Rural and urban patterns of severe injuries and hospital mortality in Australia: An analysis of the Australia New Zealand Trauma Registry: 2015-2019

Quantifying the prevalence of activity limitation for Māori in Aotearoa New Zealand using the Washington Group Short Set on Functioning: A national survey

BACKGROUND

Māori, the Indigenous people of Aotearoa/New Zealand, experience higher rates of activity limitation compared to the general population, and are therefore at greater risk of disability, yet disaggregated data within this population remain limited.

OBJECTIVE

The primary aim was to quantify the prevalence and types of activity limitation among Māori adults using the Washington Group Short Set (WG-SS) of Questions on Functioning, with a secondary objective to examine demographic variations in reported limitations.

METHODS

This cross-sectional study analysed data from a nationally representative survey of 7230 Māori adults. Participants self-reported activity limitations across six functional domains (vision, hearing, mobility, cognition, self-care, and communication) using the WG-SS. Weighted analyses were performed to estimate prevalence and demographic variations, with results presented for both "At least a lot of difficulty", "Some difficulty" and "Any difficulty" categories.

RESULTS

In total, 15.1 % reported "At least a lot of difficulty" and 70.2 % reported "Any difficulty". Almost 50 % of participants experienced multiple limitations. Cognitive difficulties were most prevalent, affecting 47.6 % of participants, with 8 % reporting severe difficulty. No significant differences in prevalence were observed between males and females, age, nor urbanicity.

CONCLUSION

A substantial burden of activity limitation, particularly cognitive, were found amongst Māori. The WG-SS, while effective for quantifying activity limitation, does not fully capture socio-cultural dimensions or broader participation barriers critical to understanding the experience of disability for Māori. Culturally responsive disability frameworks are urgently required to inform policies and practices which recognize the unique needs and address the existing inequities of Māori.

Time-series projecting road traffic fatalities in Australia: Insights for targeted safety interventions

Despite substantial progress in road safety, road traffic fatalities (RTFs) continue to be a persistent issue in Australia. This study aims to forecast RTFs trends up to 2050 by analyzing factors such as geographic location, age, gender, speed limits, and time of occurrence. Utilizing historical data from 1989 to 2024, fatalities were categorized by road user type, demographics, and day of the week. The Facebook Prophet time series model, incorporating categorical variables like region, age, and speed limits, was employed to predict future trends. The analysis reveals significant regional disparities in fatality reduction rates, with some areas lagging others. Gender-specific forecasts indicate a sharper decline in male fatalities compared to females, while projections highlight persistent risks for older drivers. Additionally, highways with higher speed limits are expected to see a substantial decrease in fatalities. These insights emphasize the need for targeted interventions in areas with slower reductions and high-risk demographic groups, aiding policymakers in refining safety measures, enforcing speed limits, and enhancing public awareness campaigns.

Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan

BACKGROUND

Traumatic diaphragmatic injury (TDI) is well-known worldwide as rare and life-threatening. However, because no nationwide cohort study of penetrating and blunt TDI has been conducted in Japan and other countries where penetrating trauma is relatively uncommon, the clinical characteristics of all TDI are unknown. We aimed to describe the characteristics of TDI patients, compare penetrating TDI with blunt TDI, and identify mortality risk factors in Japan.

METHODS

We retrospectively identified TDI patients between 2004 and 2019 using data from the Japan Trauma Data Bank. We extracted data on patient demographics, type of trauma, cause of trauma, physiological parameters, region of concomitant injury, associated injury, and management. We compared penetrating and blunt TDI for each variable. The primary outcome was mortality. Multivariable logistic regression was performed to identify mortality risk factors.

RESULTS

Of the 338,744 patients, 1,147 (0.3%) had TDI, of which 771 were eligible for analysis (excluding 308 in cardiac arrest on arrival). Penetrating TDI represented 29.8% and blunt TDI 70.2%, and comparing penetrating and blunt TDI, the most common cause was self-inflicted (48.7%) vs. accident (85.6%), males were 68.7% vs. 66.0% of the patients (P = 0.50), and the mortality rate was 8.3% vs. 26.4% (P < 0.001). Multivariable analysis found that age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.04), Injury Severity Score (OR 1.03, 95%CI 1.006-1.06), Revised Trauma Score (OR 0.55, 95%CI 0.45-0.67), severe concomitant abdominal injury (OR 2.45, 95%CI 1.32-4.56), severe concomitant upper extremity injury (OR 3.38, 95%CI 1.24-9.17) were independent predictors of mortality, and computed tomography (CT) (OR 0.32, 95%CI 0.15-0.69) and diaphragm repair (OR 0.44, 95%CI 0.25-0.78) were protective factors.

CONCLUSIONS

In Japan, we found that penetrating TDI was mainly caused by self-injury and the male-female ratio was the same as for blunt TDI, although blunt TDI was much more frequent. TDI was considered highly lethal, with over 25% of patients in cardiac arrest on arrival. Our unique independent predictors were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. These findings may help in the management of TDI in countries with less common penetrating trauma.

Trauma Outcomes Based on Remoteness of Injury in Australia: A Systemic Review

INTRODUCTION

Research suggests a significant disparity between rural and urban trauma patient outcomes, causing substantial social, economic and emotional costs, impacting health-related quality of life and functionality, and straining our healthcare system. There has not been a systematic examination of contributing factors in Australia.

OBJECTIVE

This study aims to systematically describe the nature of research on trauma outcomes by geographical location and (where possible) describe factors found to increase or decrease the likelihood and severity of injury in rural Australia.

DESIGN

Five databases (EMBASE, PubMed/MEDLINE, Web of Science, Scopus, CINAHL) and reference lists were searched. Eligible studies compared injury outcomes by geographic location in Australia, using a quantitative study design. No restrictions were placed on publication year or outcomes explored. The results were synthesised narratively.

FINDINGS

We found 14 papers. Mortality, the most studied outcome (n = 11), was overall positively related to traumatic incidents in more rural locations. Other data outcomes included hospital admissions and length of stay, admission to ICU, 28-day hospital readmission, rehabilitation, and patient-reported quality of life. Study findings show different mechanisms of injury (e.g., falls) and limited accounts of pre-hospital experiences.

DISCUSSION

Geographical location of trauma may impact the likelihood of injury mortality but is potentially confounded by the different mechanisms and severity of injury. There is insufficient evidence to make conclusions on other non-mortality and longer-term outcomes, and a greater understanding of prehospital outcomes is also needed.

CONCLUSION

This relationship is considered weak due to the limited geographic representation across Australia and the general paucity of recent literature.

Investigating the Burden of Traumatic Injuries and Access to Trauma Centers in Rural Riyadh

INTRODUCTION

Trauma is a major cause of death and disability among young adults in Saudi Arabia, with a road traffic fatality rate three times higher than other high-income countries. The vast expanse of the Riyadh region comprises 21 governorates over 156,078 square miles, most of which is rural. Although delays in access to trauma care pose a significant mortality and economic burden, regions at highest risk of delays have not been previously studied. This paper aims to identify the trauma center distribution, trauma burden, and areas with delayed access to trauma care in the rural governorates of the Riyadh region.

METHODS

We conducted a retrospective review of 24,268 reports from 17 rural governorates in the Riyadh region from the official data registry of the Red Crescent of Saudi Arabia from January 2021 to March 2023. Higher severity cases were classified under the red criteria (for age 15-64 ys: systolic blood pressure (SBP) < 90 mmHg or heart rate > SBP); for age ≥65 ys: SBP <110 mmHg or heart rate > SBP) based on established trauma activation criteria. We geospatially mapped all level 1-3 trauma centers in the rural governorates of the Riyadh region with an overlay of trauma burden, and identified red criteria cases and those that had delayed access to trauma centers in each of the governorates. Data were mapped using Quantum Geographic Information System, and analysis was performed using R statistics.

RESULTS

Rural Riyadh lacks level 1 trauma centers, with level 3 facilities primarily delivering trauma care. Among the reported trauma cases, majority were classified under the red criteria (67.7%, n = 16,433). Al-Kharj emerged as a hotspot for trauma cases, reporting the highest number of cases (21.4%, n = 5202) and red criteria cases (21.4%, n = 3512), followed by Al-Quwayiyah (14.4%, n = 3490) and Al-Majma'ah (9.8%, n = 2369). Blunt trauma predominated (79.4%, n = 19,280), with a substantial portion meeting the red criteria (62.4%, n = 12,032), while penetrating injuries were less common (14.5%, n = 3524). Of the red criteria cases, 38.2% (n = 6048) were delayed, most notably in Al-Kharj (21.8%, n = 1320).

CONCLUSIONS

In conclusion, our study reveals significant gaps in trauma care access and burden across rural governorates in the Riyadh region. The absence of level 1 trauma centers, coupled with high proportions of red criteria cases and delays in accessing care, underscores the need for targeted interventions and resource optimization. Addressing these challenges requires standardized trauma systems, improved transfer protocols, and a national trauma registry for comprehensive monitoring of patient outcomes.

Optimizing Trauma Activation Criteria for a Rural Trauma Center

BACKGROUND

There is a need for activation criteria that reflect the different factors affecting rural trauma patients.

OBJECTIVE

To develop effective activation criteria for a rural trauma center among adults, incorporating variables specific to the geography, mechanisms of injury, and population served.

METHODS

This is a single-center, retrospective cohort study conducted from (23 years) January 1, 2000, to July 31, 2023. The data collected patient demographics, injury details, morbidity, and preexisting comorbidity. This research included all adult (≥15 years) true Level I trauma activations defined as an injury severity score > 25 and met the need for trauma intervention criteria. The patients were grouped into adult and elderly categories. The analysis utilized a logistic regression model with the outcome of a true Level I trauma activation.

RESULTS

A total of 19,480 patients were included in the sample; 2,858 (14.6%) met the Level I activation criteria. Elderly Level I activation included assault, pedestrian struck, multiple pelvic fractures, traumatic pneumo/hemothorax, mediastinal fracture, sternum fracture, and flail rib fracture.

CONCLUSION

Using the findings of the logistic regression model, this center has made more robust activation guidelines adapted to its rural population.

Association between out-of-hospital cardiac arrest quality indicator and prehospital management and clinical outcomes for major trauma

INTRODUCTION

It is unclear whether emergency medical service (EMS) agencies with good out-of-hospital cardiac arrest (OHCA) quality indicators also perform well in treating other emergency conditions. We aimed to evaluate the association of an EMS agency's non-traumatic OHCA quality indicators with prehospital management processes and clinical outcomes of major trauma.

METHODS

This retrospective cross-sectional study analyzed data from registers of nationwide, population-based OHCA (adult EMS-treated non-traumatic OHCA patients from 2017 to 2018) and major trauma (adult, EMS-treated, and injury severity score ≥16 trauma patients in 2018) in South Korea. We developed a prehospital ROSC prediction model to categorize EMS agencies into quartiles (Q1-Q4) based on the observed-to-expected (O/E) ROSC ratio for each EMS agency. We evaluated the national EMS protocol compliance of on-scene management according to O/E ROSC ratio quartile. The association between O/E ROSC ratio quartiles and trauma-related early mortality was determined in a multi-level logistic regression model by adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI).

RESULTS

Among 30,034 severe trauma patients, 4,836 were analyzed. Patients in Q4 showed the lowest early mortality rate (5.6 %, 5.5 %, 4.8 %, and 3.4 % in Q1, Q2, Q3, and Q4, respectively). In groups Q1 to Q4, increasing compliance with the national EMS on-scene management protocol (trauma center transport, basic airway management for patients with altered mentality, spinal motion restriction for patients with spinal injury, and intravenous access for patients with hypotension) was observed (p for trend <0.05). Multivariable multi-level logistic regression analysis showed significantly lower early mortality in Q4 than in Q1 (adjusted OR [95 % CI] 0.56 [0.35-0.91]).

CONCLUSION

Major trauma patients managed by EMS agencies with high success rates in achieving prehospital ROSC in non-traumatic OHCA were more likely to receive protocol-based care and exhibited lower early mortality.

Increased distance or time from a major trauma centre in South Australia is not associated with worse outcomes after moderate to severe traumatic brain injury

OBJECTIVE

Considerations in traumatic brain injury (TBI) management include time to critical interventions and neurosurgical care, which can be influenced by the geographical location of injury. In Australia, these distances can be vast with varying degrees of first-responder experience. The present study aimed to evaluate the association that distance and/or time to a major trauma centre (MTC) had on patient outcomes with moderate to severe TBI.

METHODS

A retrospective cohort study was conducted using data from the Royal Adelaide Hospital's (RAH) Trauma Registry over a 3-year period (1 January 2018 to 31 December 2020). All patients with a moderate to severe TBI (Glasgow Coma Scale [GCS] ≤13 and abbreviated injury score head of ≥2) were included. The association of distance and time to the RAH and patient outcomes were compared by calculating the odds ratio utilising a logistic regression model.

RESULTS

A total of 378 patients were identified; of these, 226 met inclusion criteria and comprised our study cohort. Most patients were male (79%), injured in a major city (55%), with median age of 38 years old and median injury severity score (ISS) of 25. After controlling for age, ISS, ED GCS on arrival and pre-MTC intubation, increasing distance or time from injury site to the RAH was not shown to be associated with mortality or discharge destination in any of the models investigated.

CONCLUSION

Our analysis revealed that increasing distance or time from injury site to a MTC for patients with moderate to severe TBI was not significantly associated with adverse patient outcomes.

Splenic trauma in the Northern Territory; the impact of an interventional radiology service on splenic trauma management and outcomes

Background

The spleen is the most commonly injured organ in abdominal trauma. Guidelines suggest non-operative management (NOM) is preferred over splenectomy for all haemodynamically stable patients, regardless of injury severity. The availability of splenic angioembolization has been shown to improve outcomes for high-grade splenic injuries by decreasing failure rates of NOM. Trauma incidence and fatality rates are higher in regional and remote areas, and rurality is associated with increased mortality from trauma. Additionally, rural hospitals have difficulty with staff retention and may offer less specialist services compared with urban centres.

Methods

A single-centre retrospective cohort study was conducted at the Royal Darwin Hospital, using the National Critical Care and Trauma Response Centre database. All patients with splenic injury admitted between January 2018 and December 2021 were selected, and divided into control and intervention cohorts, before and after January 1, 2020, correlating with interventional radiology availability. Demographic information included age, gender, mechanism of injury, AIS grade of splenic injury, injury severity score, and shock index. The primary outcome was management of splenic injury and failure rate of NOM. Secondary outcomes included mortality, ICU length of stay and hospital length of stay.

Results

Sixty-six patients met inclusion criteria, 32 controls and 34 interventions. Intervention and control groups were statistically similar for baseline demographics, and outcome measures of mortality and ICU length of stay. There was significant difference in the management of splenic injury, either OM or NOM, between intervention and control cohorts among high-grade splenic injury patients (AIS grade 4 and 5). In logistic regression analysis, the absence of interventional radiology was associated with increased OM (OR 12.8, SE 15.7, p = 0.04, 95%CI 1.15-142).

Conclusion

The absence of an interventional radiology service was associated with an increased risk of operative management, suggesting interventional radiology helps to prevent splenectomy, improving long term outcomes for splenic trauma patients in regional settings. The effects of availability of IR seen in international publications on decreased mortality and shorter length of stay were not replicated in this study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic accuracy of transthoracic echocardiography for the identification of proximal aortic dissection: a systematic review and meta-analysis

This systematic review and meta-analysis evaluated the performance of transthoracic echocardiography (TTE) for diagnosis of proximal aortic dissections based on the identification of specific sonographic features. A systematic literature search of major databases was conducted on human studies investigating the diagnostic accuracy of TTE for proximal aortic dissection. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of studies was evaluated using Quality Assessment of Diagnostic Accuracy Studies 2 tool. Data were gathered for the following sonographic findings: intimal flap, tear, or intramural hematoma; enlargement of aortic root or widening of aortic walls; aortic valve regurgitation; or pericardial effusion. Sensitivity, specificity, diagnostic odds ratio, number needed to diagnose values, and likelihood ratios were determined. Fourteen studies were included in our final analysis. More than half of the included studies demonstrated low risk of bias. The identification of intimal flap, tear, or intramural hematoma was shown to have an exceptional ability as a diagnostic tool to rule in proximal aortic dissections. TTE should be considered during the initial evaluation of patients presenting to the emergency department with suspected proximal aortic dissection. Positive sonographic findings on TTE may aid in rapid assessment, coordination of care, and treatment of individuals awaiting advanced imaging.

A critical analysis of Discovery Health's claims-based risk adjustment of mortality rates in South African private sector hospitals

In 2019, Discovery Health published a risk adjustment model to determine standardised mortality rates across South African private hospital systems, with the aim of contributing towards quality improvement in the private healthcare sector. However, the model suffers from limitations due to its design and its reliance on administrative data. The publication's aim of facilitating transparency is unfortunately undermined by shortcomings in reporting. When designing a risk prediction model, patient-proximate variables with a sound theoretical or proven association with the outcome of interest should be used. The addition of key condition-specific clinical data points at the time of hospital admission will dramatically improve model performance. Performance could be further improved by using summary risk prediction scores such as the EUROSCORE II for coronary artery bypass graft surgery or the GRACE risk score for acute coronary syndrome. In general, model reporting should conform to published reporting standards, and attempts should be made to test model validity by using sensitivity analyses. In particular, the limitations of machine learning prediction models should be understood, and these models should be appropriately developed, evaluated and reported.