Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008-17

The Relationship between Hospital Volume and In-Hospital Mortality of Severely Injured Patients in Dutch Level-1 Trauma Centers

Centralization of trauma centers leads to a higher hospital volume of severely injured patients (Injury Severity Score (ISS) > 15), but the effect of volume on outcome remains unclear. The aim of this study was to determine the association between hospital volume of severely injured patients and in-hospital mortality in Dutch Level-1 trauma centers. A retrospective observational cohort study was performed using the Dutch trauma registry. All severely injured adults (ISS > 15) admitted to a Level-1 trauma center between 2015 and 2018 were included. The effect of hospital volume on in-hospital mortality was analyzed with random effects logistic regression models with a random intercept for Level-1 trauma center, adjusted for important demographic and injury characteristics. A total of 11,917 severely injured patients from 13 Dutch Level-1 trauma centers was included in this study. Hospital volume varied from 120 to 410 severely injured patients per year. Observed mortality rates varied between 12% and 24% per center. After case-mix correction, no statistically significant differences between low- and high-volume centers were demonstrated (adjusted odds ratio 0.97 per 50 extra patients per year, 95% Confidence Interval 0.90–1.04, p = 0.44). The variation in hospital volume of the included Level-1 trauma centers was not associated with the outcome of severely injured patients. Our results suggest that well-organized trauma centers with a similar organization of care could potentially achieve comparable outcomes.

Pelvic and acetabular fracture care in England: current workload and future directions

INTRODUCTION

Fractures of the pelvis and acetabulum (PAFs) are challenging injuries, requiring specialist surgical input. Since implementation of the major trauma network in England in 2012, little has been published regarding the available services, workforce organisation and burden of PAF workload. The aim of this study was to assess the recent trends in volume of PAF workload, evaluate the provision of specialist care, and identify variation in available resources, staffing and training opportunity.

METHODS

Data on PAF volume, operative caseload, route of admission and time to surgery were requested from the Trauma Audit and Research Network. In order to evaluate current workforce provision and services, an online survey was distributed to individuals known to provide PAF care at each of the 22 major trauma centres (MTCs).

RESULTS

From 2013 to 2019, 23,823 patients with PAF were admitted to MTCs in England, of whom 12,480 (52%) underwent operative intervention. On average, there are 3,971 MTC PAF admissions and 2,080 operative fixations each year. There has been an increase in admissions and cases treated operatively since 2013. Three-quarters (78%) of patients present directly to the MTC while 22% are referred from regional trauma units. Annually, there are on average 37 operatively managed PAF injuries per million population. Notwithstanding regional differences in case volume, the average number of annual PAF operative cases per surgeon in England is 30. There is significant variation in frequency of surgeon availability. There is also variation in rota organisation regarding consistent specialist surgeon availability.

CONCLUSIONS

This article describes the provision of PAF services since the reorganisation of trauma services in England. Future service development should take into account the current distribution of activity, future trends for increased volume and casemix, and the need for a PAF registry.

Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks

In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.

New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults

Caring for older people is an important part of prehospital practice, including appropriate triage and transportation decisions. However, prehospital triage criteria are designed to predominantly assess injury severity or high-energy mechanism which is not the case for older people who often have injuries compounded by multimorbidity and frailty. This has led to high rates of under-triage in this population. This narrative review aimed to assess aspects other than triage criteria to better understand and improve prehospital triage decisions for older trauma patients. This includes integrating frailty assessment in prehospital trauma triage, which was shown to predict adverse outcomes for older trauma patients. Furthermore, determining appropriate outcome measures and the benefits of Major Trauma Centers (MTCs) for older trauma patients should be considered in order to direct accurate and more beneficial prehospital trauma triage decisions. It is still not clear what are the appropriate outcome measures that should be applied when caring for older trauma patients. There is also no strong consensus about the benefits of MTC access for older trauma patients with regards to survival, in-hospital length of stay, discharge disposition, and complications. Moreover, looking into factors other than triage criteria such as distance to MTCs, patient or relative choice, training, unfamiliarity with protocols, and possible ageism, which were shown to impact prehospital triage decisions but their impact on outcomes has not been investigated yet, should be more actively assessed and investigated for this population. Therefore, this paper aimed to discuss the available evidence around frailty assessment in prehospital care, appropriate outcome measures for older trauma patients, the benefits of MTC access for older patients, and factors other than triage criteria that could adversely impact accurate prehospital triage decisions for older trauma patients. It also provided several suggestions for the future.

A profile of a major trauma centre of North West England between 2011 and 2018

This study examined the trends and patterns of major trauma (MT) activities, causes, mortality and survival at the Aintree Major Trauma Centre (MTC), Liverpool, between 2011 and 2018. The number of trauma team activations (TTAs) rose sharply over time (n = 699 in 2013; n = 1522 in 2018). The proportion of TTAs that involved MT patients decreased from 75.1% in 2013 to 67.4% in 2018. The leading cause of MT was a fall from less than 2 m (36%). There has been a fivefold increase in the overall number of trauma procedures between 2011 and 2018. Orthopaedic surgeons have performed 80% of operations (n = 7732), followed by neurosurgeons, oral and maxillofacial surgeons, and general trauma surgeons. Both types of fall (> 2 m and < 2 m) and road traffic accidents were the three leading causes of death during the study period. The observed mortality rates exceeded that of expected rates in years 2012, 2014, 2016 and 2017. The all-cause observed to expected mortality ratio was 1.08 between 2012 and 2018. A change in care for MT patients was not directly associated with improved survival, although the marginally ascending trend line in survival rates between 2012 and 2018 reflects a gradual positive change.

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BACKGROUND

Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making.

AIM

To provide guidelines for surgeons and units delivering revision KR services.

METHODS

A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data.

RESULTS

There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model.

CONCLUSIONS

Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

Patient Perspectives on Key Outcomes for Vocational Rehabilitation Interventions Following Traumatic Injury

Returning to work after traumatic injury can have a range of benefits, but there is currently little research that incorporates patient perspectives to identify outcomes of vocational rehabilitation interventions that are important to survivors. Trauma survivors (n = 17) participated in in-depth semi-structured interviews or focus groups exploring outcomes that were important to them for recovery and return to work. Data were analysed using thematic analysis. Participants identified a range of outcomes that they considered important and necessary to facilitate a successful and sustainable return to work: physical and psychological recovery, purposeful life engagement, managing expectations of recovery, managing expectations about return to work, and employers’ expectations. Our participants advocated for a multifaceted and biopsychosocial understanding of recovery and outcomes that need to be captured for vocational rehabilitation interventions. Implications for practice and research are discussed, and recommendations are given based on the findings.

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review

BACKGROUND

Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care.

METHODS

Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings.

RESULTS

Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting.

CONCLUSION

Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds.

LEVEL OF EVIDENCE

Systematic review, level III.

National temporal variation in major trauma in England, Wales and Northern Ireland

Introduction

Trauma is one of the leading causes of mortality worldwide, but little is known of the temporal variation in major trauma across England, Wales and Northern Ireland. Proper workforce and infrastructure planning requires identification of the caseload burden and its temporal variation.

Materials and Methods

The Trauma Audit Research Network (TARN) database for admissions attending Major Trauma Centres (MTCs) between 1st April 2011 and 31st March 2018 was analysed. TARN records data on all trauma patients admitted to hospital who are alive at the time of admission to hospital. Major trauma was classified as an Injury Severity Score (ISS) >15.

Results

A total of 158,440 cases were analysed. Case ascertainment was over 95% for 2013 onwards. There was a statistically significant variation in caseload by year (p < 0.0001), times of admissions (p < 0.0001), caseload admitted during weekends vs weekdays, 53% vs 47% (p < 0.0001), caseload by season with most patients admitted during summer (p < 0.0001). The ISS varied by time of admission with most patients admitted between 1800 and 0559 (p < 0.0001), weekend vs weekday with more severely injured patients admitted during the weekend (p < 0.0001) and by season p < 0.0001). Discussion and Conclusion: There is a significant national temporal variation in major trauma workload. The reasons are complex and there are multiple theories and confounding factors to explain it. This is the largest dataset for hospitals submitting to TARN which can help guide workforce and resource allocation to further improve trauma outcomes.

Patient experiences of rehabilitation following traumatic complex musculoskeletal injury – A mixed methods pilot study

Introduction

The aim of this pilot study was to measure patient reported outcomes and evaluate their rehabilitation experience following traumatic complex musculoskeletal (CMSK) injury.

Methods

A mixed methods prospective observational study was undertaken between December 2015 and March 2018 to explore patient reported outcomes following CMSK injury sustained as a result of major trauma and perception of their rehabilitation and its impact on their recovery. The participants were asked to complete a series of outcome measures at 18-months post-injury. The data was anonymised and analysed by the lead researcher.

Results

Thirty patients were recruited into the study (19 males, 11 females) between 23 and 76 years of age (median 52 years). Their injury profile was split between open fractures 30%, pelvic fractures 23%, multiple fractures 27% and polytrauma 20%. The majority (60%) reported moderate disability at 18-months post injury with 50% returning to full time employment. Patients with multiple or open fractures reported the worst outcomes. There was no relationship between frequency, quantity or duration of physiotherapy and outcome. However, 77% reported supplementing their NHS rehabilitation with other interventions such as gym membership, hydrotherapy and psychological therapies. The thematic analysis showed that patients considered intensity, quality and coordinated timely access to rehabilitation as the most important factors.

Conclusion

From a patient perspective, the current NHS rehabilitation provision does not appear to meet their complex needs. In addition to physical and vocational rehabilitation, patients wanted effective pain management and psychological support. Strengthening current therapy services and involving other sectors (e.g. Citizen’s Advice) could help achieve this. Early access to an intensive multidisciplinary rehabilitation programme was perceived to have positive benefits and improve outcomes.

Impact of military medicine on civilian medical practice in the UK from 2009 to 2020

INTRODUCTION

The positive impact of advances in military medicine and the influence these have had on civilian medical practice have been well documented throughout history: this review will be looking specifically between 2009 and 2020.

AIMS

Review of innovations that have been implemented or have influenced civilian practice within the areas of trauma, disease outbreak management and civilian systems between 2009 and 2020. This review will also aim to explore the impact that working with or within the military can have on individuals within civilian healthcare systems and the future challenges we face to maintain skills.

RESULTS

Using a narrative approach to this review, we found that there have been numerous changes to trauma management within the UK, based on military practice and research during conflict, which have improved survival outcomes. In addition, the use of niche military skills as part of a coordinated response, during both internal and international disease outbreaks, are thought to have supported civilian systems enabling an efficient and prolonged response. Furthermore, adaptation of military concepts and their application to the NHS through consultant-led prehospital teams, centralisation of specialties in the form of major trauma centres and the introduction of guidelines to manage 'major incidents and mass casualty events' in 2018 have improved patient outcomes.

CONCLUSION

From 2009 to 2020, lessons learnt from the British and other nations' militaries have been integrated into UK practice and have likely contributed to improved outcomes in the management of major incidents both nationally and internationally.

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis

OBJECTIVES

To systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.

DESIGN

Systematic review with meta-analyses.

METHODS

Included were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs-heterogeneity was assessed using I2 statistics.

RESULTS

Of 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).

CONCLUSIONS

This study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped

Background

Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies.

Methods

We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers.

Results

This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p < 0.001). Spinal cord injuries were rare (0.71% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were trapped (p < 0.001).

Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10–29) vs 13 (IQR 9–22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale, GCS (all p < 0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p < 0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p < 0.001).

Conclusion

Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for < 0.7% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.

Outcomes of orthopaedic trauma patients undergoing surgery during the peak period of COVID-19 infection at a UK major trauma centre

Background

To review the clinical outcomes of all patients undergoing emergency orthopaedic trauma surgery at a UK major trauma centre during the first 6 weeks of the COVID-19 related lockdown.

Methods

A retrospective review was performed of all patients who underwent emergency orthopaedic trauma surgery at a single urban major trauma centre over the first six-week period of national lockdown. Demographics, co-morbidities, injuries, injury severity scores, surgery, COVID-19 status, complications and mortalities were analysed.

Results

A total of 76 patients were included for review who underwent multiple procedures. Significant co-morbidity was present in 72%. The overall COVID-19 infection rate of the study population at any time was 22%. Sub-group analysis indicated 13% had active COVID-19 at the time of surgery. Only 4% of patients developed COVID-19 post surgery with no mortalities in this sub-group. The overall mortality rate was 4%. The overall complication rate was 14%. However mortality and complications rates were higher if the patients had active COVID-19 at surgery, if they were over 70 years and had sustained life-threatening injuries.

Conclusion

The overall survival rate for patients undergoing emergency orthopaedic trauma surgery during the COVID-19 peak was 96%. The rate of any complication was more significant in those presenting with active COVID-19 infections who had sustained potentially life threatening injuries and were over 70 years of age. Conversely those without active COVID-19 infection and who lacked significant co-morbidities experienced a lower complication and mortality rate.

Bypassing the nearest emergency department for a more distant neurosurgical centre in traumatic brain injury patients

BACKGROUND AND OBJECTIVE

Major trauma triage within regional trauma networks (RTN) select patients with suspected TBI for bypass to specialist neuroscience centres (SNC), expediting neurosurgical care but may delay resuscitation. This comparative effectiveness study assessed the impact of this strategy on the risk adjusted hospital survival rates of patients confirmed to have intracranial injury on brain computed tomography (CT) scan.

METHOD

A retrospective cohort study was conducted using Trauma Audit and Research Network trauma registry data. Adult patients with a TBI on CT scan were included if they presented between June 2015 to February 2016 to SNCs or non-specialist acute hospitals (NSAH) in the North of England (South Cumbria, Lancashire and the North East Region). Patients were identified as having bypassed a nearer NSAH emergency department (ED) to a SNC using google maps. Their standardised excess survival rate was compared to TBI patients who received primary treatment at a NSAH. A multivariate logistic regression model predicting 30-day survival after TBI (Ps14ⁿ)¹ was used to adjust for variation in casemix between cohorts.

STUDY DESIGN AND RESULTS

355 patients met the study inclusion criteria, with 89/355 (25%) of TBI patients bypassing a nearer NSAH to a SNC, and 266/355 (75%) receiving primary treatment at an NSAH. The median severity of intracranial injury was equivalent (median Head Abbreviated Injury Scale 4 (IQR 4-5) in each group. There was no statistically significant difference in the standardised excess survival rate between the two cohorts; +6.15% for bypass (95% CI -1.24% to +13.55%) versus -1.12% for non-bypass (95% CI -4.51% to +2.25%).

CONCLUSION AND FUTURE RESEARCH

No statistically significant survival benefit was identified for TBI patients who bypassed the nearest ED to attend a SNC compared to those receiving treatment at the nearest NSAH, however a clinically significant 7% excess survival rate merits a larger study.

The impact of injury: The experiences of children and families after a child's traumatic injury

Objective:

To explore the experiences of children and families after a child’s traumatic injury (Injury Severity Score >8).

Design:

Qualitative interview study.

Setting:

Two children’s major trauma centres in England.

Participants:

32 participants: 13 children with traumatic injuries, their parents/guardians (n = 14) and five parents whose injured child did not participate.

Methods:

Semi-structured interviews exploring the emotional, social, practical and physical impacts of children’s injuries, analysed by thematic analysis.

Results:

Interviews were conducted a median of 8.5 months (IQR 9.3) post-injury. Injuries affected the head, chest, abdomen, spine, limbs or multiple body parts. Injured children struggled with changes to their appearance, physical activity restrictions and late onset physical symptoms, which developed after hospital discharge when activity levels increased. Social participation was affected by activity restrictions, concerns about their appearance and interruptions to friendships. Psychological impacts, particularly post-traumatic stress type symptoms often affected both children and parents. Parents’ responsibilities suddenly increased, which affected family relationships and roles, their ability to work and carry out daily tasks. Rapid hospital discharge was wanted, but participants often felt vulnerable on return home. They valued continued contact with a healthcare professional and practical supports from family and friends, which enabled resumption of their usual lives.

Conclusions:

Injured children experience changes to their appearance, friendships, physical activity levels and develop new physical and mental health symptoms after hospital discharge. Such challenges can be addressed by the provision of advice about potential symptoms, alternative activities during recovery, strategies to build resilience and how to access services after hospital discharge.

Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline

BACKGROUND

The burden of knee replacement prosthetic joint infection (KR PJI) is increasing. KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available to guide treatment decisions.

AIM

To provide guidelines for surgeons and units treating KR PJI.

METHODS

Guideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings.

RESULTS

Improved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT. This document outlines practice guidelines for units providing a KR PJI service and sets out: CONCLUSIONS: KR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.

Qualitative study of the needs of injured children and their families after a child's traumatic injury

OBJECTIVE

To explore the needs of children and their families after a child's traumatic injury.

DESIGN

Semi-structured qualitative interviews with purposeful sampling for different types of injuries and a theoretical thematic analysis.

PARTICIPANTS

32 participants; 13 children living at home after a traumatic injury, their parents/guardians (n=14) and five parents whose injured child did not participate.

SETTING

Two Children's Major Trauma Centres (hospitals) in England.

RESULTS

Interviews were conducted a median 8.5 months (IQR 9.3) postinjury. Injuries affected the limbs, head, chest, abdomen, spine or multiple body parts. Participants highlighted needs throughout their recovery (during and after the hospital stay). Education and training were needed to help children and families understand and manage the injury, and prepare for discharge. Information delivery needed to be timely, clear, consistent and complete, include the injured child, but take into account individuals' capacity to absorb detail. Similarly, throughout recovery, services needed to be timely and easily accessible, with flexible protocols and eligibility criteria to include injured children. Treatment (particularly therapy) needed to be structured, goal directed and of sufficient frequency to return injured children to their full function. A central point of contact is required after hospital discharge for advice, reassurance and to coordinate ongoing care. Positive partnerships with professionals helped injured children and their families maintain a sense of hope and participate in joint decision making about their care.

CONCLUSION

Throughout the full trajectory of recovery injured children and their families need family centred, accessible, flexible, coordinated health services, with more effective harmonious, communication between professionals, the child and their family. There is a requirement for support from a single point of contact and a system that monitors the needs of the injured child and their family after hospital discharge.

An observational study assessing the impact of a cardiac arrest centre on patient outcomes after out-of-hospital cardiac arrest (OHCA)

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Recent guidelines recommend the centralisation of OHCA services in cardiac arrest centres to improve outcomes. In 2015, two major tertiary cardiac centres in London merged to form a large dedicated tertiary cardiac centre. This study aimed to compare the short-term mortality of patients admitted with an OHCA before-and-after the merger of services had taken place and admission criteria were relaxed, which led to managing OHCA in higher volume.

METHODS

We retrospectively analysed the data of OHCA patients pre- and post-merger. Baseline demographic and medical characteristics were recorded, along with factors relating to the cardiac arrest. The primary endpoint was in-hospital mortality.

RESULTS

OHCA patients (N =728; 267 pre- and 461 post-merger) between 2013 and 2018 were analysed. Patients admitted pre-merger were older (65.0 vs. 62.4 years, p=0.027), otherwise there were similar baseline demographic and peri-arrest characteristics. There was a greater proportion of non-acute coronary syndrome-related OHCA admission post-merger (10.1% vs. 23.4%, p=0.0001) and a corresponding decrease in those admitted with ST-elevation myocardial infarction (80.2% vs. 57.0%, p=0.0001) and those treated with percutaneous coronary intervention (78.8% vs. 54.0%, p=0.0001). Despite this, in-hospital mortality was lower post-merger (63.7% vs. 44.3%, p=0.0001), which persisted after adjustment for demographic and arrest-related characteristics using stepwise logistic regression (p=0.036) between the groups.

CONCLUSION

Despite an increase in non-acute coronary syndrome-related OHCA cases, the formation of a centralised invasive heart centre was associated with improved survival in OHCA patients. This suggests there may be a benefit of a cardiac arrest centre model of care.

The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients

Purpose

The study aimed to examine the changing incidence of geriatric trauma and evaluate the predictive ability of different scoring tools for in-hospital mortality in geriatric trauma patients.

Methods

Annual reports released by the National Trauma Database (NTDB) in the USA from 2005 to 2015 and the Trauma Register DGU® in Germany from 1994 to 2012 were analyzed to examine the changing incidence of geriatric trauma. Secondary analysis of a single-center cohort study conducted among 311 severely injured geriatric trauma patients in a level I trauma center in Switzerland was completed. According to the in-hospital survival status, patients were divided into the survival and non-survival group. The differences of the ISS (injury severity score), NISS (new injury severity score), TRISS (Trauma and Injury Severity Score), APACHE II (Acute Physiology and Chronic Health Evaluation II), and SPAS II (simplified acute physiology score II) between two groups were evaluated. Then, the areas under the receiver-operating characteristic curve (AUC-ROC) of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients were calculated.

Results

The analysis of the NTDB showed that the increase in the number of geriatric trauma ranged from 18 to 30% between 2005 and 2015. The analysis of the DGU® showed that the mean age of trauma patients rose from 39.11 in 1993 to 51.10 in 2013, and the proportion of patients aged ≥ 60 years rose from 16.5 to 37.5%. The findings from the secondary analysis showed that 164 (52.73%) patients died in the hospital. The ISS, NISS, APACHE II, and SAPS II in the death group were significantly higher than those in the survival group, and the TRISS in the death group was significantly lower than those in the survival group. The AUCs of the ISS, NISS, TRISS, APACHE II, and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients were 0.807, 0.850, 0.828, 0.715, and 0.725, respectively.

Conclusion

The total number of geriatric trauma is increasing as the population ages. The accuracy of ISS, NISS and TRISS was higher than the APACHE II and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients.

Development and pilot implementation of a standardised trauma documentation form to inform a national trauma registry in a low-resource setting: lessons from Tanzania

OBJECTIVES

Trauma registries are an integral part of a well-organised trauma system. Tanzania, like many low and middle-income countries, does not have a trauma registry. We describe the development, structure, implementation and impact of a context appropriate standardised trauma form based on the adaptation of the WHO Data Set for Injury (DSI), for clinical documentation and use in a national trauma registry.

SETTING

Our study was conducted in emergency units of five regional referral hospitals in Tanzania.

PROCEDURES

Mixed methods participatory action research was employed. After an assessment of baseline trauma documentation, we conducted semi-structured interviews with a purposefully selected sample of 33 healthcare providers from all participating hospitals to understand, develop, pilot and implement a standardised trauma form. We compared the number and types of variables captured before and after the form was implemented.

OUTCOMES

Change in proportion of variables of DSI captured after implementation of a standardised trauma documentation form.

RESULTS

Piloting and feedback informed the development of a context appropriate standardised trauma documentation paper form with carbonless copy that could be used as both the clinical chart and data capture. Among 721 patients (seen by 21 clinicians) during the initial 30-day pilot, overall variable capture was 86.4% of required variables. After modifications of the form and training of healthcare providers, the form was implemented for 7 months, during which the capture improved to 96.3% among 6302 patients (seen by 31 clinicians). The providers reported the form was user-friendly, resulted in less time documenting, and served as a guide to managing trauma patients.

CONCLUSIONS

The development and implementation of a contextually appropriate, standardised trauma form were successful, yielding increased capture rates of injury variables. This system will facilitate expansion of the trauma registry across the country and inform similar initiatives in Sub-Saharan Africa.

There Is No Weekend Effect in the Trauma Patient

BACKGROUND

The presence of a "weekend effect", that is, increased morbidity/mortality for patients admitted to the hospital on a weekend, has been reported in numerous studies across many specialties. Postulated causes include reduced weekend staffing, increased time between admission and undergoing procedures/surgery, and decreased subspecialty availability. The aim of this study is to evaluate if a "weekend effect" exists in trauma care in the United States.

METHODS

Using the 2012-2015 National In-patient Sample database from the Healthcare Cost and Utilization Project, adults with trauma diagnoses who were admitted nonelectively were analyzed. Using logistic and negative binomial regression adjusted for survey-related discharge weights and statistically significant covariables, mortality and length of stay (LOS) were assessed, respectively. Subgroup analysis was conducted using rural, urban teaching, and urban nonteaching hospital-type subgroups. Additional subgroup analysis of patients who required surgery during admission was also performed.

RESULTS

A total of 22,451 patients were identified, with 3.94% admitted to rural and 81.42% to urban hospitals. Weekend admission did not have a statistically significant difference in adjusted-mortality (OR 0.928; 95% CI 0.858-1.003; P = 0.059) or LOS (IRR 0.978; 95% CI 0.945-1.011; P = 0.199). There was also no statistically significant increase in mortality or LOS for weekend admits in any of the hospital subgroups.

CONCLUSIONS

There does not appear to be a weekend effect for trauma admission. This may be explained by the nature of trauma care in the United States, in which there is often 24-h in-house coverage regardless of day of the week. Replicating a trauma service coverage schedule may help other services decrease the presence of the weekend effect.

Provision of revision knee surgery and calculation of the effect of a network service reconfiguration: An analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BACKGROUND

Revision knee replacement (KR) is technically challenging, expensive, and outcomes can be poor. It is well established that increasing surgeon and unit volumes results in improved outcomes and cost-effectiveness for complex procedures. The aim of this study was to 1) describe the current provision of revision KR in England, Wales and Northern Ireland at the individual surgeon and unit level and 2) investigate the effect on workload of case distribution in a network model.

METHODS

Current practice was mapped using NJR summary statistics containing all revision KR procedures performed over a three-year period (2016-2018). Units were identified as revision centres based on threshold volumes. Units undertaking <20 revisions per year were classified as Primary Arthroplasty Units (PAUs) in calculations on the effect of workload centralisation.

RESULTS

Revision KR was performed by 1353 surgeons at 232 NHS sites. The majority of surgeons and units were low-volume; >1000 surgeons performed <7 and 125 sites performed <20 procedures per year. Reallocation of work from these 125 PAUs (1235 cases, 21% of total workload) to a network model with even redistribution of cases between centres undertaking revision surgery would result in an additional average annual case increase of 11 per unit per year (range six to 14).

CONCLUSIONS

Revision KR workload re-allocation would lift all revision centres above a 30 per year threshold and would appear to be a manageable increase in workload for specialist revision KR centres. Case complexity and local referral agreements will significantly affect the real increase in workload; these factors were not incorporated here.

Time to definitive care within major trauma networks in England

BACKGROUND

Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016.

METHODS

An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death.

RESULTS

Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001).

CONCLUSION

Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.

The impact of ‘unofficial trauma’ on a Major Trauma Centre: A service evaluation of accident and emergency department trauma team activations

Introduction

Trauma remains a leading cause of death worldwide. In the UK, data for trauma patients are prospectively collected locally and collated by the Trauma Audit and Research Network. This study assesses and describes the subgroup of patients who triggered a trauma call but who subsequently did not meet criteria for Trauma Audit and Research Network.

Methods

A single centre, retrospective observational study of trauma calls between 1 June 2012 and 31 August 2018 was performed, determining which trauma calls had been submitted to Trauma Audit and Research Network by cross referencing with the submission database. Data were tested for normality (Shapiro–Wilk test) and appropriate statistical tests employed to determine differences between inclusion and non-inclusion groups. For categorical data, we used Chi-squared tests to examine for differences.

Results

There were 6529 trauma calls and over half (3837 (58.8%)) were not registered on Trauma Audit and Research Network. Patients excluded were significantly younger (mean 42.4 years SD 19.2) than those who met inclusion criteria (mean 50.3 years, SD 21.8), p < 0.001 and were significantly more likely to suffer from penetrating trauma (18.6% versus 8.2%, p < 0.001), the majority (77.8%, 553/713) caused by stabbings. Patients excluded were less likely to be involved in a road traffic accident (31.1% versus 35.3%, p < 0.001), less likely to have fallen downstairs (15.2% versus 18.7%, p < 0.001) and less likely to have fallen from a height > 2 m (8.1% versus 12.7%, p < 0.001).

Discussion

Patients who trigger a trauma call but who subsequently do not meet the criteria for Trauma Audit and Research Network inclusion place a significant burden on healthcare provision. To our knowledge this is the first investigation to specifically explore this group of at-risk patients. To enable medical planners a more accurate view of activity on the ‘shop floor’, particularly in reference to knife crime injuries we ask the question as to whether a separate database should now be held of trauma calls?

Managing polytrauma patients

Embedding physiological markers into treatment algorithms has helped trauma teams rationalise interventions safely and signifies a departure from the dichotomy of damage control orthopaedics (DCO) and early total care (ETC) to early appropriate care (EAC). This has been shown to reduce length of stay and cost to treating centres. This article seeks to provide a clear summary of current concepts for managing orthopaedic injuries in the multiply injured patient.

Conceptualizing the key components of rehabilitation following major musculoskeletal trauma: A mixed methods service evaluation

RATIONALE, AIMS, AND OBJECTIVES

The reorganization of acute major trauma pathways in England has increased survival following traumatic injury, resulting in an increased patient population with diverse and complex needs requiring specialist rehabilitation. However, national audit data indicate that only 5% of patients with traumatic injuries have access to specialist rehabilitation, and there are limited guidelines or standards to inform the delivery of rehabilitation interventions for individuals following major trauma. This group concept mapping project aimed to identify the clinical service needs of individuals accessing our major trauma rehabilitation service, prioritize these needs, determine whether each of these needs is currently being met, and plan targeted service enhancements.

METHODS

Participants contributed towards a statement generation exercise to identify the key components of rehabilitation following major trauma, and individually sorted these statements into themes. Each statement was rated based on importance and current success. Multi-dimensional scaling and hierarchical cluster analysis were applied to the sorted data to produce themed clusters of ideas within concept maps. Priority values were applied to these maps to identify key areas for targeted service enhancement.

RESULTS

Fifty-eight patients and health care professionals participated in the ideas generation activity, 34 in the sorting, and 49 in the rating activity. A 7-item cluster map was agreed upon, containing the following named clusters: Communication and Coordination; Emotional and psychological wellbeing; Rehabilitation environment; Early rehabilitation; Structured therapy input; Planning for home; and Long-term support. Areas for targeted service enhancement included access to timely and adequate information provision, collaborative goal setting, and specialist pain management across the rehabilitation pathway.

CONCLUSION

The conceptual framework presented in this article illustrates the importance of a continuum of rehabilitation provision across the injury trajectory, and provides a platform to track future service changes and facilitate the codesign of new rehabilitation interventions for individuals following major trauma.

Prediction of mortality in critically-ill elderly trauma patients: a single centre retrospective observational study and comparison of the performance of trauma scores

Background

Trauma in the elderly (≥ 65 years) population is increasing. This study compares the performance of trauma scoring systems in predicting 30-day mortality among the traumatised elderly patients admitted to the intensive care unit in a major trauma centre.

Methods

We collected retrospective data for all elderly trauma patients admitted to our intensive care units between January 2012 and December 2017. We assessed Injury Severity Score (ISS), Geriatric Trauma Outcome Score (GTOS) and the Trauma Audit and Research Network’s (TARN) Probability of Survival (Ps17) between survivors and non-survivors. Receiver operator characteristic (ROC) curves were used to assess the performance of these scoring systems.

Results

There were 255 elderly trauma patients with overall 30-day survival of 76%. There was a statistically significant difference in ISS, GTOS and Ps17 scores between survivors and non-survivors (p < 0.001). The area under the ROC curve (AUROC) was statistically significant for all 3, with AUROC of 0.66 (95% CI 0.59–0.74) for the ISS, 0.68 (95% CI 0.61–0.76) for the GTOS and 0.79 (95% CI 0.72–0.85) for the Ps17. The optimal cut-off points were ≥ 28, ≥ 142, ≤ 76.73 for ISS, GTOS and Ps17, respectively.

Conclusion

Both ISS and GTOS scoring systems preformed equally in predicting 30-day mortality in traumatised elderly patients admitted to the intensive care unit, however neither were robust enough to utilise in clinical practise. The Ps17 performed more robustly, although was not developed for prognosticating on individual patients. Larger prospective studies are needed to validate these scoring systems in critically-ill elderly traumatised patients, which may help to facilitate early prognostication.

A mixed methods randomised feasibility trial investigating the management of benign paroxysmal positional vertigo in acute traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of long-term disability in working age adults. Recent studies show that most acute TBI patients demonstrate vestibular features of dizziness and imbalance, often from combined peripheral and central vestibular dysfunction. Effective treatment for vestibular impairments post-TBI is important given its significant adverse impact upon quality of life and employment prospects. The most frequent peripheral vestibular disorder in acute TBI is benign paroxysmal positional vertigo (BPPV), affecting approximately half of acute cases. Although there is effective treatment for idiopathic BPPV, there are no high-quality clinical data for post-TBI BPPV regarding its prevalence, natural history, which treatment is most effective and when is the best time to treat. In particular, observational studies suggest post-TBI BPPV may be recurrent, indicating that hyperacute treatment of BPPV may be futile. Given the potential hurdles and the lack of accurate post-TBI BPPV data, the current study was designed to provide information regarding the feasibility and optimal design of future large-scale prospective treatment studies that would compare different interventions and their timing for post-TBI BPPV.

METHOD

A multi-centre randomised mixed methods feasibility study design was employed. We aim to recruit approximately 75 acute TBI patients across a range of clinical severities, from three major trauma centres in London. Patients will be randomised to one of three treatment arms: (1) therapist-led manoeuvres, (2) patient-led exercises and (3) advice. Participants will be re-assessed by blinded outcome assessors at 4 and 12 weeks. Acceptability of the intervention will be obtained by patient interviews at the end of their treatment and therapist interviews at the end of the study. Primary outcomes relate to feasibility parameters including recruitment and retention rates, adverse events and intervention fidelity. We will also aim to provide a more accurate estimate of the prevalence of BPPV in TBI cases on the trauma ward.

DISCUSSION

The multi-centre nature of our feasibility study will inform the design of a future prospective treatment trial of BPPV in acute TBI. Important parameters we will obtain from this study, key for designing a future prospective treatment study, include estimating the prevalence of BPPV in TBI patients admitted to UK major trauma wards, and elucidating both patient and care-provider barriers in delivering BPPV treatment.

TRIAL REGISTRATION

ISRCTN, ISRCTN91943864. Registered on 10 February 2020.

An overview of the key principles and guidelines in the management of pelvic fractures

Pelvic fractures are complex injuries with a range of different presentations depending on the mechanism of trauma. Due to the morbidity and mortality of pelvic fractures, patients require thorough investigation and timely management with multidisciplinary input. Various surgical and non-surgical techniques can be used to treat pelvic fractures, as well as any associated visceral injuries. Following repair, it is important to remain vigilant for postoperative complications such as infection, sexual and urinary dysfunction, chronic pain and adverse psychological health. This article summarises the relevant UK guidance and literature and presents them in a format that follows the patient’s journey. In doing so, it highlights the key perioperative factors that need to be considered in cases of pelvic fracture.

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise

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.

Mortality of trauma patients treated at trauma centers compared to non-trauma centers in Sweden: a retrospective study

Objective

The main objective was to compare the 30-day mortality rate of trauma patients treated at trauma centers as compared to non-trauma centers in Sweden. The secondary objective was to evaluate how injury severity influences the potential survival benefit of specialized care.

Methods

This retrospective study included 29,864 patients from the national Swedish Trauma Registry (SweTrau) during the period 2013–2017. Three sampling exclusion criteria were applied: (1) Injury Severity Score (ISS) of zero; (2) missing data in any variable of interest; (3) data falling outside realistic values and duplicate registrations. University hospitals were classified as trauma centers; other hospitals as non-trauma centers. Logistic regression was used to analyze the effect of trauma center care on mortality rate, while adjusting for other factors potentially affecting the risk of death.

Results

Treatment at a trauma center in Sweden was associated with a 41% lower adjusted 30-day mortality (odds ratio 0.59 [0.50–0.70], p < 0.0001) compared to non-trauma center care, considering all injured patients (ISS ≥ 1). The potential survival benefit increased substantially with higher injury severity, with up to > 70% mortality decrease for the most critically injured group (ISS ≥ 50).

Conclusions

There exists a potentially substantial survival benefit for trauma patients treated at trauma centers in Sweden, especially for the most severely injured. This study motivates a critical review and possible reorganization of the national trauma system, and further research to identify the characteristics of patients in most need of specialized care.

Helicopter and ground emergency medical services transportation to hospital after major trauma in England: a comparative cohort study

Background

The utilization of helicopter emergency medical services (HEMS) in modern trauma systems has been a source of debate for many years. This study set to establish the true impact of HEMS in England on survival for patients with major trauma.

Methods

A comparative cohort design using prospectively recorded data from the UK Trauma Audit and Research Network registry. 279 107 patients were identified between January 2012 and March 2017. The primary outcome measure was risk adjusted in-hospital mortality within propensity score matched cohorts using logistic regression analysis. Subset analyses were performed for subjects with prehospital Glasgow Coma Scale <8, respiratory rate <10 or >29 and systolic blood pressure <90.

Results

The analysis was based on 61 733 adult patients directly admitted to major trauma centers: 54 185 ground emergency medical services (GEMS) and 7548 HEMS. HEMS patients were more likely male, younger, more severely injured, more likely to be victims of road traffic collisions and intubated at scene. Crude mortality was higher for HEMS patients. Logistic regression demonstrated a 15% reduction in the risk adjusted odds of death (OR=0.846; 95% CI 0.684 to 1.046) in favor of HEMS. When analyzed for patients previously noted to benefit most from HEMS, the odds of death were reduced further but remained statistically consistent with no effect. Sensitivity analysis on 5685 patients attended by a doctor on scene but transported by GEMS demonstrated a protective effect on mortality versus the standard GEMS response (OR 0.77; 95% CI 0.62 to 0.95).

Discussion

This prospective, level 3 cohort analysis demonstrates a non-significant survival advantage for patients transported by HEMS versus GEMS. Despite the large size of the cohort, the intrinsic mismatch in patient demographics limits the ability to statistically assess HEMS true benefit. It does, however, demonstrate an improved survival for patients attended by doctors on scene in addition to the GEMS response. Improvements in prehospital data and increased trauma unit reporting are required to accurately assess HEMS clinical and cost-effectiveness.

Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK

INTRODUCTION

Major trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI).

METHODS

Retrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus.

RESULTS

193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2-78.8) and median ISS 9 (IQR 9-16). The most common mechanism of injury was falls <2 m (52.1%), followed by road traffic collisions (22.2%). 15.1% received one or more LSIs. The probability of a receiving an LSI increased with increasing ISS, but only a low to moderate correlation was evident (0.334, p<0.001). A clinically significant number of cases (5.3% and 7.6%) received an LSI despite having an ISS ≤8 or <15, respectively.

CONCLUSIONS

A clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.

The impact of the national clinical outcome review programmes in England: a review of the evidence

BACKGROUND

There is a lack of evidence about the effectiveness of the national clinical outcome review programmes in England.

METHODS

We undertook a scoping review of the published literature for evidence of the impact of any of the current programmes or their predecessors, and asked programme leads to share examples of the impact of their work. Data were thematically analysed.

FINDINGS

Evidence about impact related to clinicians' awareness and practice, structural aspects of healthcare, processes of care and patient outcomes.

CONCLUSIONS

The national clinical outcome review programmes appear to have had significant impact, but none are funded to assess the outcome and impact of the recommendations they make or to deliver a programme of change. There is no structured and systematic way in which the findings and recommendations of each programme are taken forward, nor in which the findings from across programmes are collated and considered.

Reflections from London's Level-1 Major Trauma Centres during the COVID crisis

Emergence of the Covid-19 pandemic resulted in dramatic changes in global healthcare provision. Resources were redirected across all healthcare sectors to support the treatment of viral pneumonia with resultant effects on other essential services. We describe the impact of this on the provision of major trauma care in a major capital city.

Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014)

INTRODUCTION

The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care.

METHODS

The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR).

RESULTS

2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant.

CONCLUSION

Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

High Riding Prostate: Epidemiology of Genitourinary Injury in Motorcyclists from a UK Register of over 12,000 Victims

BACKGROUND

The mechanism of motorcycle accidents (high speeds, pelvis behind fuel tank) may predispose to genitourinary injury (GUI) but the epidemiology is poorly understood. Previous studies have assessed GUI patterns in cyclists, and road traffic accident victims in general, but no study has analyzed GUI patterns in a large cohort of motorcyclists.

OBJECTIVES

We aimed to better understand patterns of urological injuries among motorcyclists admitted to hospital. We aimed to determine any relationship between pelvic fracture and GUI patterns or severity.

METHODS

The Trauma Audit Research Network was reviewed to identify motorcyclists admitted between January 2012 and December 2016 (n = 12,374). Cases were divided into riders (n = 11,926) and pillion passengers (n = 448), and the data analyzed to identify urological injuries and their associations. The associations between pelvic fracture and other injury types were tested for significance by one- and two-way χ 2.

RESULTS

GUI was identified in 6%. Renal trauma was the most common GUI among riders (4%) and pillions (2%). There was no statistically significant relationship between grade of renal trauma and presence of pelvic fracture. Urethral injury occurred in 0.2% of riders and passengers, and bladder injury in 0.4% of riders and 0.7% of pillions. Urethral and bladder injuries were positively associated with pelvic fracture, which was present in 81 and 92%, respectively. Testicular trauma occurred in 0.4% of riders and 0.7% of pillions. Body armor was recorded in 3% of casualties with urological trauma, and 3% overall.

CONCLUSIONS

A significant proportion of motorcyclists brought to accident and emergency department have GUI, most commonly renal trauma. Pelvic fracture is more common in pillion passengers than riders, and associated with urethral and bladder injuries, but it does not predict severity of renal trauma. External genital injuries are rare, but we recommend examination in the tertiary survey, as consequences of missed injury are severe. Further research is needed to explore protective effects of motorcyclist clothing.

Managing the multiply injured patient: the impact of multidisciplinary teams

Management of trauma has been tackled at a national level to improve patient care and mortality. Decision making through a multidisciplinary team approach has resulted in improved patient outcomes through a complex combination of changes. While the focus of trauma care delivery has been towards establishing an effective multidisciplinary trauma service, there are still improvements which can be made. This article reviews the history of trauma care in the UK, and the impact that multidisciplinary teams have had on the management of the multiply injured patient.

Geo-temporal provision of pre-hospital emergency anaesthesia by UK Helicopter Emergency Medical Services: an observational cohort study

BACKGROUND

Pre-hospital emergency anaesthesia (PHEA) is frequently required for injured patients. National Institute for Health and Care Excellence (NICE) quality standards state that PHEA should be delivered within 45 min of an emergency call. We investigated whether there is geo-temporal variation in service provision to the UK population.

METHODS

We retrospectivly audited the time of day when PHEA is provided by UK Helicopter Emergency Medical Services (HEMS), by recording PHEA provision on a randomly selected week and weekend day in 2018. Pre-hospital emergency anaesthesia in the United Kingdom: an observational cohort study retrospectively assessed the time from emergency call to pre-hospital emergency anaesthesia delivery by HEMS during a 1 yr period from April 2017 to March 2018. The population coverage likely to receive pre-hospital emergency anaesthesia in accord with NICE guidelines was estimated by integrating population data with the median time to PHEA, hours of service provision, geographic location, and transport modality.

RESULTS

On a weekday 20 HEMS units (comprising from four to 31 enhanced care teams) were estimated to be able to meet NICE guidelines for delivery of PHEA to a poulation of 6.6-35.2 million individuals (at times of minimum and maximal staffing, respectively). At the weekend, 17 HEMS units (comprising from 5 to 28 enhanced care teams) were estimated to be able to meet NICE guidelines for PHEA deliveryto a population of 6.8-34.1 million individuals (minimum and maximal staffing, respectively).

CONCLUSIONS

There is marked geo-temporal variation in the ability of HEMS organisations to deliver pre-hospital emergency anaesthesia in the UK.

Blunt major trauma: now two different diseases?

Major trauma in the UK has changed and can now be thought of as two different diseases: the traditional type of high energy transfer major trauma occurring in younger patients, and low energy transfer major trauma (usually an older person falling on one level). The current NHS trauma system is not well set up to treat low energy transfer major trauma - adapting to the changing disease is the next big challenge.

A public-private collaborative model for a trauma program implementation: findings from a prospective trauma registry at 14 hospitals in Buenos Aires, Argentina

INTRODUCTION

Trauma is a leading cause of mortality and comprises an important cause of functional impairment among young people worldwide. The trauma registry (TR) is an integral component of modern comprehensive trauma care systems. Nevertheless, TRs have not been yet established in most developing countries. The objective of this study was to summarize the challenges, results, and lessons learned from a trauma program including initial results from a TR at tertiary-care public hospitals of Buenos Aires, Argentina.

MATERIAL AND METHODS

This is a descriptive study of the implementation of a trauma program in 14 hospitals and analysis of the initial results in the period between January 2010 and December 2018, using data from Fundación Trauma TR. Patients fitting injury definition that remained in hospital for more than 23 h were included. Injured patients were divided by age groups. Data on patients' demographics, mechanism of injury and severity, complications, treatments, and in-hospital mortality were analyzed between groups. A descriptive analysis is presented.

RESULTS

There were 29,970 trauma cases during the study period. Median age was 23 years (RIC 12, 39) with a 2.4:1 male-to-female ratio. Road traffic injuries (RTI) were the leading mechanism (30.8%) of admission and head was the most frequently injured body region (33.2%). Two-thirds of RTIs were motorcycle-related. Overall in-hospital mortality was 6.1%. Intentional self-harm in adult males and burns in adult females had the highest mortality rates (17.6% and 17.9%, respectively).

CONCLUSIONS AND DISCUSSION

The implementation of a trauma program within a public-private collaborative program in a resource-limited environment is feasible. The hospital-based TR can be used as a tool for injury surveillance, monitoring of the quality of trauma care, development of a trauma system, and to guide public health policies.

Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.

The volume-outcome relationship among severely injured patients admitted to English major trauma centres: a registry study

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.

Mapping the Steroid Response to Major Trauma From Injury to Recovery: A Prospective Cohort Study

CONTEXT

Survival rates after severe injury are improving, but complication rates and outcomes are variable.

OBJECTIVE

This cohort study addressed the lack of longitudinal data on the steroid response to major trauma and during recovery.

DESIGN

We undertook a prospective, observational cohort study from time of injury to 6 months postinjury at a major UK trauma centre and a military rehabilitation unit, studying patients within 24 hours of major trauma (estimated New Injury Severity Score (NISS) > 15).

MAIN OUTCOME MEASURES

We measured adrenal and gonadal steroids in serum and 24-hour urine by mass spectrometry, assessed muscle loss by ultrasound and nitrogen excretion, and recorded clinical outcomes (ventilator days, length of hospital stay, opioid use, incidence of organ dysfunction, and sepsis); results were analyzed by generalized mixed-effect linear models.

FINDINGS

We screened 996 multiple injured adults, approached 106, and recruited 95 eligible patients; 87 survived. We analyzed all male survivors <50 years not treated with steroids (N = 60; median age 27 [interquartile range 24-31] years; median NISS 34 [29-44]). Urinary nitrogen excretion and muscle loss peaked after 1 and 6 weeks, respectively. Serum testosterone, dehydroepiandrosterone, and dehydroepiandrosterone sulfate decreased immediately after trauma and took 2, 4, and more than 6 months, respectively, to recover; opioid treatment delayed dehydroepiandrosterone recovery in a dose-dependent fashion. Androgens and precursors correlated with SOFA score and probability of sepsis.

CONCLUSION

The catabolic response to severe injury was accompanied by acute and sustained androgen suppression. Whether androgen supplementation improves health outcomes after major trauma requires further investigation.

Age and the distribution of major injury across a national trauma system

Background

Trauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution.

Objectives

There is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between.

Methods

The TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England.

Results

About 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs.

Conclusions

Within adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.

Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on Deep Surgical Site Infection After Surgery for Lower Limb Fractures Associated With Major Trauma: The WHIST Randomized Clinical Trial

IMPORTANCE

Following surgery to treat major trauma-related fractures, deep wound infection rates are high. It is not known if negative pressure wound therapy can reduce infection rates in this setting.

OBJECTIVE

To assess outcomes in patients who have incisions resulting from surgery for lower limb fractures related to major trauma and were treated with either incisional negative pressure wound therapy or standard wound dressing.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial conducted at 24 trauma hospitals representing the UK Major Trauma Network that included 1548 patients aged 16 years or older who underwent surgery for a lower limb fracture caused by major trauma from July 7, 2016, through April 17, 2018, with follow-up to December 11, 2018.

INTERVENTIONS

Incisional negative pressure wound therapy (n = 785), which involved a specialized dressing used to create negative pressure over the wound, vs standard wound dressing not involving negative pressure (n = 763).

MAIN OUTCOMES AND MEASURES

The primary outcome measure was deep surgical site infection at 30 days diagnosed according to the criteria from the US Centers for Disease Control and Prevention. A preplanned secondary analysis of the primary outcome was performed at 90 days. The secondary outcomes were patient-reported disability (Disability Rating Index), health-related quality of life (EuroQol 5-level EQ-5D), surgical scar assessment (Patient and Observer Scar Assessment Scale), and chronic pain (Douleur Neuropathique Questionnaire) at 3 and 6 months, as well as other local wound healing complications at 30 days.

RESULTS

Among 1548 participants who were randomized (mean [SD] age, 49.8 [20.3] years; 561 [36%] were aged ≤40 years; 583 [38%] women; and 881 [57%] had multiple injuries), 1519 (98%) had data available for the primary outcome. At 30 days, deep surgical site infection occurred in 5.84% (45 of 770 patients) of the incisional negative pressure wound therapy group and in 6.68% (50 of 749 patients) of the standard wound dressing group (odds ratio, 0.87 [95% CI, 0.57 to 1.33]; absolute risk difference, -0.77% [95% CI, -3.19% to 1.66%]; P = .52). There was no significant difference in the deep surgical site infection rate at 90 days (11.4% [72 of 629 patients] in the incisional negative pressure wound therapy group vs 13.2% [78 of 590 patients] in the standard wound dressing group; odds ratio, 0.84 [95% CI, 0.59 to 1.19]; absolute risk difference, -1.76% [95% CI, -5.41% to 1.90%]; P = .32). For the 5 prespecified secondary outcomes reported, there were no significant differences at any time point.

CONCLUSIONS AND RELEVANCE

Among patients who underwent surgery for major trauma-related lower limb fractures, use of incisional negative pressure wound therapy, compared with standard wound dressing, resulted in no significant difference in the rate of deep surgical site infection. The findings do not support the use of incisional negative pressure wound therapy in this setting, although the event rate at 30 days was lower than expected.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN12702354.