma centres to enable quality improvement programs may be a cost-effective measure to reduce in-hospital mortality following road trauma.

Young peoples' experience and self-management in the six months following major injury: A qualitative study

PURPOSE

The aim of this qualitative study was to explore how young people aged 16-24 years' experience, perceive and manage the effects of major traumatic injury during the initial six months following major traumatic injury. Specifically: (1) how do young people manage the physical and emotional effects of major injury within the trauma system of care? (2) What are young peoples' perceived needs for healthcare and how are these met within the trauma system of care? (3) What do young people perceive as the role of family in supporting them?

METHODS

This study forms part of the qualitative follow-up phase of an explanatory sequential mixed methods study investigating the characteristics and experience of major traumatic injury for young people 16-24 years, and the role of family in supporting them, in the initial six months following injury. The paper reports on young peoples' (aged 16-24 years) experiences of being admitted with major traumatic injury to two Australian Level 1 Trauma Centres. Twelve injured young people aged 17-23 years (mean=19 years) participated in the study. Two semi-structured in-depth interviews with young people were conducted and transcribed verbatim; the first prior to hospital discharge (n=12), and the second (n=7) within 3 months of hospital discharge. Data were managed using NVivo software, and thematically analysed.

FINDINGS

During the initial 6 months following injury, young people experienced a complex process of adaptation involving feelings of vulnerability and loss of control over their physicality, environment and life-course. Self-management strategies included use of Information technology as a form of distraction; family and friends to create a sense of familiarity and normality; and information and validation-seeking from health care professionals as a means of understanding and regaining a sense of self.

CONCLUSION

Key elements of resilience theory applicable to the findings such as problem-based coping, self-efficacy and strong social support offer a useful framework for anticipatory guidance that is responsive to the psychosocial needs of injured young people and facilitates a strength-based patient-centred approach to managing major traumatic injury.

Health status and return to work in trauma patients at 3 and 6 months post-discharge: an Australian major trauma centre study

INTRODUCTION

The aim of this study was to describe post-discharge outcomes, and determine predictors of 3 and 6 months health status outcomes in a population of trauma patients at an inner city major trauma centre.

METHODS

This was a prospective cohort study of adult trauma patients admitted to this hospital with 3 and 6 months post-discharge outcomes assessment. Outcome measures were the Physical Component Scores (PCS) and Mental Component Scores (MCS) of the Short Form 12, EQ-5D, and return to work (in any capacity) if working prior to injury. Repeated measures mixed models and generalised estimating equation models were used to determine predictors of outcomes at 3 and 6 months.

RESULTS

One hundred and seventy-nine patients were followed up. Patients with lower limb injuries reported lower mean PCS scores between 3 and 6 months (coefficient -4.21, 95 % CI -7.58, -0.85) than those without lower limb injuries. Patients involved in pedestrian incidents or assaults and those with pre-existing mental health diagnoses reported lower mean MCS scores. In adjusted models upper limb injuries were associated with reduced odds of return to work at 3 and 6 months (OR 0.20, 95 % CI 0.07, 0.57) compared to those without upper limb injuries.

DISCUSSION

Predictors of poorer physical health status were lower limb injuries and predictors of mental health were related to the mechanism of injury and past mental health. Increasing injury severity score and upper limb injuries were the only predictors of reduced return to work. The results provide insights into the feasibility of routine post-discharge follow-up at a trauma service level.

Data linkage capabilities in Australia: practical issues identified by a Population Health Research Network 'Proof of Concept project'

OBJECTIVE

To describe the practical issues that need to be overcome to conduct national data linkage projects in Australia and propose recommendations to improve efficiency.

METHODS

Review of the processes, documentation and applications required to conduct national data linkage in Australia.

RESULTS

The establishment of state and national data linkage centres in Australia has placed Australia at the forefront of research linking health-related administrative data collections. However, improvements are needed to reduce the clerical burden on researchers, simplify the process of obtaining ethics approval, improve data accessibility, and thus improve the efficiency of data linkage research.

CONCLUSIONS

While a sound state and national data linkage infrastructure is in place, the current complexity, duplication and lack of cohesion undermines any attempts to conduct research involving national record linkage in a timely manner.

IMPLICATIONS

Data linkage applications and Human Research Ethics Committee approval processes need to be streamlined and duplication removed, in order to reduce the administrative and financial burden on researchers if national data linkage research is to be viable.

"After-hours" staffing of trauma centres and outcomes among patients presenting with acute traumatic coagulopathy

OBJECTIVE

To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC).

DESIGN, PARTICIPANTS AND SETTING

Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011.

MAIN OUTCOME MEASURE

Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality.

RESULTS

There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10-2.87).

CONCLUSION

The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.

Ten years of trauma in the 'top end' of the Northern Territory, Australia: a retrospective analysis

AIM

To examine characteristics of traumatic injury in adults and children at the Royal Darwin Hospital (RDH) over a 10 year period.

METHOD

A retrospective review of the RDH Trauma Registry data from 1 January 2003 to 31 December 2012, with analysis of patient demographics, mechanism of injury, Injury Severity Score (ISS), and outcome.

PARTICIPANTS

Two thousand seven hundred twenty-five patients with an ISS greater than or equal to 9 and met all other study inclusion criteria.

RESULTS

Motor vehicle crashes, assaults and falls consistently remained the three most common mechanisms of injury throughout the 10 year period. Indigenous admissions showed a significant downward trend (p = 0.009). Upward trends were noted in presentations from patients aged greater than 44 (p = 0.002), all-terrain vehicle accidents (p <0.001), and hangings (p = 0.003). No other trends were noted to significant at a p <0.05 level. Admitted Indigenous patients were significantly more likely to be present due to assault (p <0.001) and female patients were more likely to present due to assault, falls and motor vehicle crashes (p <0.01) than their counterparts.

CONCLUSION

Presentations for traumatic injury to Royal Darwin Hospital have remained in the most part, consistently stable for the period of 2003-2012. Though there were some increases/decreases in regard to specific demographics and mechanisms, few were found to be statistically significant at a p < 0.05 level.

Saving lives, limbs and livelihoods: considerations in restructuring a national trauma service

STUDY HYPOTHESIS

Level 1 trauma centers reduce mortality and improve functional outcomes in major trauma. Despite this, many countries, including Ireland, do not have officially designated major trauma centers (MTC). This study aimed to examine international trauma systems, and determine how to "best fit" trauma care in a small country (Ireland) to international models.

METHODS

The literature was reviewed to examine international models of trauma systems. An estimate of Irish trauma burden and distribution was made using data from the Road Safety Authority (RSA) on serious or fatal RTAs. Models of a restructured trauma service were constructed and compared with international best practice.

RESULTS

Internationally, a major trauma center surrounded by a regional trauma network has emerged as the gold standard in trauma care. In Ireland, there are no nationally coordinated trauma networks and care is provided by 26 acute hospitals with a mean distance to hospital from RTAs of 20.6 km ± 15.6. Based on our population, Ireland needs two Level 1 MTCs (in the two areas of major population density in the east and south), with robust surrounding trauma networks including Level 2 or 3 trauma centers. With this model, the estimated mean number of cases per Level 1 MTC per year would be 628, with a mean distance to MTC of 80.5 ± 59.2 km, (maximum distance 263.5 km).

CONCLUSION

Clearly designated and adequately resourced MTCs with trauma networks are needed to improve trauma outcomes, with concomitant investment in pre-hospital infrastructure.

Preventable mortality in geriatric hip fracture inpatients

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Cite this article: Bone Joint J 2014;96-B:1178–84.

Neutrophil oxidative burst capacity for peri-operative immune monitoring in trauma patients

BACKGROUND

Post injury immune dysfunction can result in serious complications. Measurement of biomarkers may guide the optimal timing of surgery in clinically borderline patients and therefore prevent complications.

AIM

peri-operative measurement of neutrophil oxidative burst capacity as an indicator of the immune response to major orthopaedic surgical procedures.

METHODS

Prospective cohort study of trauma patients aged ≥16 yrs with pelvic, acetabular, femoral shaft or tibial shaft fractures requiring surgical intervention. Blood samples were taken immediately pre-op and at 30 min, 7, 24 and 72-9 6 h post-operatively. Neutrophil oxidative burst capacity was measured both with and without stimulation by formyl-methionyl-leucyl-phenylalanine (fMLP, a chemotactic factor). Clinical outcomes measured were mortality, length of stay, MOF, pneumonia, acute respiratory distress syndrome (ARDS) and sepsis.

RESULTS

100 consecutive orthopaedic trauma patients were enrolled over a 16 month period. 78% were male, with a mean age of 42 ± 18 years and an average ISS of 19 ± 13. Neutrophil oxidative burst capacity was significantly elevated at 7 h (p = 0.006) and 24 h (p = 0.022) post operatively. Patients who developed infective complications (pneumonia and sepsis) had higher levels of oxidative burst capacity pre-operatively (pneumonia: 1.52 ± 0.93 v 0.99 ± 0.66 p = 0.032, sepsis: 1.39 ± 0.86 v 0.97 ± 0.56 p = 0.024) and at 24 h post op (pneumonia: 2.72 ± 2.38 v 1.12 ± 0.63 p = < 0.001, sepsis: 2.16 ± 2.09 v 1.10 ± 0.54 p = < 0.001). When analysed by operation type, no statistical difference was seen between major and minor operations. No correlation was found between length of stay, length of ICU stay, ISS or age and neutrophil oxidative burst capacity at any time point.

CONCLUSIONS

Neutrophil oxidative burst capacity response to orthopaedic trauma surgery is associated with the infective post injury complications. There was no correlation between magnitude of injury or operation and oxidative burst capacity. These results are promising for the development of tools for prediction of post-operative complications and guidance for optimal timing for surgical intervention.

The effect of a nurse team leader on communication and leadership in major trauma resuscitations

BACKGROUND

Effective assessment and resuscitation of trauma patients requires an organised, multidisciplinary team. Literature evaluating leadership roles of nurses in trauma resuscitation and their effect on team performance is scarce.

AIM

To assess the effect of allocating the most senior nurse as team leader of trauma patient assessment and resuscitation on communication, documentation and perceptions of leadership within an Australian emergency department.

METHODS

The study design was a pre-post-test survey of emergency nursing staff (working at resuscitation room level) perceptions of leadership, communication, and documentation before and after the implementation of a nurse leader role. Patient records were audited focussing on initial resuscitation assessment, treatment, and nursing clinical entry. Descriptive statistical analyses were performed.

RESULTS

Communication trended towards improvement. All (100%) respondents post-test stated they had a good to excellent understanding of their role, compared to 93.2% pre-study. A decrease (58.1-12.5%) in 'intimidating personality' as a negative aspect of communication. Nursing leadership had a 6.7% increase in the proportion of those who reported nursing leadership to be good to excellent. Accuracy of clinical documentation improved (P = 0.025).

CONCLUSION

Trauma nurse team leaders improve some aspects of communication and leadership. Development of trauma nurse leaders should be encouraged within trauma team training programmes.

A trauma quality improvement programme associated with improved patient outcomes: 21 years of experience at an Australian Major Trauma Centre

INTRODUCTION

Quality improvement programmes are an important part of care delivery in trauma centres. The objective was to describe the effect of a comprehensive quality improvement programme on long term patient outcome trends at a low volume major trauma centre in Australia.

METHODS

All patients aged 15 years and over with major trauma (Injury Severity Score>15) admitted to a single inner city major trauma centre between 1992 and 2012 were studied. The outcomes of interest were in-hospital mortality and transfer to rehabilitation. Time series analysis using integer valued autoregressive Poisson models was used to determine the reduction in adjusted monthly count data associated with the intervention period (2007-2012). Risk adjusted odds ratios for mortality over three yearly intervals was also obtained using multivariable logistic regression. Crude and risk adjusted mortality was compared before and after the implementation period.

RESULTS

3856 patients were analysed. Crude in-hospital mortality fell from 16% to 10% after implementation (p<0.001). The intervention period was associated with a 25% decrease in monthly mortality counts. Risk adjusted mortality remained stable from 1992 to 2006 and did not fall until the intervention period. Crude and risk adjusted transfer to in-patient rehabilitation after major trauma also declined during the intervention period.

CONCLUSION

In this low volume major trauma centre, the implementation of a comprehensive quality improvement programme was associated with a reduction in crude and risk adjusted mortality and risk adjusted discharge to rehabilitation in severely injured patients.