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Davies M, Lawrence T, Edwards A, McKay C, Lecky FE, Stokes KA, Williams S. Sport-related major trauma incidence in young people and adults in England and Wales: a national registry-based study. Inj Prev 2024; 30:60-67. [PMID: 37875378 PMCID: PMC10850652 DOI: 10.1136/ip-2023-044887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/24/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVES Data on sport and physical activity (PA) injury risk can guide intervention and prevention efforts. However, there are limited national-level data, and no estimates for England or Wales. This study sought to estimate sport and PA-related major trauma incidence in England and Wales. METHODS Nationwide, hospital registry-based cohort study between January 2012 and December 2017. Following Trauma Audit and Research Network Registry Research Committee approval, data were extracted in April 2018 for people ≥16 years of age, admitted following sport or PA-related injury in England and Wales. The population-based Active Lives Survey was used to estimate national sport and PA participation (ie, running, cycling, fitness activities). The cumulative injury incidence rate was estimated for each activity. Injury severity was described by Injury Severity Score (ISS) >15. RESULTS 11 702 trauma incidents occurred (mean age 41.2±16.2 years, 59.0% male), with an ISS >15 for 28.0% of cases, and 1.3% were fatal. The overall annual injury incidence rate was 5.40 injuries per 100 000 participants. The incidence rate was higher in men (6.44 per 100 000) than women (3.34 per 100 000), and for sporting activities (9.88 per 100 000) than cycling (2.81 per 100 000), fitness (0.21 per 100 000) or walking (0.03 per 100 000). The highest annual incidence rate activities were motorsports (532.31 per 100 000), equestrian (235.28 per 100 000) and gliding (190.81 per 100 000). CONCLUSION Injury incidence was higher in motorsports, equestrian activity and gliding. Targeted prevention in high-risk activities may reduce admissions and their associated burden, facilitating safer sport and PA participation.
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Affiliation(s)
- Madeleine Davies
- Institute of Sport, Exercise and Health, UCL, London, UK
- Department for Health, University of Bath, Bath, UK
| | - Tom Lawrence
- National Institute for Health and Care Excellence, London, UK
- Division of Population Health, Trauma Audit and Research Network, The University of Manchester, Manchester, UK
| | - Antoinette Edwards
- Division of Population Health, Trauma Audit and Research Network, The University of Manchester, Manchester, UK
| | - Carly McKay
- Department for Health, University of Bath, Bath, UK
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Fiona E Lecky
- Division of Population Health, Trauma Audit and Research Network, The University of Manchester, Manchester, UK
- Centre for Urgent and Emergency Care Research, University of Sheffield School of Health and Related Research, Sheffield, UK
| | - Keith A Stokes
- Department for Health, University of Bath, Bath, UK
- Rugby Football Union, London, UK
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2
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Dipnall JF, Lyons J, Lyons RA, Ameratunga S, Brussoni M, Lecky FE, Beck B, Schneeberg A, Harrison JE, Gabbe BJ. Impact of an injury hospital admission on childhood academic performance: a Welsh population-based data linkage study. Inj Prev 2023:ip-2023-045027. [PMID: 38124009 DOI: 10.1136/ip-2023-045027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND While injuries can impact on children's educational achievements (with threats to their development and employment prospects), these risks are poorly quantified. This population-based longitudinal study investigated the impact of an injury-related hospital admission on Welsh children's academic performance. METHODS The Secure Anonymised Information Linkage databank, 55 587 children residing in Wales from 2006 to 2016 who had an injury hospital admission (58.2% males; 16.8% born in most deprived Wales area; 80.1% one injury hospital admission) were linked to data from the Wales Electronic Cohort for Children. The primary outcome was the Core Subject Indicator reflecting educational achievement at key stages 2 (school years 3-6), 3 (school years 7-9) and 4 (school years 10-11). Covariates in models included demographic, birth, injury and school characteristics. RESULTS Educational achievement of children was negatively associated with: pedestrian injuries (adjusted risk ratio, (95% CIs)) (0.87, (0.83 to 0.92)), cyclist (0.96, (0.94 to 0.99)), high fall (0.96, (0.94 to 0.97)), fire/flames/smoke (0.85, (0.73 to 0.99)), cutting/piercing object (0.96, (0.93 to 0.99)), intentional self-harm (0.86, (0.82 to 0.91)), minor traumatic brain injury (0.92, (0.86 to 0.99)), contusion/open wound (0.93, (0.91 to 0.95)), fracture of vertebral column (0.78, (0.64 to 0.95)), fracture of femur (0.88, (0.84 to 0.93)), internal abdomen/pelvic haemorrhage (0.82, (0.69 to 0.97)), superficial injury (0.94, (0.92 to 0.97)), young maternal age (<18 years: 0.91, (0.88 to 0.94); 19-24 years: 0.94, (0.93 to 0.96)); area based socioeconomic status (0.98, (0.97 to 0.98)); moving to a more deprived area (0.95, (0.93 to 0.97)); requiring special educational needs (0.46, (0.44 to 0.47)). Positive associations were: being female (1.04, (1.03 to 1.06)); larger pupil school sizes and maternal age 30+ years. CONCLUSION This study highlights the importance on a child's education of preventing injuries and implementing intervention programmes that support injured children. Greater attention is needed on equity-focused educational support and social policies addressing needs of children at risk of underachievement, including those from families experiencing poverty. VIBES-JUNIOR STUDY PROTOCOL: http://dx.doi.org/10.1136/bmjopen-2018-024755.
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Affiliation(s)
- Joanna F Dipnall
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University Faculty of Health, Geelong, Victoria, Australia
| | - Jane Lyons
- Population Data Science, Faculty of Medicine, Health & Life Science, Swansea University Medical School, Swansea, UK
- Administrative Data Research Wales, Wales, UK
| | - Ronan A Lyons
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Population Data Science, Faculty of Medicine, Health & Life Science, Swansea University Medical School, Swansea, UK
- Administrative Data Research Wales, Wales, UK
- National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, UK
| | - Shanthi Ameratunga
- School of Population Health, The University of Auckland, Auckland, New Zealand
- Counties Manukau District Health Board, Kidz First Hospital and Population Health Directorate, Auckland, New Zealand
| | - Mariana Brussoni
- Department of Pediatrics, Human Early Learning Partnership, School of Population and Public Health, The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
- British Columbia Injury Research and Prevention Unit, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Fiona E Lecky
- Centre for Urgent and Emergency Care Research, The University of Sheffield School of Health and Related Research, Sheffield, UK
- Emergency Department, Salford Royal Hospital, Salford, UK
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Amy Schneeberg
- British Columbia Injury Research and Prevention Unit, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Occupational Science and Occupational Therapy, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - James E Harrison
- Flinders University, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Population Data Science, Faculty of Medicine, Health & Life Science, Swansea University Medical School, Swansea, UK
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3
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Maas AIR, Bragge P, Silverberg ND, Undén J, Lecky FE. French Guidelines for the Management of Patients with mild Traumatic Brain injury. Anaesth Crit Care Pain Med 2023:101261. [PMID: 37285920 DOI: 10.1016/j.accpm.2023.101261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Andrew I R Maas
- Antwerp University Hospital, Edegem, and University of Antwerp, Edegem, Belgium.
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Australia
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver Coastal Health Research Institute, Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada
| | - Johan Undén
- Dept. of Operation and Intensive Care, Hallands Hospital Halmstad, Lund University, Lund, Sweden
| | - Fiona E Lecky
- Emergency Department, Salford Royal Hospital, Salford, UK; Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
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4
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Dipnall JF, Rivara FP, Lyons RA, Ameratunga S, Brussoni M, Lecky FE, Bradley C, Beck B, Lyons J, Schneeberg A, Harrison JE, Gabbe BJ. Predictors of health-related quality of life following injury in childhood and adolescence: a pooled analysis. Inj Prev 2021; 28:301-310. [PMID: 34937765 DOI: 10.1136/injuryprev-2021-044309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/12/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Injury is a leading contributor to the global disease burden in children and places children at risk for adverse and lasting impacts on their health-related quality of life (HRQoL) and development. This study aimed to identify key predictors of HRQoL following injury in childhood and adolescence. METHODS Data from 2259 injury survivors (<18 years when injured) were pooled from four longitudinal cohort studies (Australia, Canada, UK, USA) from the paediatric Validating Injury Burden Estimates Study (VIBES-Junior). Outcomes were the Paediatric Quality of Life Inventory (PedsQL) total, physical, psychosocial functioning scores at 1, 3-4, 6, 12, 24 months postinjury. RESULTS Mean PedsQL total score increased with higher socioeconomic status and decreased with increasing age. It was lower for transport-related incidents, ≥1 comorbidities, intentional injuries, spinal cord injury, vertebral column fracture, moderate/severe traumatic brain injury and fracture of patella/tibia/fibula/ankle. Mean PedsQL physical score was lower for females, fracture of femur, fracture of pelvis and burns. Mean PedsQL psychosocial score was lower for asphyxiation/non-fatal submersion and muscle/tendon/dislocation injuries. CONCLUSIONS Postinjury HRQoL was associated with survivors' socioeconomic status, intent, mechanism of injury and comorbidity status. Patterns of physical and psychosocial functioning postinjury differed according to sex and nature of injury sustained. The findings improve understanding of the long-term individual and societal impacts of injury in the early part of life and guide the prioritisation of prevention efforts, inform health and social service planning to help reduce injury burden, and help guide future Global Burden of Disease estimates.
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Affiliation(s)
- Joanna F Dipnall
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia .,Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Frederick P Rivara
- Departments of Pediatrics and Epidemiology, and the Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Ronan A Lyons
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Health Data Research UK, Swansea University, Swansea, UK.,National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, UK
| | - Shanthi Ameratunga
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Population Health, University of Auckland, Auckland, New Zealand.,Kidz First Hospital and Population Health Directorate, Counties Manukau District Health Board, Auckland, New Zealand
| | - Mariana Brussoni
- Department of Pediatrics, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,British Columbia Injury Research and Prevention Unit, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Fiona E Lecky
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK.,Emergency Department, Salford Royal Hospital, Salford, UK
| | - Clare Bradley
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jane Lyons
- Health Data Research UK, Swansea University, Swansea, UK
| | - Amy Schneeberg
- British Columbia Injury Research and Prevention Unit, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - James E Harrison
- Flinders Institute for Health and Medical Research, Flinders University, Adelaide, South Australia, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Health Data Research UK, Swansea University, Swansea, UK
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Lecky FE, Otesile O, Marincowitz C, Majdan M, Nieboer D, Lingsma HF, Maegele M, Citerio G, Stocchetti N, Steyerberg EW, Menon DK, Maas AIR. The burden of traumatic brain injury from low-energy falls among patients from 18 countries in the CENTER-TBI Registry: A comparative cohort study. PLoS Med 2021; 18:e1003761. [PMID: 34520460 PMCID: PMC8509890 DOI: 10.1371/journal.pmed.1003761] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 10/12/2021] [Accepted: 08/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is an important global public health burden, where those injured by high-energy transfer (e.g., road traffic collisions) are assumed to have more severe injury and are prioritised by emergency medical service trauma triage tools. However recent studies suggest an increasing TBI disease burden in older people injured through low-energy falls. We aimed to assess the prevalence of low-energy falls among patients presenting to hospital with TBI, and to compare their characteristics, care pathways, and outcomes to TBI caused by high-energy trauma. METHODS AND FINDINGS We conducted a comparative cohort study utilising the CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) Registry, which recorded patient demographics, injury, care pathway, and acute care outcome data in 56 acute trauma receiving hospitals across 18 countries (17 countries in Europe and Israel). Patients presenting with TBI and indications for computed tomography (CT) brain scan between 2014 to 2018 were purposively sampled. The main study outcomes were (i) the prevalence of low-energy falls causing TBI within the overall cohort and (ii) comparisons of TBI patients injured by low-energy falls to TBI patients injured by high-energy transfer-in terms of demographic and injury characteristics, care pathways, and hospital mortality. In total, 22,782 eligible patients were enrolled, and study outcomes were analysed for 21,681 TBI patients with known injury mechanism; 40% (95% CI 39% to 41%) (8,622/21,681) of patients with TBI were injured by low-energy falls. Compared to 13,059 patients injured by high-energy transfer (HE cohort), the those injured through low-energy falls (LE cohort) were older (LE cohort, median 74 [IQR 56 to 84] years, versus HE cohort, median 42 [IQR 25 to 60] years; p < 0.001), more often female (LE cohort, 50% [95% CI 48% to 51%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001), more frequently taking pre-injury anticoagulants or/and platelet aggregation inhibitors (LE cohort, 44% [95% CI 42% to 45%], versus HE cohort, 13% [95% CI 11% to 14%]; p < 0.001), and less often presenting with moderately or severely impaired conscious level (LE cohort, 7.8% [95% CI 5.6% to 9.8%], versus HE cohort, 10% [95% CI 8.7% to 12%]; p < 0.001), but had similar in-hospital mortality (LE cohort, 6.3% [95% CI 4.2% to 8.3%], versus HE cohort, 7.0% [95% CI 5.3% to 8.6%]; p = 0.83). The CT brain scan traumatic abnormality rate was 3% lower in the LE cohort (LE cohort, 29% [95% CI 27% to 31%], versus HE cohort, 32% [95% CI 31% to 34%]; p < 0.001); individuals in the LE cohort were 50% less likely to receive critical care (LE cohort, 12% [95% CI 9.5% to 13%], versus HE cohort, 24% [95% CI 23% to 26%]; p < 0.001) or emergency interventions (LE cohort, 7.5% [95% CI 5.4% to 9.5%], versus HE cohort, 13% [95% CI 12% to 15%]; p < 0.001) than patients injured by high-energy transfer. The purposive sampling strategy and censorship of patient outcomes beyond hospital discharge are the main study limitations. CONCLUSIONS We observed that patients sustaining TBI from low-energy falls are an important component of the TBI disease burden and a distinct demographic cohort; further, our findings suggest that energy transfer may not predict intracranial injury or acute care mortality in patients with TBI presenting to hospital. This suggests that factors beyond energy transfer level may be more relevant to prehospital and emergency department TBI triage in older people. A specific focus to improve prevention and care for patients sustaining TBI from low-energy falls is required.
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Affiliation(s)
- Fiona E. Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Emergency Department, Salford Royal Hospital, Salford, United Kingdom
- * E-mail:
| | - Olubukola Otesile
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Carl Marincowitz
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Marek Majdan
- Department of Public Health, University of Trnava, Trnava, Slovakia
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marc Maegele
- Institute for Research in Operative Medicine, Witten/Herdecke University, Köln, Germany
| | - Giuseppe Citerio
- Neurointensive Care, Azienda Socio Sanitaria Territoriale di Monza, Monza, Italy
- School of Medicine and Surgery, Università degli Studi di Milano–Bicocca, Milan, Italy
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - David K. Menon
- University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, Edegem, Belgium
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6
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Sewalt CA, Gravesteijn BY, Menon D, Lingsma HF, Maas AIR, Stocchetti N, Venema E, Lecky FE. Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study. Scand J Trauma Resusc Emerg Med 2021; 29:113. [PMID: 34348784 PMCID: PMC8340517 DOI: 10.1186/s13049-021-00930-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00930-1.
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Affiliation(s)
- Charlie Aletta Sewalt
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Benjamin Yaël Gravesteijn
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Anesthesiology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Esmee Venema
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - Fiona E Lecky
- Center for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Williams J, Roberts I, Shakur-Still H, Lecky FE, Chaudhri R, Miners A. Cost-effectiveness analysis of tranexamic acid for the treatment of traumatic brain injury, based on the results of the CRASH-3 randomised trial: a decision modelling approach. BMJ Glob Health 2020; 5:e002716. [PMID: 32878899 PMCID: PMC7470492 DOI: 10.1136/bmjgh-2020-002716] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION An estimated 69 million traumatic brain injuries (TBI) occur each year worldwide, with most in low-income and middle-income countries. The CRASH-3 randomised trial found that intravenous administration of tranexamic acid within 3 hours of injury reduces head injury deaths in patients sustaining a mild or moderate TBI. We examined the cost-effectiveness of tranexamic acid treatment for TBI. METHODS A Markov decision model was developed to assess the cost-effectiveness of treatment with and without tranexamic acid, in addition to current practice. We modelled the decision in the UK and Pakistan from a health service perspective, over a lifetime time horizon. We used data from the CRASH-3 trial for the risk of death during the trial period (28 days) and patient quality of life, and data from the literature to estimate costs and long-term outcomes post-TBI. We present outcomes as quality-adjusted life years (QALYs) and 2018 costs in pounds for the UK, and US dollars for Pakistan. Incremental cost-effectiveness ratios (ICER) per QALY gained were estimated, and compared with country specific cost-effective thresholds. Deterministic and probabilistic sensitivity analyses were also performed. RESULTS Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI, at £4288 per QALY in the UK, and US$24 per QALY in Pakistan. Tranexamic acid was 99% and 98% cost-effective at the cost-effectiveness thresholds for the UK and Pakistan, respectively, and remained cost-effective across all deterministic sensitivity analyses. Tranexamic acid was even more cost-effective with earlier treatment administration. The cost-effectiveness for those with severe TBI was uncertain. CONCLUSION Early administration of tranexamic acid is highly cost-effective for patients with mild or moderate TBI in the UK and Pakistan, relative to the cost-effectiveness thresholds used. The estimated ICERs suggest treatment is likely to be cost-effective across all income settings globally.
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Affiliation(s)
- Jack Williams
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Fiona E Lecky
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
- Emergency Department, Salford Royal Hospital NHS Foundation Trust, Salford, Salford, UK
| | - Rizwana Chaudhri
- Holy Family Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Alec Miners
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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8
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Lecky FE, Reynolds T, Otesile O, Hollis S, Turner J, Fuller G, Sammy I, Williams-Johnson J, Geduld H, Tenner AG, French S, Govia I, Balen J, Goodacre S, Marahatta SB, DeVries S, Sawe HR, El-Shinawi M, Mfinanga J, Rubiano AM, Chebbi H, Do Shin S, Ferrer JME, Haddadi M, Firew T, Taubert K, Lee A, Convocar P, Jamaluddin S, Kotecha S, Yaqeen EA, Wells K, Wallis L. Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise. BMC Emerg Med 2020; 20:68. [PMID: 32867675 PMCID: PMC7457362 DOI: 10.1186/s12873-020-00362-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions. METHODS The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings. RESULTS The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs. CONCLUSIONS Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.
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Affiliation(s)
- Fiona E Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK
| | | | - Olubukola Otesile
- School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK
| | - Sara Hollis
- World Health Organisation, Geneva, Switzerland
| | - Janette Turner
- School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK
| | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK
| | - Ian Sammy
- Scarborough General Hospital, Tobago, Canada
| | | | - Heike Geduld
- Divsion of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | | | | | - Ishtar Govia
- The University of West Indies, Kingston, Jamaica
| | - Julie Balen
- School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK
| | | | - Shaheem DeVries
- Emergency Medical Services for the Western Cape Government, Cape Town, South Africa
| | - Hendry R Sawe
- Emergency Medical Association of Tanzania (EMAT), Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | | | - Juma Mfinanga
- Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Andrés M Rubiano
- Neurosciences Institute, El Bosque University, Bogotá, Colombia
- Colombian Trauma Association, Bogotá, Colombia
| | | | - Sang Do Shin
- Seoul National University Hospital, Seoul, South Korea
| | | | | | - Tsion Firew
- Columbia University, Emergency Medicine, New York, NY, USA
- Ministry of Health, Addis Ababa, Ethiopia
| | | | - Andrew Lee
- School of Health and Related Research, University of Sheffield, Sheffield, and Emergency Deparment, Salford Royal Hospital, Salford, UK
| | - Pauline Convocar
- Philippine College of Emergency Medicine, Parañaque, Philippines
| | | | | | | | - Katie Wells
- Divsion of Emergency Medicine, University of Vermont, Burlington, Vermont, USA
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, F51 Old Main Building, Groote Schuur Hospital Observatory, Cape Town, South Africa.
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9
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Coats TJ, Lecky FE. The CRASH3 study: prehospital TXA for every injured patient? Emerg Med J 2020; 37:392-394. [PMID: 32220860 DOI: 10.1136/emermed-2019-209264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/18/2020] [Accepted: 03/07/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Timothy J Coats
- Emergency Medicine Academic Group (EMAG), College of Medicine Biological Sciences and Psychology, University of Leicester, Leicester, UK
| | - Fiona E Lecky
- Centre for Urgent and Emergency Care Research (CURE), School of Health and Related Research, Unviersity of Sheffield, Sheffield, UK
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10
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Sewalt CA, Wiegers EJA, Lecky FE, den Hartog D, Schuit SCE, Venema E, Lingsma HF. The volume-outcome relationship among severely injured patients admitted to English major trauma centres: a registry study. Scand J Trauma Resusc Emerg Med 2020; 28:18. [PMID: 32143661 PMCID: PMC7059707 DOI: 10.1186/s13049-020-0710-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/06/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Many countries have centralized and dedicated trauma centres with high volumes of trauma patients. However, the volume-outcome relationship in severely injured patients (Injury Severity Score (ISS) > 15) remains unclear. The aim of this study was to determine the association between hospital volume and outcomes in Major Trauma Centres (MTCs). METHODS A retrospective observational cohort study was conducted using the Trauma Audit and Research Network (TARN) consisting of all English Major Trauma Centres (MTCs). Severely injured patients (ISS > 15) admitted to a MTC between 2013 and 2016 were included. The effect of hospital volume on outcome was analysed with random effects logistic regression models with a random intercept for centre and was tested for nonlinearity. Primary outcome was in-hospital mortality. RESULTS A total of 47,157 severely injured patients from 28 MTCs were included in this study. Hospital volume varied from 69 to 781 severely injured patients per year. There were small between-centre differences in mortality after adjusting for important demographic and injury severity characteristics (adjusted 95% odds ratio range: 0.99-1.01). Hospital volume was found to be linear and not associated with in-hospital mortality (adjusted odds ratio (aOR) 1.02 per 10 patients, 95% confidence interval (CI) 0.68-1.54, p = 0.92). CONCLUSIONS Despite the large variation in volume of the included MTCs, no relationship between hospital volume and outcome of severely injured patients was found. These results suggest that centres with similar structure and processes of care can achieve comparable outcomes in severely injured patients despite the number of severely injured patients they treat.
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Affiliation(s)
- Charlie A Sewalt
- Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Fiona E Lecky
- School of Health and Related Research, Sheffield University. Salford Royal NHS Foundation Trust, Salford, UK.,Trauma Audit and Research Network, University of Manchester, Salford, Manchester, UK
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Stephanie C E Schuit
- Department of Emergency Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.,Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Esmee Venema
- Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
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11
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Marincowitz C, Lecky FE, Allgar V, Hutchinson P, Elbeltagi H, Johnson F, Quinn E, Tarantino S, Townend W, Kolias AG, Sheldon TA. Development of a Clinical Decision Rule for the Early Safe Discharge of Patients with Mild Traumatic Brain Injury and Findings on Computed Tomography Brain Scan: A Retrospective Cohort Study. J Neurotrauma 2019; 37:324-333. [PMID: 31588845 PMCID: PMC6964807 DOI: 10.1089/neu.2019.6652] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
International guidelines recommend routine hospital admission for all patients with mild traumatic brain injury (TBI) who have injuries on computed tomography (CT) brain scan. Only a small proportion of these patients require neurosurgical or critical care intervention. We aimed to develop an accurate clinical decision rule to identify low-risk patients safe for discharge from the emergency department (ED) and facilitate earlier referral of those requiring intervention. A retrospective cohort study of case notes of patients admitted with initial Glasgow Coma Scale 13–15 and injuries identified by CT was completed. Data on a primary outcome measure of clinically important deterioration (indicating need for hospital admission) and secondary outcome of neurosurgery, intensive care unit admission, or intubation (indicating need for neurosurgical admission) were collected. Multi-variable logistic regression was used to derive models and a risk score predicting deterioration using routinely reported clinical and radiological candidate variables identified in a systematic review. We compared the performance of this new risk score with the Brain Injury Guideline (BIG) criteria, derived in the United States. A total of 1699 patients were included from three English major trauma centers. A total of 27.7% (95% confidence interval [CI], 25.5–29.9) met the primary and 13.1% (95% CI, 11.6–14.8) met the secondary outcomes of deterioration. The derived clinical decision rule suggests that patients with simple skull fractures or intracranial bleeding <5 mm in diameter who are fully conscious could be safely discharged from the ED. The decision rule achieved a sensitivity of 99.5% (95% CI, 98.1–99.9) and specificity of 7.4% (95% CI, 6.0–9.1) to the primary outcome. The BIG criteria achieved the same sensitivity, but lower specificity (5%). Our empirical models showed good predictive performance and outperformed the BIG criteria. This would potentially allow ED discharge of 1 in 20 patients currently admitted for observation. However, prospective external validation and economic evaluation are required.
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Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Fiona E Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Victoria Allgar
- Hull York Medical School, John Hughlings Jackson Building, University of York, Heslington, United Kingdom
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Hadir Elbeltagi
- Emergency Department, Salford Royal Hospital, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Faye Johnson
- Salford Royal Hospital, Acute Research Delivery Team, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Eimhear Quinn
- Emergency Department, Salford Royal Hospital, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Silvia Tarantino
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Will Townend
- Emergency Department, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Trevor A Sheldon
- Department of Health Sciences, University of York, Alcuin Research Resource Centre, Heslington, United Kingdom
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12
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Sewalt CA, Venema E, Wiegers EJA, Lecky FE, Schuit SCE, den Hartog D, Steyerberg EW, Lingsma HF. Trauma models to identify major trauma and mortality in the prehospital setting. Br J Surg 2019; 107:373-380. [PMID: 31503341 PMCID: PMC7079101 DOI: 10.1002/bjs.11304] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/31/2019] [Accepted: 06/08/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with major trauma might benefit from treatment in a trauma centre, but early identification of major trauma (Injury Severity Score (ISS) over 15) remains difficult. The aim of this study was to undertake an external validation of existing prognostic models for injured patients to assess their ability to predict mortality and major trauma in the prehospital setting. METHODS Prognostic models were identified through a systematic literature search up to October 2017. Injured patients transported by Emergency Medical Services to an English hospital from the Trauma Audit and Research Network between 2013 and 2016 were included. Outcome measures were major trauma (ISS over 15) and in-hospital mortality. The performance of the models was assessed in terms of discrimination (concordance index, C-statistic) and net benefit to assess the clinical usefulness. RESULTS A total of 154 476 patients were included to validate six previously proposed prediction models. Discriminative ability ranged from a C-statistic value of 0·602 (95 per cent c.i. 0·596 to 0·608) for the Mechanism, Glasgow Coma Scale, Age and Arterial Pressure model to 0·793 (0·789 to 0·797) for the modified Rapid Emergency Medicine Score (mREMS) in predicting in-hospital mortality (11 882 patients). Major trauma was identified in 52 818 patients, with discrimination from a C-statistic value of 0·589 (0·586 to 0·592) for mREMS to 0·735 (0·733 to 0·737) for the Kampala Trauma Score in predicting major trauma. None of the prediction models met acceptable undertriage and overtriage rates. CONCLUSION Currently available prehospital trauma models perform reasonably in predicting in-hospital mortality, but are inadequate in identifying patients with major trauma. Future research should focus on which patients would benefit from treatment in a major trauma centre.
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Affiliation(s)
- C A Sewalt
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - E Venema
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.,Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - E J A Wiegers
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - F E Lecky
- School of Health and Related Research, Sheffield University, Salford Royal NHS Foundation Trust, Salford, UK.,Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - S C E Schuit
- Department of Emergency Medicine, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.,Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - D den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - E W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - H F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
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13
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Marincowitz C, Lecky FE, Morris E, Allgar V, Sheldon TA. Impact of the SIGN head injury guidelines and NHS 4-hour emergency target on hospital admissions for head injury in Scotland: an interrupted times series. BMJ Open 2018; 8:e022279. [PMID: 30580260 PMCID: PMC6318526 DOI: 10.1136/bmjopen-2018-022279] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Head injury is a common reason for emergency department (ED) attendance. Around 1% of patients have life-threatening injuries, while 80% of patients are discharged. National guidelines (Scottish Intercollegiate Guidelines Network (SIGN)) were introduced in Scotland with the aim of achieving early identification of those with acute intracranial lesions yet safely reducing hospital admissions.This study aims to assess the impact of these guidelines and any effect the national 4-hour ED performance target had on hospital admissions for head injury. SETTING All Scottish hospitals between April 1998 and March 2016. PARTICIPANTS Patients admitted to hospital for head injury or traumatic brain injury (TBI) diagnosed by CT imaging identified using administrative Scottish Information Services Division data. There are 275 hospitals in Scotland. In 2015/2016, there were 571 221 emergency hospital admissions in Scotland. INTERVENTIONS The SIGN head injury guidelines introduced in 2000 and 2009. The 4-hour ED target introduced in 2004. OUTCOMES The monthly rate of hospital admissions for head injury and traumatic brain injury. STUDY DESIGN An interrupted time series analysis. RESULTS The first guideline was associated with a reduction in monthly admissions of 0.14 (95% CI 0.09 to 4.83) per 100 000 population. The 4-hour target was associated with a monthly increase in admissions of 0.13 (95% CI 0.06 to 0.20) per 100 000 population. The second guideline reduced monthly admissions by 0.09 (95% CI-0.13 to -0.05) per 100 000 population. These effects varied between age groups.The guidelines were associated with increased admissions for patients with injuries identified by CT imaging-guideline 1: 0.06 (95% CI 0.004 to 0.12); guideline 2: 0.05 (95% CI 0.04 to 0.06) per 100 000 population. CONCLUSION Increased CT imaging of head injured patients recommended by SIGN guidelines reduced hospital admissions. The 4-hour ED target and the increased identification of TBI by CT imaging acted to undermine this effect.
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Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
| | - Fiona E Lecky
- University of Sheffield, School of Health and Related Research, Sheffield, UK
| | - Eleanor Morris
- Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
| | - Victoria Allgar
- Hull York Medical School, John Hughlings, University of York, York, UK
| | - Trevor A Sheldon
- Department of Health Sciences, Alcuin Research Resource Centre, University of York, York, UK
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14
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Gabbe BJ, Dipnall JF, Lynch JW, Rivara FP, Lyons RA, Ameratunga S, Brussoni M, Lecky FE, Bradley C, Simpson PM, Beck B, Demmler JC, Lyons J, Schneeberg A, Harrison JE. Validating injury burden estimates using population birth cohorts and longitudinal cohort studies of injury outcomes: the VIBES-Junior study protocol. BMJ Open 2018; 8:e024755. [PMID: 30082368 PMCID: PMC6078268 DOI: 10.1136/bmjopen-2018-024755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Traumatic injury is a leading contributor to the global disease burden in children and adolescents, but methods used to estimate burden do not account for differences in patterns of injury and recovery between children and adults. A lack of empirical data on postinjury disability in children has limited capacity to derive valid disability weights and describe the long-term individual and societal impacts of injury in the early part of life. The aim of this study is to establish valid estimates of the burden of non-fatal injury in children and adolescents. METHODS AND ANALYSIS Five longitudinal studies of paediatric injury survivors <18 years at the time of injury (Australia, Canada, UK and USA) and two whole-of-population linked administrative data paediatric studies (Australia and Wales) will be analysed over a 3-year period commencing 2018. Meta-analysis of deidentified patient-level data (n≈2,600) from five injury-specific longitudinal studies (Victorian State Trauma Registry; Victorian Orthopaedic Trauma Outcomes Registry; UK Burden of Injury; British Columbia Children's Hospital Longitudinal Injury Outcomes; Children's Health After Injury) and >1 million children from two whole-of-population cohorts (South Australian Early Childhood Data Project and Wales Electronic Cohort for Children). Systematic analysis of pooled injury-specific cohort data using a variety of statistical techniques, and parallel analysis of whole-of-population cohorts, will be used to develop estimated disability weights for years lost due to disability, establish appropriate injury classifications and explore factors influencing recovery. ETHICS AND DISSEMINATION The project was approved by the Monash University Human Research Ethics Committee project number 12 311. Results of this study will be submitted for publication in internationally peer-reviewed journals. The findings from this project have the capacity to improve the validity of paediatric injury burden measurements in future local and global burden of disease studies.
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Affiliation(s)
- Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University, Swansea, UK
- National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, UK
| | - Joanna F Dipnall
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - John W Lynch
- School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Frederick P Rivara
- Departments of Pediatrics and Epidemiology, and the Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Ronan A Lyons
- Health Data Research UK, Swansea University, Swansea, UK
- National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, UK
| | - Shanthi Ameratunga
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Mariana Brussoni
- Department of Pediatrics, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- British Columbia Injury Research and Prevention Unit, Children's Hospital Research Institute, Vancouver, Canada
| | - Fiona E Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Clare Bradley
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Pam M Simpson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Jane Lyons
- Health Data Research UK, Swansea University, Swansea, UK
| | - Amy Schneeberg
- British Columbia Injury Research and Prevention Unit, Children's Hospital Research Institute, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - James E Harrison
- Research Centre for Injury Studies, Flinders University, Adelaide, South Australia, Australia
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15
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Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis. J Neurotrauma 2018; 35:703-718. [PMID: 29324173 PMCID: PMC5831640 DOI: 10.1089/neu.2017.5259] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.
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Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Fiona E. Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - William Townend
- Emergency Department, Hull and East Yorkshire NHS Trust, Hull, United Kingdom
| | - Aditya Borakati
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Andrea Fabbri
- Emergency Unit, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, Forlì, Italy
| | - Trevor A. Sheldon
- Department of Health Sciences, University of York, Alcuin Research Resource Center, Heslington, York, United Kingdom
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16
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Talbot C, Davis N, Majid I, Young M, Bouamra O, Lecky FE, Jones S. Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks. Bone Joint J 2018; 100-B:109-118. [PMID: 29305459 DOI: 10.1302/0301-620x.100b1.bjj-2016-1315.r3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.
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Affiliation(s)
- C Talbot
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - N Davis
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - I Majid
- Royal Manchester Children's Hospital
| | - M Young
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - O Bouamra
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - F E Lecky
- University of Sheffield, School of Health and Related Research, Western Bank, Sheffield S10 2TN, UK
| | - S Jones
- Royal Manchester Children's Hospital
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17
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Marincowitz C, Lecky FE, Townend W, Allgar V, Fabbri A, Sheldon TA. A protocol for the development of a prediction model in mild traumatic brain injury with CT scan abnormality: which patients are safe for discharge? Diagn Progn Res 2018; 2:6. [PMID: 31093556 PMCID: PMC6460841 DOI: 10.1186/s41512-018-0027-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 04/10/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Head injury is an extremely common clinical presentation to hospital emergency departments (EDs). Ninety-five percent of patients present with an initial Glasgow Coma Scale (GCS) score of 13-15, indicating a normal or near-normal conscious level. In this group, around 7% of patients have brain injuries identified by CT imaging but only 1% of patients have life-threatening brain injuries. It is unclear which brain injuries are clinically significant, so all patients with brain injuries identified by CT imaging are admitted for monitoring. If risk could be accurately determined in this group, admissions for low-risk patients could be avoided and resources could be focused on those with greater need.This study aims to (a) estimate the proportion of GCS13-15 patients with traumatic brain injury identified by CT imaging admitted to hospital who clinically deteriorate and (b) develop a prognostic model highly sensitive to clinical deterioration which could help inform discharge decision making in the ED. METHODS A retrospective case note review of 2000 patients with an initial GCS13-15 and traumatic brain injury identified by CT imaging (2007-2017) will be completed in two English major trauma centres. The prevalence of clinically significant deterioration including death, neurosurgery, intubation, seizures or drop in GCS by more than 1 point will be estimated. Candidate prognostic factors have been identified in a previous systematic review. Multivariable logistic regression will be used to derive a prognostic model, and its sensitivity and specificity to the outcome of deterioration will be explored. DISCUSSION This study will potentially derive a statistical model that predicts clinically relevant deterioration and could be used to develop a clinical risk tool guiding the need for hospital admission in this group.
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Affiliation(s)
- Carl Marincowitz
- 0000 0004 0412 8669grid.9481.4Hull York Medical School, University of Hull, Allam Medical Building, Hull, HU6 7RX UK
| | - Fiona E. Lecky
- 0000 0004 1936 9262grid.11835.3eSchool of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA UK
| | - William Townend
- grid.417700.5Emergency Department, Hull and East Yorkshire NHS Trust, Anlaby Road, Hull, HU3 2JZ UK
| | - Victoria Allgar
- 0000 0004 1936 9668grid.5685.eHull York Medical School, University of York, John Hughlings Jackson Building, Heslington, York, YO10 5DD UK
| | - Andrea Fabbri
- Emergency Unit, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, via Forlanini 34, 47121 Forlì, FC Italy
| | - Trevor A. Sheldon
- 0000 0004 1936 9668grid.5685.eDepartment of Health Sciences, Alcuin Research Resource Centre, University of York, Heslington, York, YO10 5DD UK
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Reith FCM, Lingsma HF, Gabbe BJ, Lecky FE, Roberts I, Maas AIR. Differential effects of the Glasgow Coma Scale Score and its Components: An analysis of 54,069 patients with traumatic brain injury. Injury 2017; 48:1932-1943. [PMID: 28602178 DOI: 10.1016/j.injury.2017.05.038] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 05/16/2017] [Accepted: 05/29/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Glasgow Coma Scale (GCS) is widely used in the assessment of clinical severity and prediction of outcome after traumatic brain injury (TBI). The sum score is frequently applied, but the differential influence of the components infrequently addressed. We aimed to investigate the contribution of the GCS components to the sum score, floor and ceiling effects of the components, and their prognostic effects. METHODS Data on adult TBI patients were gathered from three data repositories: TARN (n=50,064), VSTR (n=14,062), and CRASH (n=9,941). Data on initial hospital GCS-assessment and discharge mortality were extracted. A descriptive analysis was performed to identify floor and ceiling effects. The relation between GCS and outcome was studied by comparing case fatality rates (CFR) between different component-profiles adding up to identical sum scores using Chi2-tests, and by quantifying the prognostic value of each component and sum score with Nagelkerke's R2 derived from logistic regression analyses across TBI severities. RESULTS In the range 3-7, the sum score is primarily determined by the motor component, as the verbal and eye components show floor-effects at sum scores 7 and 8, respectively. In the range 8-12, the effect of the motor component attenuates and the verbal and eye components become more relevant. The motor, eye and verbal scores reach their ceiling-effects at sum 13, 14 and 15, respectively. Significant variations were exposed in CFR between different component-profiles despite identical sum scores, except in sum scores 6 and 7. Regression analysis showed that the motor score had highest R2 values in severe TBI patients, whereas the other components were more relevant at higher sum scores. The prognostic value of the three components combined was consistently higher than that of the sum score alone. CONCLUSION The GCS-components contribute differentially across the spectrum of consciousness to the sum score, each having floor and ceiling effects. The specific component-profile is related to outcome and the three components combined contain higher prognostic value than the sum score across different TBI severities. We, therefore, recommend a multidimensional use of the three-component GCS both in clinical practice, and in prognostic studies.
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Affiliation(s)
- Florence C M Reith
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Belinda J Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; The Farr Institute @ CIPHER, Swansea University, Singleton Park, UK
| | - Fiona E Lecky
- Emergency Medicine Research in Sheffield (EMRiS) Group, Health Services Research, School of Health and Related Research (SCHaRR), University of Sheffield, Sheffield, UK; Trauma Audit and Research Network, Centre for Epidemiology, Institute of Population Health, Health Service Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Salford Royal Hospital, Salford, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Battle C, Abbott Z, Hutchings HA, O’Neill C, Groves S, Watkins A, Lecky FE, Jones S, Gagg J, Body R, Evans PA. Protocol for a multicentre randomised feasibility STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients: STUMBL trial. BMJ Open 2017; 7:e015972. [PMID: 28698337 PMCID: PMC5541613 DOI: 10.1136/bmjopen-2017-015972] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION A new prognostic model has been developed and externally validated, the aim of which is to assist in the management of the blunt chest wall trauma patient in the emergency department (ED). A definitive randomised controlled trial (impact trial) is required to assess the clinical and cost effectiveness of the new model before it can be accepted in clinical practice. The purpose of this trial is to assess the feasibility and acceptability of such a definitive trial and inform its design. METHODS/ANALYSIS This feasibility trial is designed to test the methods of a multicentre, cluster-randomised (stepped- wedge) trial, with a substantial qualitative component. Four EDs in England and Wales will collect data for all blunt chest wall trauma patients over a 5-month period; in the initial period acting as the controls (normal care), and in the second period acting as the interventions (in which the new model will be used). Baseline measurements including completion of the SF-12v2 will be obtained on initial assessment in the ED. Patient outcome data will then be collected for any subsequent hospitalisations. Data collection will conclude with a 6-week follow-up completion of two surveys (SF-12v2 and Client Services Receipt Inventory). Analysis of outcomes will focus on feasibility, acceptability and trial processes and will include recruitment and retention rates, attendance at clinician training rates and use of model in the ED. Qualitative feedback will be obtained through clinician interviews and a research nurse focus group. An evaluation of the feasibility of health economics outcomes data will be completed. ETHICS AND DISSEMINATION Wales Research Ethics Committee 6 granted approval for the trial in September 2016. Patient recruitment will commence in February 2017. Planned dissemination is through publication in a peer-reviewed Emergency Medicine Journal, presentation at appropriate conferences and to stakeholders at professional meetings. TRIAL REGISTRATION NUMBER ISRCTN95571506; Pre-results.
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Affiliation(s)
- Ceri Battle
- Emergency Department, Welsh Institute of Biomedical and Emergency Medicine Research, Morriston Hospital, Swansea, UK
| | - Zoe Abbott
- Swansea University Medical School,Swansea University, Swansea, UK
| | | | - Claire O’Neill
- Swansea University Medical School,Swansea University, Swansea, UK
| | - Sam Groves
- College of Human and Health Sciences,Swansea University, Swansea, UK
| | - Alan Watkins
- Swansea University Medical School,Swansea University, Swansea, UK
| | - Fiona E Lecky
- School of Health and Related Research,Sheffield University. Salford Royal NHS Foundation Trust, Salford, UK
| | - Sally Jones
- Emergency Department, Royal Gwent Hospital, Newport, UK
| | - James Gagg
- Emergency Department, Musgrove Park Hospital, Taunton, UK
| | - Richard Body
- Emergency Department, Manchester Royal Infirmary, Manchester, UK
| | - Philip A Evans
- Emergency Department, Welsh Institute of Biomedical and Emergency Medicine Research, Morriston Hospital, Swansea, UK
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20
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Body R, Boachie C, McConnachie A, Carley S, Van Den Berg P, Lecky FE. Feasibility of the Manchester Acute Coronary Syndromes (MACS) decision rule to safely reduce unnecessary hospital admissions: a pilot randomised controlled trial. Emerg Med J 2017; 34:586-592. [PMID: 28500087 PMCID: PMC5574380 DOI: 10.1136/emermed-2016-206148] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 02/03/2017] [Accepted: 02/23/2017] [Indexed: 12/27/2022]
Abstract
Background Observational studies suggest that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively ‘rule out’ and ‘rule in’ acute coronary syndromes (ACS) following a single blood test. In a pilot randomised controlled trial, we aimed to determine whether a large trial is feasible. Methods Patients presenting to two EDs with suspected cardiac chest pain were randomised to receive care guided by the MACS decision rule (intervention group) or standard care (controls). The primary efficacy outcome was a successful discharge from the ED, defined as a decision to discharge within 4 hours of arrival providing that the patient did not have a missed acute myocardial infarction (AMI) or develop a major adverse cardiac event (MACE: death, AMI or coronary revascularisation) within 30 days. Feasibility outcomes included recruitment and attrition rates. Results In total, 138 patients were included between October 2013 and October 2014, of whom 131 (95%) were randomised (66 to intervention and 65 controls). Nine (7%) patients had prevalent AMI and six (5%) had incident MACE within 30 days. All 131 patients completed 30-day follow-up and were included in the final analysis with no missing data for the primary analyses. Compared with standard care, a significantly greater proportion of patients whose care was guided by the MACS rule were successfully discharged within 4 hours (26% vs 8%, adjusted OR 5.45, 95% CI 1.73 to 17.11, p=0.004). No patients in either group who were discharged within 4 hours had a diagnosis of AMI or incident MACE within 30 days (0.0%, 95% CI 0% to 20.0% in the intervention group). Conclusions In this pilot trial, use of the MACS rule led to a significant increase in safe discharges from the ED but a larger, fully powered trial remains necessary. Our findings seem to support the feasibility of that trial. Trial registration number ISRCTN 86818215. Research Ethics Committee reference 13/NW/0081. UKCRN registration ID 14334.
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Affiliation(s)
- Richard Body
- Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK
| | - Charles Boachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Simon Carley
- Emergency Department, Central Manchester University Hospitals Foundation NHS Trust, Manchester, UK.,Healthcare Sciences, Manchester Metropolitan University, Manchester, UK
| | | | - Fiona E Lecky
- Emergency Department, Salford Royal Infirmary, Manchester, UK
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21
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Davies FC, Lecky FE, Fisher R, Fragoso-Iiguez M, Coats TJ. Major trauma from suspected child abuse: a profile of the patient pathway. Emerg Med J 2017; 34:562-567. [DOI: 10.1136/emermed-2016-206296] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 12/29/2016] [Accepted: 01/12/2017] [Indexed: 02/03/2023]
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Metcalfe D, Perry DC, Bouamra O, Salim A, Woodford M, Edwards A, Lecky FE, Costa ML. Regionalisation of trauma care in England. Bone Joint J 2017; 98-B:1253-61. [PMID: 27587529 DOI: 10.1302/0301-620x.98b9.37525] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 05/09/2016] [Indexed: 02/03/2023]
Abstract
AIMS We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England. PATIENTS AND METHODS An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital. RESULTS AND CONCLUSION A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.
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Affiliation(s)
- D Metcalfe
- University of Oxford, NDORMS, Oxford, OX3 7HE, UK
| | - D C Perry
- University of Liverpool, Liverpool, Institute of Translational Medicine, Liverpool, L12 2AP, UK
| | - O Bouamra
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester, M6 8HD, UK
| | - A Salim
- Harvard Medical School, Center for Surgery and Public Health, Boston, MA 02115, USA
| | - M Woodford
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester, M6 8HD, UK
| | - A Edwards
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester, M6 8HD, UK
| | - F E Lecky
- University of Sheffield, School of Health and Related Research, Sheffield, S1 4DA, UK
| | - M L Costa
- University of Oxford, NDORMS, Oxford, OX3 7HE, UK
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23
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Metcalfe D, Perry DC, Bouamra O, Salim A, Lecky FE, Woodford M, Edwards A, Costa ML. Is there a ‘weekend effect’ in major trauma? Emerg Med J 2016; 33:836-842. [DOI: 10.1136/emermed-2016-206049] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/30/2016] [Accepted: 07/04/2016] [Indexed: 11/03/2022]
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Abstract
Introduction Non-accidental injury (NAI) in children is an important cause of major injury. The Trauma Audit Research Network (TARN) recently analysed data on the demographics of paediatric trauma and highlighted NAI as a major cause of death and severe injury in children. This paper examined TARN data to characterise accidental versus abusive cases of major injury. Methods The national trauma registry of England and Wales (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals’ submissions were classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons. Results In the study population of 14 845 children, 13 708 (92.3%, CI 91.9% to 92.8%) were classified as accidental injury, 368 as alleged assault (2.5%, CI 2.2% to 2.7%) and 769 as SCA (5.2%, CI 4.8% to 5.5%). Nearly all cases of severely injured children suffering trauma because of SCA occurred in the age group of 0–5 years (751 of 769, 97.7%), with 76.3% occurring in infants under the age of 1 year. Compared with accidental injury, suspected victims of abuse have higher overall injury severity scores, have a higher proportion of head injury and a threefold higher mortality rate of 7.6% (CI 5.51% to 9.68%) vs 2.6% (CI 2.3% to 2.9%). Conclusions This study highlights that major injury occurring as a result of SCA has a typical demographic pattern. These children tend to be under 12 months of age, with more severe injury. Understanding these demographics could help receiving hospitals identify children with major injuries resulting from abuse and ensure swift transfer to specialist care.
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Affiliation(s)
- Ffion C Davies
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Timothy J Coats
- Department of Emergency Medicine, University of Leicester, Leicester, UK
| | - Ross Fisher
- Department of Surgery, Sheffield Children's Hospital, Sheffield, UK
| | - Thomas Lawrence
- Trauma Audit Research Network, Salford Royal NHS Foundation Trust, Salford, UK
| | - Fiona E Lecky
- Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Grieve R, Sadique Z, Gomes M, Smith M, Lecky FE, Hutchinson PJA, Menon DK, Rowan KM, Harrison DA. An evaluation of the clinical and cost-effectiveness of alternative care locations for critically ill adult patients with acute traumatic brain injury. Br J Neurosurg 2016; 30:388-96. [PMID: 27188663 DOI: 10.3109/02688697.2016.1161166] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre. METHODS The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses. FINDINGS Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000. CONCLUSIONS For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced mortality, improvement in QOL and is cost-effective.
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Affiliation(s)
- R Grieve
- a Department of Health Services Research and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - Z Sadique
- a Department of Health Services Research and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - M Gomes
- a Department of Health Services Research and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - M Smith
- b National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust , London , UK
| | - F E Lecky
- c School of Health and Related Research, University of Sheffield , Sheffield , UK
| | - P J A Hutchinson
- d School of Clinical Medicine, University of Cambridge , Cambridge , UK
| | - D K Menon
- d School of Clinical Medicine, University of Cambridge , Cambridge , UK
| | - K M Rowan
- e Clinical Trials Unit, Intensive Care National Audit and Research Centre , London , UK
| | - D A Harrison
- e Clinical Trials Unit, Intensive Care National Audit and Research Centre , London , UK
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Stanworth SJ, Davenport R, Curry N, Seeney F, Eaglestone S, Edwards A, Martin K, Allard S, Woodford M, Lecky FE, Brohi K. Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice. Br J Surg 2016; 103:357-65. [DOI: 10.1002/bjs.10052] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/15/2015] [Accepted: 10/12/2015] [Indexed: 12/18/2022]
Abstract
Abstract
Background
The aim of this study was to describe the prevalence, patterns of blood use and outcomes of major haemorrhage in trauma.
Methods
This was a prospective observational study from 22 hospitals in the UK, including both major trauma centres and smaller trauma units. Eligible patients received at least 4 units of packed red blood cells (PRBCs) in the first 24 h of admission with activation of the massive haemorrhage protocol. Case notes, transfusion charts, blood bank records and copies of prescription/theatre charts were accessed and reviewed centrally. Study outcomes were: use of blood components, critical care during hospital stay, and mortality at 24 h, 30 days and 1 year. Data were used to estimate the national trauma haemorrhage incidence.
Results
A total of 442 patients were identified during a median enrolment interval of 20 (range 7–24) months. Based on this, the national incidence of trauma haemorrhage was estimated to be 83 per million. The median age of patients in the study cohort was 38 years and 73·8 per cent were men. The incidence of major haemorrhage increased markedly in patients aged over 65 years. Thirty-six deaths within 24 h of admission occurred within the first 3 h. At 24 h, 79 patients (17·9 per cent) had died, but mortality continued to rise even after discharge. Patients who received a cumulative ratio of fresh frozen plasma to PRBCs of at least 1 : 2 had lower rates of death than those who received a lower ratio. There were delays in administration of blood. Platelets and cryoprecipitate were either not given, or transfused well after initial resuscitation.
Conclusion
There is a high burden of trauma haemorrhage that affects all age groups. Research is required to understand the reasons for death after the first 24 h and barriers to timely transfusion support.
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Affiliation(s)
- S J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - R Davenport
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Curry
- Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - F Seeney
- NHS Blood and Transplant, Statistics and Clinical Studies, Bristol, UK
| | - S Eaglestone
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Edwards
- Trauma Audit and Research, Academic Health Science Centre, Institute of Population Health, University of Manchester, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - K Martin
- NHS Blood and Transplant, Statistics and Clinical Studies, Bristol, UK
| | - S Allard
- University of Sheffield/University of Manchester/Salford Royal Hospitals NHS Foundation Trust, EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - M Woodford
- Trauma Audit and Research, Academic Health Science Centre, Institute of Population Health, University of Manchester, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - F E Lecky
- University of Sheffield/University of Manchester/Salford Royal Hospitals NHS Foundation Trust, EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - K Brohi
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Battle CE, Lecky FE, Stacey T, Edwards A, Evans PA. Management of the anticoagulated trauma patient in the emergency department: a survey of current practice in England and Wales. Emerg Med J 2016; 33:403-7. [PMID: 26727974 DOI: 10.1136/emermed-2015-205120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/13/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim of this study was to investigate current management of the anticoagulated trauma patient in the emergency departments (EDs) in England and Wales. METHODS A survey exploring management strategies for anticoagulated trauma patients presenting to the ED was developed with two patient scenarios concerning assessment of coagulation status, reversal of international normalised ratio (INR), management of hypotension and management strategies for each patient. Numerical data are presented as percentages of total respondents to that particular question. RESULTS 106 respondents from 166 hospitals replied to the survey, with 24% of respondents working in a major trauma unit with a specialist neurosurgical unit. Variation was reported in the assessment and management strategies of the elderly anticoagulated poly-trauma patient described in scenario one. Variation was also evident in the responses between the neurosurgical and non-neurosurgical units for the head-injured, anticoagulated trauma patient in scenario two. CONCLUSION The results of this study highlight the similarities and variation in the management strategies used in the EDs in England and Wales for the elderly, anticoagulated trauma patient. The variations in practice reported may be due to the differences evident in the available guidelines for these patients.
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Affiliation(s)
- Ceri E Battle
- NISCHR Haemostasis Biomedical Research Unit Epidemiology Division, Morriston Hospital, Swansea, UK
| | - Fiona E Lecky
- The Trauma Audit and Research Network, University of Manchester, University of Sheffield/University of Manchester/Salford Royal Hospital NHS Foundation Trust. Emergency Medicine Research in Sheffield (EMRiS), Health Services Research, School of Health and Related Research, Sheffield, UK
| | - Tom Stacey
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Antoinette Edwards
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Phillip A Evans
- NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK
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Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, Abera SF, Abraham JP, Adofo K, Alsharif U, Ameh EA, Ammar W, Antonio CAT, Barrero LH, Bekele T, Bose D, Brazinova A, Catalá-López F, Dandona L, Dandona R, Dargan PI, De Leo D, Degenhardt L, Derrett S, Dharmaratne SD, Driscoll TR, Duan L, Petrovich Ermakov S, Farzadfar F, Feigin VL, Franklin RC, Gabbe B, Gosselin RA, Hafezi-Nejad N, Hamadeh RR, Hijar M, Hu G, Jayaraman SP, Jiang G, Khader YS, Khan EA, Krishnaswami S, Kulkarni C, Lecky FE, Leung R, Lunevicius R, Lyons RA, Majdan M, Mason-Jones AJ, Matzopoulos R, Meaney PA, Mekonnen W, Miller TR, Mock CN, Norman RE, Orozco R, Polinder S, Pourmalek F, Rahimi-Movaghar V, Refaat A, Rojas-Rueda D, Roy N, Schwebel DC, Shaheen A, Shahraz S, Skirbekk V, Søreide K, Soshnikov S, Stein DJ, Sykes BL, Tabb KM, Temesgen AM, Tenkorang EY, Theadom AM, Tran BX, Vasankari TJ, Vavilala MS, Vlassov VV, Woldeyohannes SM, Yip P, Yonemoto N, Younis MZ, Yu C, Murray CJL, Vos T. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev 2015; 22:3-18. [PMID: 26635210 PMCID: PMC4752630 DOI: 10.1136/injuryprev-2015-041616] [Citation(s) in RCA: 779] [Impact Index Per Article: 86.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 07/30/2015] [Indexed: 12/14/2022]
Abstract
Background The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country. Methods Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures. Results In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries. Conclusions Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.
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Affiliation(s)
- Juanita A Haagsma
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA ErasmusMC, Rotterdam, Netherlands
| | - Nicholas Graetz
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Ian Bolliger
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Hideki Higashi
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Erin C Mullany
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Semaw Ferede Abera
- Mekelle University, College of Health Sciences, School of Public Health, Mekelle, Tigray, Ethiopia Kilte Awlaelo-Health and Demographic Surveillance Site, Mekelle, Tigray, Ethiopia
| | - Jerry Puthenpurakal Abraham
- University of Southern California (USC) Family Medicine Residency Program at California Hospital, a Dignity Health member, Los Angeles, California, USA Harvard School of Public Health/Harvard Institute for Global Health, Boston, Massachusetts, USA
| | - Koranteng Adofo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
| | | | | | | | - Carl Abelardo T Antonio
- Department of Health Policy and Administration, College of Public Health, University of the Philippines Manila, Manila, Philippines
| | - Lope H Barrero
- Department of Industrial Engineering, Pontificia Universidad Javeriana, Bogota, Cundinamarca, Colombia
| | - Tolesa Bekele
- Madawalabu University, Ethiopia, Bale Goba, Oromia, Ethiopia
| | | | - Alexandra Brazinova
- Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Ferrán Catalá-López
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Medicines and Healthcare Products Agency (AEMPS), Ministry of Health, Madrid, Spain
| | - Lalit Dandona
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA Public Health Foundation of India, New Delhi, India
| | | | - Paul I Dargan
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Diego De Leo
- Griffith University, Brisbane, Queensland, Australia
| | | | - Sarah Derrett
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand School of Public Health, College of Health, Massey University, Palmerston North, New Zealand
| | | | - Tim R Driscoll
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Leilei Duan
- National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC, Beijing, China
| | - Sergey Petrovich Ermakov
- The Institute of Social and Economic Studies of Population at the Russian Academy of Sciences, Moscow, Russia Federal Research Institute for Health Organization and Informatics of Ministry of Health of Russian Federation, Moscow, Russia
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrine and Metabolic Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, AUT University, Auckland, New Zealand
| | | | | | - Richard A Gosselin
- University of California in San Francisco, San Francisco, California, USA
| | - Nima Hafezi-Nejad
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Martha Hijar
- Fundacion Entornos AC, Cuernavaca, Morelos, Mexico
| | - Guoqing Hu
- Central South University, School of Public Health, Changsha, Hunan, China
| | | | - Guohong Jiang
- Tianjin Centers for Diseases Control and Prevention, Tianjin, China
| | | | - Ejaz Ahmad Khan
- Health Services Academy, Islamabad, Punjab, Pakistan Expanded Programme on Immunization, Islamabad, Punjab, Pakistan
| | | | - Chanda Kulkarni
- Rajrajeswari Medical College & Hospital, Bangalore, Karnataka, India
| | - Fiona E Lecky
- EMRiS, Health Services Research, University of Sheffield, Sheffield, South Yorkshire, UK
| | | | - Raimundas Lunevicius
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK School of Medicine, University of Liverpool, Liverpool, UK
| | | | - Marek Majdan
- Faculty of Health Sciences and Social Work, Department of Public Health, Trnava University, Trnava, Slovakia
| | | | - Richard Matzopoulos
- South African Medical Research Council, Cape Town, South Africa University of Cape Town School of Public Health and Family Medicine, Cape Town, South Africa
| | - Peter A Meaney
- Pereleman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Children's Hospital of Philadelphia
| | | | - Ted R Miller
- Pacific Institute for Research & Evaluation, Calverton, Maryland, USA Curtin University Centre for Population Health, Perth, Western Australia, Australia
| | | | - Rosana E Norman
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ricardo Orozco
- National Institute of Psychiatry, Mexico City, Distrito Federal, Mexico
| | | | - Farshad Pourmalek
- University of British Columbia, School of Population and Public Health, Vancouver, British Columbia, Canada
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - David Rojas-Rueda
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Catalonia, Spain
| | - Nobhojit Roy
- BARC Hospital, HBNI University, Mumbai, Maharashtra, India Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | | | - Sergey Soshnikov
- Federal Research Institute for Health Organization and Informatics of Ministry of Health of the Russian Federation was founded in 1999 by the order of Ministry of Health of Russia, Moscow, Russia
| | - Dan J Stein
- University of Cape Town, Cape Town, Western Province, South Africa MRC Unit on Anxiety & Stress Disorders, Cape Town, Western Cape, South Africa
| | | | - Karen M Tabb
- University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | | | | | | | - Bach Xuan Tran
- Johns Hopkins University, Baltimore, Maryland, USA Hanoi Medical University, Hanoi, Vietnam
| | | | | | | | | | - Paul Yip
- The University of Hong Kong, Hong Kong, China
| | - Naohiro Yonemoto
- National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | | | - Chuanhua Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Wuhan, Hubei, China Global Health Institute, Wuhan University, Wuhan, China
| | | | - Theo Vos
- Institute for Health Metrics and Evaluation, Seattle, Washington, USA
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Davies F, Coats T, Lecky FE. A 10-YEAR DEMOGRAPHIC COMPARISON OF MAJOR TRAUMA AS A RESULT OF NON-ACCIDENTAL INJURY VERSUS ACCIDENTAL INJURY IN THE UK. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hunt P, Bouamra O, Jenks T, Lecky FE, Edwards A, Woodford M, Yates D, Han K. EARLY WHOLE BODY VERSUS FOCUSED COMPUTED TOMOGRAPHY IMAGING FOLLOWING MAJOR TRAUMA: EXISTING EVIDENCE AND ANALYSIS OF 10 YEARS OF TARN DATA. Arch Emerg Med 2015. [DOI: 10.1136/emermed-2015-205372.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Campbell HE, Stokes EA, Bargo DN, Curry N, Lecky FE, Edwards A, Woodford M, Seeney F, Eaglestone S, Brohi K, Gray AM, Stanworth SJ. Quantifying the healthcare costs of treating severely bleeding major trauma patients: a national study for England. Crit Care 2015; 19:276. [PMID: 26148506 PMCID: PMC4517367 DOI: 10.1186/s13054-015-0987-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/12/2015] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Severely bleeding trauma patients are a small proportion of the major trauma population but account for 40% of all trauma deaths. Healthcare resource use and costs are likely to be substantial but have not been fully quantified. Knowledge of costs is essential for developing targeted cost reduction strategies, informing health policy, and ensuring the cost-effectiveness of interventions. METHODS In collaboration with the Trauma Audit Research Network (TARN) detailed patient-level data on in-hospital resource use, extended care at hospital discharge, and readmissions up to 12 months post-injury were collected on 441 consecutive adult major trauma patients with severe bleeding presenting at 22 hospitals (21 in England and one in Wales). Resource use data were costed using national unit costs and mean costs estimated for the cohort and for clinically relevant subgroups. Using nationally available data on trauma presentations in England, patient-level cost estimates were up-scaled to a national level. RESULTS The mean (95% confidence interval) total cost of initial hospital inpatient care was £19,770 (£18,177 to £21,364) per patient, of which 62% was attributable to ventilation, intensive care, and ward stays, 16% to surgery, and 12% to blood component transfusion. Nursing home and rehabilitation unit care and re-admissions to hospital increased the cost to £20,591 (£18,924 to £22,257). Costs were significantly higher for more severely injured trauma patients (Injury Severity Score ≥15) and those with blunt injuries. Cost estimates for England were £148,300,000, with over a third of this cost attributable to patients aged 65 years and over. CONCLUSIONS Severely bleeding major trauma patients are a high cost subgroup of all major trauma patients, and the cost burden is projected to rise further as a consequence of an aging population and as evidence continues to emerge on the benefits of early and simultaneous administration of blood products in pre-specified ratios. The findings from this study provide a previously unreported baseline from which the potential impact of changes to service provision and/or treatment practice can begin to be evaluated. Further studies are still required to determine the full costs of post-discharge care requirements, which are also likely to be substantial.
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Affiliation(s)
- Helen E Campbell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Danielle N Bargo
- Eli Lilly and Company Limited, Lilly House, Priestley Road, Basingstoke, Hampshire, RG24 9NL, UK.
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, OX3 7LE, UK.
| | - Fiona E Lecky
- Trauma Audit and Research Network, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | - Antoinette Edwards
- Trauma Audit and Research Network, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | - Maralyn Woodford
- Trauma Audit and Research Network, 3rd Floor Mayo Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
| | - Frances Seeney
- NHS Blood and Transplant Clinical Trials Unit, Fox Den Road, Stoke Gifford, Bristol, BS34 8RR, UK.
| | - Simon Eaglestone
- Blizard Institute, Barts and The London School of Medicine and Dentistry, The Blizard Building, 4 Newark Street, London, E1 2AT, UK.
| | - Karim Brohi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, The Blizard Building, 4 Newark Street, London, E1 2AT, UK.
| | - Alastair M Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - Simon J Stanworth
- NHS Blood and Transplant and Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9BQ, UK.
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Harrison DA, Griggs KA, Prabhu G, Gomes M, Lecky FE, Hutchinson PJA, Menon DK, Rowan KM. External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom. J Neurotrauma 2015; 32:1522-37. [PMID: 25898072 DOI: 10.1089/neu.2014.3628] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Scale score of less than 15 were recruited. The primary outcomes were mortality and unfavorable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3626 critical care unit admissions, 2975 were analyzed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavorable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven and colleagues, the Medical Research Council (MRC) Corticosteroid Randomisation After Significant Head Injury (CRASH) Trial Collaborators, and the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) group. The model with the best discrimination was the IMPACT "Lab" model (C index, 0.779 for mortality and 0.713 for unfavorable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavorable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavorable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research.
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Affiliation(s)
- David A Harrison
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Kathryn A Griggs
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Gita Prabhu
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
| | - Manuel Gomes
- 2 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine , London, United Kingdom
| | - Fiona E Lecky
- 3 School of Health and Related Research, University of Sheffield , Regent Court, Sheffield, United Kingdom
| | - Peter J A Hutchinson
- 4 Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - David K Menon
- 5 Division of Anaesthesia, University of Cambridge , Cambridge, United Kingdom
| | - Kathryn M Rowan
- 1 Clinical Trials Unit, Intensive Care National Audit and Research Centre , Napier House, London, United Kingdom
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Metcalfe D, Bouamra O, Parsons NR, Aletrari MO, Lecky FE, Costa ML. Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres. Br J Surg 2014; 101:959-64. [PMID: 24915789 DOI: 10.1002/bjs.9498] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Centralization of complex healthcare services into specialist high-volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients. METHODS A retrospective before-after study was undertaken of severely injured patients attending four hospitals that became major trauma centres (MTCs) in March 2012. Consecutive patients with major trauma were identified from a national registry and divided into two groups according to injury before or after the launch of a new trauma network. The two cohorts were compared for differences in case mix, demand on hospital resources, and outcomes. RESULTS Patient volume increased from 442 to 1326 (200 per cent), operations from 349 to 1231 (253 per cent), critical care bed-days from 1100 to 3704 (237 per cent), and total hospital bed-days from 7910 to 22,772 (188 per cent). Patient age increased on MTC designation from 45.0 years before March 2012 to 48.2 years afterwards (P = 0.021), as did the proportion of penetrating injuries (1.8 versus 4.1 per cent; P = 0.025). Injury severity fell as measured by median Injury Severity Score (16 versus 14) and Revised Trauma Score (4.1 versus 7.8). Fewer patients required secondary transfer to a MTC from peripheral hospitals (19.9 versus 16.1 per cent; P = 0.100). There were no significant differences in total duration of hospital stay, critical care requirements or mortality. However, there was a significant increase, from 55.5 to 62.3 per cent (P < 0.001), in the proportion of patients coded as having a 'good recovery' at discharge after institution of the trauma network. CONCLUSION MTC designation leads to an increased case volume with considerable implications for operating theatre capacity and bed occupancy. Although no mortality benefit was demonstrated within 6 months of establishing this trauma network, early detectable advantages included improved functional outcome at discharge.
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Affiliation(s)
- D Metcalfe
- Warwick Medical School, University of Warwick, Coventry, UK; College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Harrison DA, Prabhu G, Grieve R, Harvey SE, Sadique MZ, Gomes M, Griggs KA, Walmsley E, Smith M, Yeoman P, Lecky FE, Hutchinson PJA, Menon DK, Rowan KM. Risk Adjustment In Neurocritical care (RAIN)--prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study. Health Technol Assess 2014; 17:vii-viii, 1-350. [PMID: 23763763 DOI: 10.3310/hta17230] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. DESIGN Cohort study. SETTING Sixty-seven adult critical care units. PARTICIPANTS Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. INTERVENTIONS Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. MAIN OUTCOME MEASURES Mortality, Glasgow Outcome Scale - Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. RESULTS The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the 'early' (within 18 hours of presentation) and 'no or late' (after 24 hours) transfer groups. After adjustment, the 'early' transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. CONCLUSIONS The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- D A Harrison
- Intensive Care National Audit and Research Centre, London, UK
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Cheung R, Ardolino A, Lawrence T, Bouamra O, Lecky FE, Berry K, Chaudhury A, Issa S, Koralage N, Lyttle MD, Maconochie IK. THE ACCURACY OF EXISTING PRE-HOSPITAL TRIAGE TOOLS FOR INJURED CHILDREN IN ENGLAND–AN ANALYSIS USING TRAUMA REGISTRY AND EMERGENCY DEPARTMENT DATA. Arch Emerg Med 2013. [DOI: 10.1136/emermed-2013-203113.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Gabbe BJ, Lyons RA, Lecky FE, Bouamra O, Woodford M, Coats TJ, Cameron PA. Comparison of mortality following hospitalisation for isolated head injury in England and Wales, and Victoria, Australia. PLoS One 2011; 6:e20545. [PMID: 21655237 PMCID: PMC3105093 DOI: 10.1371/journal.pone.0020545] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 05/04/2011] [Indexed: 02/03/2023] Open
Abstract
Background Traumatic brain injury (TBI) remains a leading cause of death and disability.
The National Institute for Health and Clinical Excellence (NICE) guidelines
recommend transfer of severe TBI cases to neurosurgical centres,
irrespective of the need for neurosurgery. This observational study
investigated the risk-adjusted mortality of isolated TBI admissions in
England/Wales, and Victoria, Australia, and the impact of neurosurgical
centre management on outcomes. Methods Isolated TBI admissions (>15 years, July 2005–June 2006) were
extracted from the hospital discharge datasets for both jurisdictions.
Severe isolated TBI (AIS severity >3) admissions were provided by the
Trauma Audit and Research Network (TARN) and Victorian State Trauma Registry
(VSTR) for England/Wales, and Victoria, respectively. Multivariable logistic
regression was used to compare risk-adjusted mortality between
jurisdictions. Findings Mortality was 12% (749/6256) in England/Wales and 9% (91/1048)
in Victoria for isolated TBI admissions. Adjusted odds of death in
England/Wales were higher compared to Victoria overall (OR 2.0, 95%
CI: 1.6, 2.5), and for cases <65 years (OR 2.36, 95% CI: 1.51,
3.69). For severe TBI, mortality was 23% (133/575) for TARN and
20% (68/346) for VSTR, with 72% of TARN and 86% of VSTR
cases managed at a neurosurgical centre. The adjusted mortality odds for
severe TBI cases in TARN were higher compared to the VSTR (OR 1.45,
95% CI: 0.96, 2.19), but particularly for cases <65 years (OR
2.04, 95% CI: 1.07, 3.90). Neurosurgical centre management modified
the effect overall (OR 1.12, 95% CI: 0.73, 1.74) and for cases <65
years (OR 1.53, 95% CI: 0.77, 3.03). Conclusion The risk-adjusted odds of mortality for all isolated TBI admissions, and
severe TBI cases, were higher in England/Wales when compared to Victoria.
The lower percentage of cases managed at neurosurgical centres in England
and Wales was an explanatory factor, supporting the changes made to the NICE
guidelines.
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Affiliation(s)
- Belinda J Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia.
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Lesko MM, Woodford M, White L, O'Brien SJ, Childs C, Lecky FE. Using Abbreviated Injury Scale (AIS) codes to classify Computed Tomography (CT) features in the Marshall System. BMC Med Res Methodol 2010; 10:72. [PMID: 20691038 PMCID: PMC2927606 DOI: 10.1186/1471-2288-10-72] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 08/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of Abbreviated Injury Scale (AIS) is to code various types of Traumatic Brain Injuries (TBI) based on their anatomical location and severity. The Marshall CT Classification is used to identify those subgroups of brain injured patients at higher risk of deterioration or mortality. The purpose of this study is to determine whether and how AIS coding can be translated to the Marshall Classification METHODS Initially, a Marshall Class was allocated to each AIS code through cross-tabulation. This was agreed upon through several discussion meetings with experts from both fields (clinicians and AIS coders). Furthermore, in order to make this translation possible, some necessary assumptions with regards to coding and classification of mass lesions and brain swelling were essential which were all approved and made explicit. RESULTS The proposed method involves two stages: firstly to determine all possible Marshall Classes which a given patient can attract based on allocated AIS codes; via cross-tabulation and secondly to assign one Marshall Class to each patient through an algorithm. CONCLUSION This method can be easily programmed in computer softwares and it would enable future important TBI research programs using trauma registry data.
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Affiliation(s)
- Mehdi M Lesko
- University of Manchester, Manchester Academic Health Science Centre, the Trauma Audit and Research Network, Salford Royal NHS Foundation Trust, Salford, UK.
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Patel HC, Bouamra O, Woodford M, Yates DW, Lecky FE. Clinical article: mortality associated with severe head injury in the elderly. Acta Neurochir (Wien) 2010; 152:1353-7; discussion 1357. [PMID: 20437280 DOI: 10.1007/s00701-010-0666-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 04/13/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Age is an important factor in determining prognosis following severe head injury (SHI), although mortality in patients > or =65 years is poorly reported. The aim of this study was to document mortality in patients with SHI > or =65 years. METHODS A retrospective analysis of prospectively collected data from the TARN (Trauma Audit and Research Network) database (1996-2004) was performed. Six hundred and sixty-nine patients aged > or =65 with a GCS <9 after a head injury were identified, and mortality at 3 months was recorded. FINDINGS Mortality was 71% in 65- to 70-year-old patients (n = 137) (CI, 64-79), 75% for patients aged 70-75 years (n = 147) (CI, 68-82), 85% in patients aged 75-80 years (n = 160) (79-91), and 87% for patients >80 years (n = 225) (CI, 83-91). Mortality for all patients > or =65 years with a GCS 3-5 was >80%. A better outcome was observed in patients with a GCS = 6-8 [65-70 years, 47% (CI, 30-64); 70-75 years, 56% (CI, 43-69); 75-80 years, 73% (CI, 62-85); >80 years, 79% (CI, 70-87)]. CONCLUSIONS SHI-related mortality continues to increase with age. Overall, these data support a conservative approach to the severely head-injured elderly patient; however, patients presenting with a GCS = 6-8 and below the age of 75 may represent a group where more aggressive therapy may be indicated.
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Affiliation(s)
- H C Patel
- Department of Neurosurgery, Hope Hospital, Salford, M6 8HD, UK
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Gomes E, Araújo R, Carneiro A, Dias C, Costa-Pereira A, Lecky FE. The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma. Resuscitation 2010; 81:440-5. [PMID: 20083331 DOI: 10.1016/j.resuscitation.2009.12.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2009] [Revised: 12/15/2009] [Accepted: 12/20/2009] [Indexed: 02/03/2023]
Abstract
AIM The benefit of a well organised trauma system is acknowledged but doubts remain concerning the optimal pre-hospital trauma care model. We hypothesise that the treatment of life-threatening events before arrival at trauma centre--either pre-hospital or first hospital--may be more relevant to decreasing mortality than shortening the time to trauma centre. METHODS A cohort of 727 trauma patients with life-threatening events--identified as airway, breathing, circulation or neurological disability--requiring transfer to a trauma centre were studied. Data on patient's characteristics, trauma features, and mortality were taken from a trauma registry. Patients were divided into 3 groups depending on the place of treatment of life-threatening events: pre-hospital, first hospital or trauma centre. Survival Kaplan-Meier curves and logistic regression were used to assess the effect of place of treatment of life-threatening events on mortality. RESULTS Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre. CONCLUSION In trauma patients requiring transfer to a trauma centre, pre-hospital interventions to treat life-threatening events may significantly decrease mortality when compared to similar interventions performed later at the trauma centre.
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Affiliation(s)
- Ernestina Gomes
- Unidade de Cuidados Intensivos Polivalente, Centro Hospitalar do Porto, Hospital de Santo António, 4099-001 Porto, Portugal.
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Alexandrescu R, O'Brien SJ, Lecky FE. A review of injury epidemiology in the UK and Europe: some methodological considerations in constructing rates. BMC Public Health 2009; 9:226. [PMID: 19591670 PMCID: PMC2720963 DOI: 10.1186/1471-2458-9-226] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Accepted: 07/10/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Serious injuries have been stated as a public health priority in the UK. However, there appears to be a lack of information on population-based rates of serious injury (as defined by a recognised taxonomy of injury severity) at national level from either official statistics or research papers. We aim to address this through a search and review of literature primarily focused within the UK and Europe. METHODS The review summarizes research papers on the subject of population based injury epidemiology published from 1970 to 2008. We examined critically methodological approaches in measuring injury incident rates including data sources, description of the injury pyramid, matching numerator and denominator populations as well as the relationship between injury and socioeconomic status. RESULTS National representative rates come from research papers using official statistics sources, often focusing on mortality data alone. Few studies present data from the perspective of an injury pyramid or using a standardized measure of injury severity, i.e. Injury Severity Score (ISS). The population movement that may result in a possible numerator - denominator mismatch has been acknowledged in five research studies and in official statistics. The epidemiological profile shows over the past decades in UK and Europe a decrease in injury death rates. No major trauma population based rates are available within well defined populations across UK over recent time periods. Both fatal and non-fatal injury rates occurred more frequently in males than females with higher rates in males up to 65 years, then in females over 65 years. Road traffic crashes and falls are predominant injury mechanisms. Whereas a straightforward inverse association between injury death rates and socio-economic status has been observed, the evidence of socioeconomic inequalities in non-fatal injuries rates has not been wholly consistent. CONCLUSION New methodological approaches should be developed to deal with the study design inconsistencies and the knowledge gaps identified across this review. Trauma registries contain injury data from hospitals within larger regions and code injury by Abbreviated Injury Scale enabling information on severity; these may be reliable data sources to improve understanding of injury epidemiology.
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Affiliation(s)
- Roxana Alexandrescu
- Trauma Audit and Research Network, Clinical Science Building, Hope Hospital, University of Manchester, Manchester, UK.
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Christensen MC, Nielsen TG, Ridley S, Lecky FE, Morris S. Outcomes and costs of penetrating trauma injury in England and Wales. Injury 2008; 39:1013-25. [PMID: 18417132 DOI: 10.1016/j.injury.2008.01.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 01/15/2008] [Accepted: 01/16/2008] [Indexed: 02/02/2023]
Abstract
BACKGROUND Penetrating trauma injury is generally associated with higher short-term mortality than blunt trauma, and results in substantial societal costs given the young age of those typically injured. Little information exists on the patient and treatment characteristics for penetrating trauma in England and Wales, and the acute outcomes and costs of care have not been documented and analysed in detail. METHODS Using the Trauma Audit Research Network (TARN) database, we examined patient records for persons aged 18+ years hospitalised for penetrating trauma injury between January 2000 and December 2005. Patients were stratified by injury severity score (ISS). RESULTS 1365 patients were identified; 16% with ISS 1-8, 50% ISS 9-15, 15% ISS 16-24, 16% ISS 25-34, and 4% with ISS 35-75. The median age was 30 years and 91% of patients were men. Over 90% of the injuries occurred in alleged assaults. Stabbings were the most common cause of injury (73%), followed by shootings (19%). Forty-seven percent were admitted to critical care for a median length of stay of 2 days; median total hospital length of stay was 7 days. Sixty-nine percent of patients underwent at least one surgical procedure. Eight percent of the patients died before discharge, with a mean time to death of 1.6 days (S.D. 4.0). Mortality ranged from 0% among patients with ISS 1-8 to 55% in patients with ISS>34. The mean hospital cost per patient was pound 7983, ranging from pound 6035 in patients with ISS 9-15 to pound 16,438 among patients with ISS>34. Costs varied significantly by ISS, hospital mortality, cause and body region of injury. CONCLUSION The acute treatment costs of penetrating trauma injury in England and Wales vary by patient, injury and treatment characteristics. Measures designed to reduce the incidence and severity of penetrating trauma may result in significant hospital cost savings.
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Alexandrescu R, O'Brien SJ, Lyons RA, Lecky FE. A proposed approach in defining population-based rates of major injury from a trauma registry dataset: delineation of hospital catchment areas (I). BMC Health Serv Res 2008; 8:80. [PMID: 18402693 PMCID: PMC2365946 DOI: 10.1186/1472-6963-8-80] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 04/10/2008] [Indexed: 11/23/2022] Open
Abstract
Background Determining population-based rates for major injury poses methodological challenges. We used hospital discharge data over a 10-year period (1996–2005) from a national trauma registry, the Trauma Audit and Research Network (TARN) Manchester, to construct valid numerators and denominators so that we can calculate population-based rates of major injury in the future. Methods We examined data from all hospitals reporting to TARN for continuity of numerator reporting; rates of completeness for patient postcodes, and clear denominator populations. We defined local market areas (>70% of patients originating from the same postcode district as the hospital). For relevant hospitals we assessed data quality: consistency of reporting, completeness of patient postcodes and for one selected hospital, North Staffordshire Royal Infirmary (NSRI), the capture rate of numerator data reporting. We used an established method based on patient flow to delineate market areas from hospitals discharges. We then assessed the potential competitors, and characterized these denominator areas. Finally we performed a denominator sensitivity analysis using a patient origin matrix based on Hospital Episodes Statistics (HES) to validate our approach. Results Sixteen hospitals met the data quality and patient flow criteria for numerator and denominator data, representing 12 hospital catchment areas across England. Data quality issues included fluctuations numbers of reported cases and poor completion of postcodes for some years. We found an overall numerator capture rate of 83.5% for the NSRI. In total we used 40,543 admissions to delineate hospital catchment areas. An average of 3.5 potential hospital competitors and 15.2 postcode districts per area were obtained. The patient origin matrix for NSRI confirmed the accuracy of the denominator/hospital catchment area from the patient flow analysis. Conclusion Large national trauma registries, including TARN, hold suitable data for determining population-based injury rates. Patient postcodes from hospital discharge allow identification of denominator populations using a market area approach.
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Affiliation(s)
- Roxana Alexandrescu
- Trauma Audit and Research Network, Clinical Science Building, Hope Hospital, University of Manchester, Eccles Old Road, Salford, M6 8HD, UK.
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Christensen MC, Ridley S, Lecky FE, Munro V, Morris S. Outcomes and costs of blunt trauma in England and Wales. Crit Care 2008; 12:R23. [PMID: 18298813 PMCID: PMC2374581 DOI: 10.1186/cc6797] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Revised: 02/11/2008] [Accepted: 02/19/2008] [Indexed: 12/01/2022]
Abstract
Background Trauma represents an important public health concern in the United Kingdom, yet the acute costs of blunt trauma injury have not been documented and analysed in detail. Knowledge of the overall costs of trauma care, and the drivers of these costs, is a prerequisite for a cost-conscious approach to improvement in standards of trauma care, including evaluation of the cost-effectiveness of new healthcare technologies. Methods Using the Trauma Audit Research Network database, we examined patient records for persons aged 18 years and older hospitalised for blunt trauma between January 2000 and December 2005. Patients were stratified by the Injury Severity Score (ISS). Results A total of 35,564 patients were identified; 60% with an ISS of 0 to 9, 17% with an ISS of 10 to 16, 12% with an ISS of 17 to 25, and 11% with an ISS of 26 to 75. The median age was 46 years and 63% of patients were men. Falls were the most common cause of injury (50%), followed by road traffic collisions (33%). Twenty-nine percent of patients were admitted to critical care for a median length of stay of 4 days. The median total hospital length of stay was 9 days, and 69% of patients underwent at least one surgical procedure. Seven percent of the patients died before discharge, with the highest proportion of deaths among those in the ISS 26–75 group (32%). The mean hospital cost per person was £9,530 (± 11,872). Costs varied significantly by Glasgow Coma Score, ISS, age, cause of injury, type of injury, hospital mortality, grade and specialty of doctor seen in the accident and emergency department, and year of admission. Conclusion The acute treatment costs of blunt trauma in England and Wales vary significantly by injury severity and survival, and public health initiatives that aim to reduce both the incidence and severity of blunt trauma are likely to produce significant savings in acute trauma care. The largest component of acute hospital cost is determined by the length of stay, and measures designed to reduce length of admissions are likely to be the most effective in reducing the costs of blunt trauma care.
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Guly HR, Bouamra O, Lecky FE. The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department. Resuscitation 2008; 76:57-62. [PMID: 17688997 DOI: 10.1016/j.resuscitation.2007.06.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 06/05/2007] [Accepted: 06/11/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) is recognised to cause hypotension and bradycardia (neurogenic shock). Previous studies have shown that the incidence of this in the emergency department (ED) may be low. However these studies are relatively small and have included a mix of blunt and penetrating injuries with measurements taken over different time frames. The aim was to use a large database to determine the incidence of neurogenic shock in patients with isolated spinal cord injuries. METHODS The Trauma Audit and Research Network (TARN) collects data on patients attending participating hospitals in England and Wales. The database between 1989 and 2003 was searched for patients aged over 16 who had sustained an isolated spinal cord injury. The heart rate (HR) and systolic blood pressure (SBP) on arrival at the ED were determined as was the number and percentage of patients who had both a SBP<100mm Hg and a HR<80 beats per minute (BPM) (the classic appearance of neurogenic shock). RESULTS Four hundred and ninety patients had sustained an isolated spinal cord injury (SCI) with no other injury with an abbreviated injury scale (AIS) of greater than 2. The incidence of neurogenic shock in cervical cord injuries was 19.3% (95% CI 14.8-23.7%). The incidence in thoracic and lumbar cord injuries was 7% (3-11.1%) and 3% (0-8.85%). CONCLUSIONS Fewer than 20% of patients with a cervical cord injury have the classical appearance of neurogenic shock when they arrive in the emergency department. It is uncommon in patients with lower cord injuries. The heart rate and blood pressure changes in patients with a SCI may develop over time and we hypothesise that patients arrive in the ED before neurogenic shock has become manifest.
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Affiliation(s)
- H R Guly
- Derriford Hospital, Plymouth, PL6 8DH, UK.
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Foëx BA, Gleeson AH, Lecky FE. To resuscitate? Or not to resuscitate? That is the question*. Crit Care Med 2007; 35:2432-3. [PMID: 17885376 DOI: 10.1097/01.ccm.0000284759.60703.5d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Roudsari BS, Nathens AB, Arreola-Risa C, Cameron P, Civil I, Grigoriou G, Gruen RL, Koepsell TD, Lecky FE, Lefering RL, Liberman M, Mock CN, Oestern HJ, Petridou E, Schildhauer TA, Waydhas C, Zargar M, Rivara FP. Emergency Medical Service (EMS) systems in developed and developing countries. Injury 2007; 38:1001-13. [PMID: 17583709 DOI: 10.1016/j.injury.2007.04.008] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 04/09/2007] [Accepted: 04/10/2007] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries. METHOD We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) >15 and the pre-hospital trauma care provided to these patients were compared among different countries. RESULTS A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1min) and Montreal, Canada (median 16.1min) reported the shortest and Germany (median: 30min) and Austria (median: 26min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively). CONCLUSION This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.
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Affiliation(s)
- Bahman S Roudsari
- Department of Epidemiology, University of Texas, School of Public Health, TX, USA.
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Roudsari BS, Nathens AB, Cameron P, Civil I, Gruen RL, Koepsell TD, Lecky FE, Lefering RL, Liberman M, Mock CN, Oestern HJ, Schildhauer TA, Waydhas C, Rivara FP. International comparison of prehospital trauma care systems. Injury 2007; 38:993-1000. [PMID: 17640641 DOI: 10.1016/j.injury.2007.03.028] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 03/26/2007] [Accepted: 03/27/2007] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients' outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems. METHODS Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP) <90mmHg) and early trauma fatality rate (i.e. death during the first 24h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes. RESULTS After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73-1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54-0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems. CONCLUSION These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.
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Affiliation(s)
- Bahman S Roudsari
- Department of Epidemiology, University of Texas, School of Public Health, Dallas, USA.
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Abstract
AIM To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures. METHODS A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39,073 patients with major trauma. RESULTS Of the 39,073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs). CONCLUSION The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.
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Affiliation(s)
- C M Guly
- Taunton and Somerset NHS Trust, Taunton, UK.
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