Long-term outcomes in blunt trauma: who goes back to work?

Health-related quality of life after severe trauma and available PROMS: an updated review (part I)

Introduction

Throughout the years, a decreasing trend in mortality rate has been demonstrated in patients suffering severe trauma. This increases the relevance of documentation of other outcomes for this population, including patient-reported outcome measures (PROMs), such as health-related quality of life (HRQoL). The aim of this review was to summarize the results of the studies that have been conducted regarding HRQoL in severely injured patients (as defined by the articles’ authors). Also, we present the instruments that are used most frequently to assess HRQoL in patients suffering severe trauma.

Methods

A literature search was conducted in the Cochrane Library, EMBASE, PubMed, and Web of Science for articles published from inception until the 1st of January 2022. Reference lists of included articles were reviewed as well. Studies were considered eligible when a population of patients with major, multiple or severe injury and/or polytrauma was included, well-defined by means of an ISS-threshold, and the outcome of interest was described in terms of (HR)QoL. A narrative design was chosen for this review.

Results

The search strategy identified 1583 articles, which were reduced to 113 after application of the eligibility criteria. In total, nineteen instruments were used to assess HRQoL. The SF-36 was used most frequently, followed by the EQ-5D and SF-12. HRQoL in patients with severe trauma was often compared to normative population norms or pre-injury status, and was found to be reduced in both cases, regardless of the tool used to assess this outcome. Some studies demonstrated higher scoring of the patients over time, suggesting improved HRQoL after considerable time after severe trauma.

Conclusion

HRQoL in severely injured patients is overall reduced, regardless of the instrument used to assess it. The instruments that were used most frequently to assess HRQoL were the SF-36 and EQ-5D. Future research is needed to shed light on the consequences of the reduced HRQoL in this population. We recommend routine assessment and documentation of HRQoL in severely injured patients.

Development and Validation of Indicators for Population Injury Surveillance in Hong Kong: Development and Usability Study

BACKGROUND

Injury is an increasingly pressing global health issue. An effective surveillance system is required to monitor the trends and burden of injuries.

OBJECTIVE

This study aimed to identify a set of valid and context-specific injury indicators to facilitate the establishment of an injury surveillance program in Hong Kong.

METHODS

This development of indicators adopted a multiphased modified Delphi research design. A literature search was conducted on academic databases using injury-related search terms in various combinations. A list of potential indicators was sent to a panel of experts from various backgrounds to rate the validity and context-specificity of these indicators. Local hospital data on the selected core indicators were used to examine their applicability in the context of Hong Kong.

RESULTS

We reviewed 142 articles and identified 55 indicators, which were classified into 4 domains. On the basis of the ratings by the expert panel, 13 indicators were selected as core indicators because of their good validity and high relevance to the local context. Among these indicators, 10 were from the construct of health care service use, and 3 were from the construct of postdischarge outcomes. Regression analyses of local hospitalization data showed that the Hong Kong Safe Community certification status had no association with 5 core indicators (admission to intensive care unit, mortality rate, length of intensive care unit stay, need for a rehabilitation facility, and long-term behavioral and emotional outcomes), negative associations with 4 core indicators (operative intervention, infection rate, length of hospitalization, and disability-adjusted life years), and positive associations with the remaining 4 core indicators (attendance to accident and emergency department, discharge rate, suicide rate, and hospitalization rate after attending the accident and emergency department). These results confirmed the validity of the selected core indicators for the quantification of injury burden and evaluation of injury-related services, although some indicators may better measure the consequences of severe injuries.

CONCLUSIONS

This study developed a set of injury outcome indicators that would be useful for monitoring injury trends and burdens in Hong Kong.

BEYOND PAIN AND DISABILITY: THE LASTING EFFECTS OF TRAUMA ON LIFE AFTER INJURY

BACKGROUND

The impact of traumatic injury likely extends beyond direct physical consequences and lasts well beyond the acute injury phase. Data collection is sparse after hospital discharge, however. In this observational study, we hypothesized that sequelae of injury would last at least 6 months and sought to prospectively determine patient reported physical, emotional, and social outcomes during this post-injury period.

METHODS

We surveyed patients admitted to our Level I trauma center (7/2019-10/2020) regarding baseline functioning and quality of life after injury, using the PROMIS-29 instrument, a primary care PTSD screen (PC-PTSD-5), and questions on substance use, employment, and living situation. Patients were re-surveyed at 6 months. PROMIS-29 scores are reported as t-scores compared to the U.S. population. Differences between groups were analyzed using chi square, signed-rank, and t-tests, with paired tests used for changes over time.

RESULTS

362 patients completed the baseline, 130 of whom completed 6-month follow-up. Those completing the 6-month survey were similar ages (43.3 ± 17.8 vs 44.4 ± 19.0, p = 0.57), mechanism (24.7% vs 28.0% shot or stabbed, p = 0.61), and severities (median ISS 9 vs 9, p = 0.15) as those who only completed the baseline. 55.0% reported being hospitalized for an injury previously. Patients reported decreases in ability to participate in social roles and activities (mean t-score 51.4 vs 55.3, p = 0.011) and increases in anxiety (53.8 vs 50.5, p = 0.011) and depression (51.0 vs 48.7, p = 0.025). 26.2% screened positive for PTSD at 6 months. Employment decreased at 6 months, with 63.9% reporting being "occasionally" employed or unemployed at 6 months, vs 44.6% pre-injury (p < 0.001).

CONCLUSION

The effects of injury extend beyond pain and disability, impacting several realms of life for at least 6 months following trauma. These data support the development of screening and intervention protocols for post-injury patients.

LEVEL OF EVIDENCE

III, prospective observational.

Return to work after injury in Hong Kong: prospective multi-center cohort study

PURPOSE

Trauma remains a major cause of morbidity and disability worldwide; however, reliable data on the health status of an urban Asian population after injury are scarce. The aim was to evaluate 1-year post-trauma return to work (RTW) status in Hong Kong.

METHODS

This was a prospective, multi-center cohort study involving four regional trauma centers from 2017 to 2019 in Hong Kong. Participants included adult patients entered into the trauma registry who were working or seeking employment at the time of injury. The primary outcome was the RTW status up to 1 year. The Extended Glasgow Outcome Scale, 12-item Short Form (SF-12) survey and EQ5D were also obtained during 1-, 3-, 6-, 9-, and 12-month follow-ups. Multivariable Cox proportional hazards regression analysis was used for analysis.

RESULTS

Six hundred and seven of the 1115 (54%) recruited patients had RTW during the first year after injury. Lower physical requirements (p = 0.003, HR 1.51) in pre-injury job nature, higher educational levels (p < 0.001, HR 1.95), non-work-related injuries (p < 0.001, HR 1.85), shorter hospital length of stay (p = 0.007, HR 0.98), no requirement for surgery (p = 0.006, HR 1.34), and patients who could be discharged home (p = 0.006, HR 1.43) were associated with RTW within 12 months post-injury. In addition, 1-month outcomes including extended Glasgow Outcome Scale ≥ 6 (p = 0.001, HR 7.34), higher mean SF-12 physical component summary (p = 0.002, HR 1.02) and mental component summary (p < 0.001, HR 1.03), and higher EQ5D health index (p = 0.018, HR 2.14) were strongly associated with RTW.

CONCLUSIONS

We have identified factors associated with failure to RTW during the first year following in Hong Kong including socioeconomic factors, injury factors and treatment-related factors and 1-month outcomes. Future studies should focus on the interventions that can impact on RTW outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03219424.

Causes of death following discharge after trauma in North Carolina

BACKGROUND

While a "fourth peak" of delayed trauma mortality has been described, limited data describe the causes of death (CODs) for patients in the years following an injury. This study investigates the difference in COD statewide for patients with and without a recent trauma admission.

METHODS

This retrospective cohort study compared COD for trauma and nontrauma patients in North Carolina. Death certificates in NC's death registry were matched with the NC trauma registry between January 2013 and December 2018 using matching on name and date of birth. Patients who died during the index trauma admission were excluded. Underlying COD recorded on the death certificate were used for the primary analysis.

RESULTS

Of 481,415 death records, 19,083 (4.0%) were linked to an alive discharge within the trauma registry during the study period. Prior trauma patients (PTPs) had a higher incidence of mental illness (9.2 vs. 6.1%), Alzheimer's (6.1% vs. 4.2%), and opioid-related (1.8% vs. 1.6%) COD compared to nontrauma patients, p < 0.05. Overall, suicide was higher in the nontrauma cohort (1.5% vs. 1.1%); however, PTP had higher incidences of death by motor vehicle collision and other injury (6.0% vs. 3.8%) and homicide (0.9% vs. 0.6%), p < 0.001. Prior trauma patients had 1.16 increased odds of an opioid-related death (p = 0.009; 95% confidence interval, 1.04-1.29) compared with those without prior trauma. Younger PTP had a much higher rate of death from suicide (12.0%) compared with those 41 to 65 years (2.8%) and older than 65 years (0.2%; p < 0.001). Discharge to skilled nursing facility (odds ratio, 1.87; p < 0.05) and severe injury (odds ratio, 1.93; p < 0.05) were associated with early death after discharge (≤90 days).

CONCLUSION

After hospital discharge, PTPs remain at risk of dying from future trauma and opioid-related conditions. Prevention strategies for PTP should address the increased risk of death from a subsequent traumatic injury and the at-risk populations for early death after discharge.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level IV.

Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level

BACKGROUND

Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income.

STUDY DESIGN

Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years.

RESULTS

Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points).

CONCLUSIONS

The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.

[Rehabilitation after multiple traumata]

BACKGROUND

The reintegration into the social and professional environment and the achievement of the best possible quality of life after multiple injuries can often only be achieved after a lengthy rehabilitation process and belongs in the hands of experienced doctors, therapists, and rehabilitation managers.

REHABILITATION PHASES

Rehabilitation after serious accidents must be differentiated from "normal" orthopedic rehabilitation after elective surgery. The challenges of trauma rehabilitation require coordinated rehabilitation phases. This is the only way to avoid the so-called "rehab hole" between discharge from the acute clinic and the start of post-acute rehabilitation. A 6-phase model is described. After acute treatment (phase A) and any necessary early rehabilitation (phase B), phase C of post-acute rehabilitation places special demands on the rehabilitation facility. Phase D of the follow-up rehabilitation is established. The further rehabilitation (phase E) provides measures specifically tailored to the consequences of the accident, such as pain rehabilitation or activity-oriented procedures. Long-term follow-up care for previously severely injured patients is necessary (phase F).

PROSPECTS

An integration of trauma rehabilitation centers into the existing trauma network remains the goal to improve the outcome after polytrauma.

The association of hand and wrist injuries with other injuries in multiple trauma patients. A retrospective study in a UK Major Trauma Centre

BACKGROUND

Approximately 20,000 major trauma cases occur in England every year. However, the association with concomitant upper limb injuries is unknown. This study aims to determine the incidence, injury pattern and association of hand and wrist injuries with other body injuries and the Injury Severity Score (ISS) in multiply injured trauma patients.

METHODS

Single centre retrospective study was performed at a level-one UK Major Trauma Centre (MTC). Trauma Audit and Research Network (TARN) eligible multiply injured trauma patients that were admitted to the hospital between January 2014 and December 2018 were analysed. TARN is the national trauma registry. Eligible patients were: a trauma patient of any age who was admitted for 72 h or more, or was admitted to intensive care, or died at the hospital, was transferred into the hospital for specialist care, was transferred to another hospital for specialist care or for an intensive care bed and whose isolated injuries met a set of criteria. Data extracted included: age, gender, mode of arrival, location of injuries including: hand and/or wrist and mechanism of injury. We performed a logistic regression analysis to assess the association between hand/wrist injury to ISS score of 15 points or above/below and to the presentation of other injuries.

RESULTS

107 patients were analysed. Hand and wrist injuries were the second most common injury (26.2%), after thoracic injuries. Distal radial injuries were found in 5.6%, carpal/carpometacarpal in 6.5%, concurrent distal radius and carpometacarpal in 0.9%, phalangeal injuries in 4.7%, tendon injuries in 0.9% and concurrent hand and wrist injuries in 7.5% cases. There was a significant association between hand or wrist injuries and lower limb injuries (Odds Ratio (OR): 3.84; 95% confidence intervals (CI): 1.09 to 13.50; p = 0.04) and pelvic injuries (OR: 4.78; 95% CI: 1.31 to 17.44; p = 0.02). There was no statistical association between hand and wrist injuries and ISS score (OR: 0.80; 95% CI: 0.11 to 5.79; p = 0.82).

CONCLUSIONS

Hand and wrist injuries are prevalent in trauma patients admitted to MTCs. They should not be under-estimated but routinely screened for in multiply injured patients particularly those with a pelvic or lower limb injury.

"Do You Need a Doctor's Note?" Factors Leading to Delayed Return to Work after Blunt Chest Trauma

BACKGROUND

Blunt chest trauma is associated with significant morbidity, but the long-term functional status for these patients is less well-known. Return to work (RTW) is a benchmark for functional recovery in trauma patients, but minimal data exist regarding RTW following blunt chest trauma.

MATERIALS AND METHODS

Patients ≥ 18 y old admitted to a Level 1 trauma center following blunt chest trauma with ≥ 3 rib fractures and length of stay (LOS) ≥ 3 d were included. An electronic survey assessing RTW was administered to patients after discharge. Patients were stratified as having delayed RTW (> 3 mo after discharge) or self-reported worse activities-of-daily-living (ADL) function after injury. Patient demographics, outcomes, and injury characteristics were compared between groups.

RESULTS

Median time to RTW was 3 mo (IQR 2,5). Patients with delayed RTW had higher odds of having more rib fractures than those with RTW ≤ 3 mo (median 10 versus 7; OR:1.24, 95%CI:1.04,1.48) as well as a longer LOS (median 13 versus 7 d; OR:1.15, 95% CI:1.04,1.30). Patients with stable ADL after trauma returned to work earlier than those reporting worse ADL (median 2 versus 3.5 mo, P < 0.01). 23.6% of respondents took longer than 5 mo to return to independent functioning, and 50% of respondents' report limitations in daily activities due to physical health after discharge.

CONCLUSIONS

The significant proportion of patients with poor physical health and functional status suggests ongoing burden of injury after discharge. Patients with longer LOS and greater number of rib fractures may be at highest risk for delayed RTW after injury.

Association of Severe Trauma With Work and Earnings in a National Cohort in Canada

Importance

Traumatic injury disproportionately affects adults of working age. The ability to work and earn income is a key patient-centered outcome. The association of severe injury with work and earnings appears to be unknown.

Objective

To evaluate the association of severe traumatic injury with subsequent employment and earnings in long-term survivors.

Design, Setting, and Participants

This is a retrospective, matched, national, population-based cohort study of adults who had employment and were hospitalized with severe traumatic injury in Canada between January 2008 and December 2010. All acute care hospitalizations for severe injury were included if they involved adults aged 30 to 61 years who were hospitalized with severe traumatic injury, working in the 2 years prior to injury, and alive through the third calendar year after their injury. Patients were matched with unexposed control participants based on age, sex, marital status, province of residence, rurality, baseline health characteristics, baseline earnings, self-employment status, union membership, and year of the index event. Data analysis occurred from March 2019 to December 2019.

Main Outcomes and Measures

Changes in employment status and annual earnings, compared with unexposed control participants, were evaluated in the third calendar year after injury. Weighted multivariable probit regression was used to compare proportions of individuals working between those who survived trauma and control participants. The association of injury with mean yearly earnings was quantified using matched difference-in-difference, ordinary least-squares regression.

Results

A total of 5167 adults (25.6% female; mean [SD] age, 47.3 [8.8] years) with severe injuries were matched with control participants who were unexposed (25.6% female; mean [SD] age, 47.3 [8.8] years). Three years after trauma, 79.3% of those who survived trauma were working, compared with 91.7% of control participants, a difference of -12.4 (95% CI, -13.5 to -11.4) percentage points. Three years after injury, patients with injuries experienced a mean loss of $9745 (95% CI, -$10 739 to -$8752) in earnings compared with control participants, representing a 19.0% difference in annual earnings. Those who remained employed 3 years after injury experienced a 10.8% loss of earnings compared with control participants (-$6043 [95% CI, -$7101 to -$4986]). Loss of work was proportionately higher in those with lower preinjury income (lowest tercile, -18.5% [95% CI, -20.8% to -16.2%]; middle tercile, -11.5% [95% CI, -13.2% to -9.9%]; highest tercile, -6.0% (95% CI, -7.8% to -4.3%]).

Conclusions and Relevance

In this study, severe traumatic injury had a significant association with employment and earnings of adults of working age. Those with lower preinjury earnings experienced the greatest relative loss of employment and earnings.

Perceived loss of social support after non-neurologic injury negatively impacts recovery

BACKGROUND

Traumatic injury is not only physically devastating, but also psychologically isolating, potentially leading to poor quality of life, depression and posttraumatic stress disorder (PTSD). Perceived social support (PSS) is associated with better outcomes in some populations. What is not known is if changes in PSS influence long-term outcomes following nonneurologic injury. We hypothesized that a single drop in PSS during recovery would be associated with worse quality of life.

METHODS

This is a post hoc analysis of a prospectively collected database that included patients 18 years or older admitted to a Level I trauma center with Injury Severity Score (ISS) of 10 or higher, and no traumatic brain or spinal cord injury. Demographic and injury data were collected at the initial hospital admission. Screening for depression, PTSD, and Medical Outcomes Study Short Form 36 Mental Composite Score (MCS) were obtained at the initial hospitalization, 1, 2, 4, and 12 months postinjury. The Multidimensional Scale of Perceived Social Support (MSPSS) was obtained at similar time points. Patients with high MSPSS (>5) at baseline were included and grouped by those that ever reported a score ≤5 (DROP), and those that remained high (STABLE). Outcomes were determined at 4 and 12 months.

RESULTS

Four hundred eleven patients were included with 96 meeting DROP criteria at 4 months, and 97 at 1 years. There were no differences in sex, race, or injury mechanism. The DROP patients were more likely to be single (p = 0.012 at 4 months, p = 0.0006 at 1 year) and unemployed (p = 0.016 at 4 months, and p = 0.026 at 1 year) compared with STABLE patients. At 4 months and 1 year, DROP patients were more likely to have PTSD, depression, and a lower MCS (p = 0.0006, p < 0.0001).

CONCLUSION

Patients who have a drop in PSS during the first year of recovery have significantly higher odds of poor psychological outcomes. Identifying these socially frail patients provides an opportunity for intervention to positively influence an otherwise poor quality of life.

LEVEL OF EVIDENCE

Therapeutic, Prognostic and Epidemiological, Level III.

Trajectory of functional outcome and health status after moderate-to-major trauma in Hong Kong: A prospective 5 year cohort study

BACKGROUND

Trauma care systems in Asia have been developing in recent years, but there has been little long-term outcome data from injured survivors. This study aims to evaluate the trajectory of functional outcome and health status up to five years after moderate to major trauma in Hong Kong.

METHODS

We report the five year follow up results of a multicentre, prospective cohort from the trauma registries of three regional trauma centres in Hong Kong. The original cohort recruited 400 adult trauma patients with ISS ≥ 9. Telephone follow up was conducted longitudinally at seven time points, and the extended Glasgow Outcome Scale (GOSE) and Short-Form 36 (SF36) were tracked.

RESULTS

119 out of 309 surviving patients (39%) completed follow up after 5 years. The trajectory of GOSE, PCS and MCS showed gradual improvements over the seven time points. 56/119 (47.1%) patients reported a GOSE = 8 (upper good recovery), and the mean PCS and MCS was 47.8 (95% CI 45.8, 49.9) and 55.8 (95% CI 54.1, 57.5) respectively at five years. Univariate logistic regression showed change in PCS - baseline to 1 year and 1 year to 2 years, and change in MCS - baseline to 1 year were associated with GOSE = 8 at 5 years. Linear mixed effects model showed differences in PCS and MCS were greatest between 1-month and 6-month follow up.

CONCLUSIONS

After injury, the most rapid improvement in PCS and MCS occurred in the first six to 12 months, but further recovery was still evident for MCS in patients aged under 65 years for up to five years.

Risk factors for complications and adverse outcomes in polytrauma patients with associated upper extremity injuries

Background

In terms of upper extremity fractures by patients with multiple injuires, a lot of studies have assessed the functional outcome following trauma to have less favorable outcomes in regards to functional recovery. We tested the hypothesis that differences in clinical outcome occur between shaft and articular injuries of the upper extremity, when patients that sustained neurologic deficits (e.g. brachial plexus lesions) are excluded.

Methods

We involved Patients with isolated or combined upper extremity fracture, ISS > 16 in a level one trauma center. The follow up was at least 10 years after the initial injury. Both clinical examination (range of motion, instability, contractures, peripheral nerve damage) and radiographic analysis were carried out. We evaluated also the development of heterotopic ossifications. To analyse patients were subdivided into 3 different subgroups (articular [IA], shaft [IS], and combined [C]).

Results

A statistically significant difference was found when ROM was compared between Group IS and C (p = 0.012), for contractures between Groups IA and C (p = 0.009) and full muscle elbow forces between Groups IS and C (p = 0.005) and Group IA and IS (p = 0.021). There was a significantly increased incidence in heterotopic ossifications when articular involvement was present. This applied for the isolated (p < 0.02) and the combined group (Group C vs Group IS, p = 0.003).When Brooker type I/II in group IA and Brooker types III/IV were combined, there was a significant difference (p < 0.001). In group IA (n = 1) and in group C (n = 6), HO developed or worsened after revision surgery, all of which were performed for malunion or nonunion.

Conclusions

In this study, patients with isolated shaft fractures of the upper extremity tend to have a more favorable outcome in comparison with combined to isolated articular fractures in terms of range of motion, pain and the ability to use the arm for everyday activities.In the clinical practice of the treatment of polytraumatized patients with upper extremity injuries, we feel that the relevance of these injuries should not be underestimated. They are especially prone to development of heterotopic ossifications, thus requiring prophylactic measures, if necessary. As their incidence increases with the rate of reoperations, we feel that even during initial care, meticulous surgery is required to avoiding the necessity of revision surgeries. Similar to injuries below the knee, upper extremity injuries, should be treated to avoid any functional disability.

Results and Outcomes After Midshaft Clavicle Fracture: Matched Pair Analysis of Operative Versus Nonoperative Management

This study evaluated patients with displaced clavicle fractures treated surgically vs nonoperatively. The authors hypothesized that functional outcomes would be no different. A retrospective comparative study was performed of 138 patients with closed midshaft clavicle fractures. Sixty-nine patients were treated operatively and matched for sex, age, and fracture pattern to 69 patients treated nonoperatively. Charts and radiographs were reviewed, and the American Shoulder and Elbow Surgeons survey was administered. A poor outcome was defined as a treatment complication or an American Shoulder and Elbow Surgeons score less than 60. There were 116 men and 22 women with a mean age of 37.7 years and fracture patterns of 15B-1 (n=78), 15B-2 (n=48), and 15B-3 (n=12). Thirty-seven percent were tobacco smokers, with 23 treated operatively and 28 nonoperatively. Ten (14.5%) initially nonoperative patients underwent plate fixation at a mean of 25.9 weeks (range, 7-48 weeks) because of persistent pain and motion at the fracture site. Fifteen (21.7%) of the 69 patients treated acutely with surgery had 16 complications, which resulted in secondary procedures in 11 patients (15.9%). Overall, poor outcomes occurred in 21 (30.4%) of 69 after fixation and in 19 (27.5%) of 69 in the nonoperative group. Unemployment (P=.05) and tobacco use (P=.03) were associated with poor outcome, irrespective of type of treatment. Initial nonoperative treatment presents a reasonable option for many patients. No differences in complications or poor outcomes were noted for surgical vs nonoperative treatment. Social factors proved to be greater predictors of outcome than other patient or injury features. Management of clavicle fractures should be individualized with assessment of patient expectations and activity level. Social factors should also be considered. [Orthopedics. 2018; 41(5):e689-e694.].

Health-related quality of life in trauma patients at 12 months after injury: a prospective cohort study

PURPOSE

Health-related quality of life (HRQOL) is increasingly recognized as a benchmark in trauma outcome research, with few studies having evaluated the HRQOL in trauma patients. The aim of our study was to assess the change in trauma patients' HRQOL at 12 months post-injury and to describe their living situation and return to work status.

METHODS

A prospective cohort study was performed at a Japanese tertiary care hospital from September 2013 to September 2015. The short-form (SF-36) health survey was used at discharge, and 6 and 12 months post-injury. We obtained information regarding living situation at 12 months post-injury.

RESULTS

Complete data were collected from 129 patients. The median age and injury severity score were 66 years 17, respectively. The physical and role-social component scores improved significantly between hospital discharge and 6 months post-injury. However, the mental component score decreased significantly during this period. There was no significant increase in any of the 3 SF-36 component scores between 6 and 12 months post-injury. At 12 months post-injury, 106 (82%) patients were independent and 15 (12%) patients were dependent on home care services. The return to work rate was 65% (47/72).

CONCLUSIONS

Our study suggests that the quality-of-life of Japanese trauma patients generally improved over time, but remained lower than the Japanese national average. Most trauma patients return to home and work within 12 months post-injury.

Long-term outcome in 324 polytrauma patients: what factors are associated with posttraumatic stress disorder and depressive disorder symptoms?

Background

Physical impairment is well-known to last for many years after a severe injury, and there is a high impact on the quality of the survivor’s life. The purpose of this study was to examine if this is also true for psychological impairment with symptoms of posttraumatic stress disorder or depression after polytrauma.

Design

Retrospective cohort outcome study.

Setting

Level I trauma centre.

Population

637 polytrauma trauma patients who were treated at our Level I trauma centre between 1973 and 1990. Minimum follow-up was 10 years after the injury.

Methods

Patients were asked to fill in a questionnaire, including parts of the Posttraumatic Stress Diagnostic Scale, the Impact of Event Scale-Revised and the German Hospital Anxiety and Depression Scale, to evaluate mental health. Clinical outcome was assessed before by standardised scores.

Results

Three hundred and twenty-four questionnaires were evaluated. One hundred and forty-nine (45.9%) patients presented with symptoms of mental impairment. Quality of life was significantly higher in the mentally healthy group, while the impaired group achieved a lower rehabilitation status.

Conclusions

Mental impairment can be found in multiple trauma victims, even after 10 years or more. Treating physicians should not only focus on early physical rehabilitation but also focus on early mental rehabilitation to prevent long-term problems in both physical and mental disability.

Post-trauma morbidity, measured as sick leave, is substantial and influenced by factors unrelated to injury: a retrospective matched observational cohort study

BACKGROUND

Mortality as an endpoint has been the focus of trauma research whereas few studies investigate long-term outcomes in terms of morbidity. An adequate analysis of post-injury morbidity includes several dimensions, for this reason sick leave has been used as a proxy for morbidity in the current study. The aim of this retrospective matched observational cohort study was to investigate sick leave before and after trauma and factors associated with prolonged sick leave.

METHODS

Patients from a level one trauma centre 2005-2010 were matched in a 1:5 ratio with uninjured controls. By linkage to national registries, sick leave rates were compared. The association between potential risk factors and full-time sick leave at twelve months post injury, the primary end-point, was examined in trauma patients by logistic regression.

RESULTS

Four thousand seven hundred twelve patients and 25,013 controls aged 20-63 were included. Trauma patients had more sick leave both before and after trauma. Age, psychiatric disease, low level of education, serious injury, spinal injury, reduced consciousness at admission, discharge destination other than home, and hospital length of stay >7 days were all associated with the primary end-point. The strongest risk factor was sick leave before trauma; this was also noted in the most seriously injured patients.

DISCUSSION

In this retrospective matched observational cohort study we found a significant long-term morbidity, measured as sick leave, among trauma patients. Compared to controls the difference was maximal early after trauma and sustained throughout the follow up period. In the logistic regression, factors associated with the traumatic injury as well as host factors increased the probability of not returning to work. Full sick leavemonth twelve post injury was strongly associated with pre-injury sick leave but also with age, psychiatric comorbidity, level of education, injury severity, spinal injury, low GCS at admission, length of stay at hospital and discharge to other destination than home.

CONCLUSIONS

Trauma patients suffer from significant long-term morbidity. The sustained post-trauma morbidity is largely influenced by factors not related to injury per se. These insights enable identification of patients at risk for prolonged sick leave after trauma.

Twelve-month work-related outcomes following hip fracture in patients under 65 years of age

INTRODUCTION

Recent research has highlighted the need for improved outcome reporting in younger hip fracture patients. For this population, return to work (RTW) is a particularly important measure against which to evaluate treatment outcomes. However, to date, only two small studies have reported RTW outcomes in young hip fracture patients and neither investigated factors predictive of RTW. The aims of this study were to report return to work (RTW) status and predictors of RTW 12 months after hip fracture in patients <65 years.

METHODS

Two hundred and ninety-one adults aged <65 years, admitted with hip fractures between July 2009 and June 2013 and registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) were included in this prospective cohort study. Twelve-month return to work status was collected through structured telephone interviews conducted by trained interviewers. Multivariate logistic regression was used to identify demographic and injury variables that were important predictors of 12-month work status.

RESULTS

Sixty-five per-cent of patients had returned to work 12 months after hip fracture (62% of whom had an isolated hip fracture and 38% of whom had additional injuries). Relative to patients aged 16-24 years, odds of RTW was reduced by 78%-89% for each 10-year increase in age (p=0.02). Relative to patients employed as managers/administrators/professionals, odds of RTW were 68% to 95% lower for all other workers (p<0.001). For those reporting a pre-injury disability, odds of RTW were 79% lower compared to those without disability (p=0.004) and 69% lower for patients with multiple injuries compared to isolated hip fracture patients (p=0.002). Finally, patients compensated by a work or transport insurer had a 67% lower odds of RTW relative to patients who were not compensated (p=0.02).

CONCLUSIONS

Approximately one third of patients <65years had not returned to work 12 months after hip fracture. Patients who are older, have multiple injuries or pre-existing disabilities or who work in more physical occupations may need more assistance to RTW following hip fracture. The compensation system should be examined to determine why compensated patients may be at risk of poor RTW outcomes.

Elevated Admission Base Deficit Is Associated with a Complex Dynamic Network of Systemic Inflammation Which Drives Clinical Trajectories in Blunt Trauma Patients

We hypothesized that elevated base deficit (BD) ≥ 4 mEq/L upon admission could be associated with an altered inflammatory response, which in turn may impact differential clinical trajectories. Using clinical and biobank data from 472 blunt trauma survivors, 154 patients were identified after excluding patients who received prehospital IV fluids or had alcohol intoxication. From this subcohort, 84 patients had a BD ≥ 4 mEq/L and 70 patients with BD < 4 mEq/L. Three samples within the first 24 h were obtained from all patients and then daily up to day 7 after injury. Twenty-two cytokines and chemokines were assayed using Luminex™ and were analyzed using two-way ANOVA and dynamic network analysis (DyNA). Multiple mediators of the innate and lymphoid immune responses in the BD ≥ 4 group were elevated differentially upon admission and up to 16 h after injury. DyNA revealed a higher, sustained degree of interconnectivity of the inflammatory response in the BD ≥ 4 patients during the initial 16 h after injury. These results suggest that elevated admission BD is associated with differential immune/inflammatory pathways, which subsequently could predispose patients to follow a complicated clinical course.

Trauma scores and trauma outcome measures

Objective measurement and quantification of injury severity are necessary for triage, performance evaluation and research. In order to evaluate interventions, outcomes must also be compared. While this can be done using hospital stay or mortality, these will fail to detect subtle differences. Impact of injury on health can be quantified using a variety of scoring systems. Trauma scoring and outcome measurement have grown increasingly complex in recent years and are likely to become more so in the future.

Return to Work and Functional Outcomes After Major Trauma: Who Recovers, When, and How Well?

OBJECTIVE

To describe the long-term outcomes of major trauma patients and factors associated with the rate of recovery.

BACKGROUND

As injury-related mortality decreases, there is increased focus on improving the quality of survival and reducing nonfatal injury burden.

METHODS

Adult major trauma survivors to discharge, injured between July 2007 and June 2012 in Victoria, Australia, were followed up at 6, 12, and 24 months after injury to measure function (Glasgow Outcome Scale-Extended) and return to work/study. Random-effects regression models were fitted to identify predictors of outcome and differences in the rate of change in each outcome between patient subgroups.

RESULTS

Among the 8844 survivors, 8128 (92%) were followed up. Also, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% (adjusted odds ratio 1.27, 95% confidence interval [CI] 1.19-1.36) higher compared with 6 months, and 9% (adjusted odds ratio 1.09, 95% CI, 1.02-1.17) higher at 24 months compared with 12 months. The adjusted relative risk (RR) of returning to work was 14% higher at 12 months compared with 6 months (adjusted RR 1.14, 95% CI, 1.12-1.16) and 8% (adjusted RR 1.08, 95% CI, 1.06-1.10) higher at 24 months compared with 12 months.

CONCLUSIONS

Improvement in outcomes over the study period was observed, although ongoing disability was common at 24 months. Recovery trajectories differed by patient characteristics, providing valuable information for informing prognostication and service planning, and improving our understanding of the burden of nonfatal injury.

Lower Health-Related Quality of Life in Polytrauma Patients: Long-Term Follow-Up After Over 5 Years

Although trauma-associated mortality has fallen in recent decades, and medical care has continued to improve in many fields, the quality of life after experiencing polytrauma has attracted little attention in the literature. This group of patients suffer from persisting physical disabilities. Moreover, they experience long-term social, emotional, and psychological effects that limit/lower considerably their quality of life.We analyzed retrospective data on 147 polytraumatized patients by administering written questionnaires and conducting face-to-face interviews 6 ± 0.8 years after the trauma in consideration of the following validated scores: Glasgow Outcome Scale, European Quality of Life Score, Short Form-36, Trauma Outcome Profile, and Beck Depressions Inventory II.Our analysis of these results reveals that polytraumatized patients suffer from persistent pain and functional disabilities after >5 years. We also observed changes in their socioeconomic situation, as well as psychological after-effects.The rehabilitation of this particular group of patients should not only address their physical disabilities. The psychological after-effects of trauma must be acknowledged and addressed for an even longer period of time.

Characterizing common workplace communication skills for disorders associated with traumatic brain injury: A qualitative study

BACKGROUND

Interpersonal skill deficits are the primary reason for workplace separation after traumatic brain injury (TBI). Communication is integral to interpersonal skills, but workplace communication demands are inadequately described in the rehabilitation literature.

OBJECTIVE

This study describes inter-stakeholder examples of workplace communication behaviors for a level of employment to which people with TBI commonly attempt to return.

METHODS

Setting: Mid-level workplaces.Design: Semi-structured interviews were audio recorded, transcribed verbatim, then analyzed using thematic content analysis. Findings were linked to common communication deficits in persons with TBI.Participants: A volunteer sample of twenty healthy individuals employed in the mid-level workplaces, ten employees and ten supervisors.Main Outcome Measure(s): Taxonomy of communication skill deficits common in persons with TBI and associated with mid-level workplaces.

RESULTS

Interviews revealed seven communication-related skills associated with mid-level employment: 1) spoken language processing; 2) verbal memory; 3) reading and writing; 4) verbal reasoning; 5) expressive pragmatics; 6) multi-tasking; and 7) social cognition.

CONCLUSION

Workers and supervisors from an assortment of mid-level jobs with differing job contents all identified similarly common and important cross-occupational communication-related skills. Findings provide a preliminary guide to assess and treat communication skills for patients who have work re-entry as a goal.

Job stability in skilled work and communication ability after moderate-severe traumatic brain injury

PURPOSE

Communication deficits may play a critical role in maintaining employment after traumatic brain injury (TBI), but links between specific communication deficits and employment outcomes have not been determined. This study identified communication measures that distinguished stably employed versus unstably employed adults with TBI.

METHODS

Participants were 31 adults with moderate-severe TBI who were employed full-time for at least 12 consecutive months before injury in skilled jobs and had attempted return to skilled jobs after injury. Sixteen had achieved stable employment (SE) post-injury, defined as full-time employment for ≥12 consecutive months; and 15 had unstable employment (UE). Participants completed a battery of communication tests identified in a prior qualitative study of communication skills required for skilled work.

RESULTS

Measures of spoken language comprehension, verbal reasoning, social inference, reading and politeness in spoken discourse significantly discriminated between SE and UE groups. Two nested models were completed and compared. The first model excluded discourse data because of missing data for two UE and one SE participant. This model revealed that measures of verbal reasoning speed (β = -0.18, p = 0.05) and social inference (β = 0.19, p = 0.05) were predictive independent of the overall model. The second model included discourse politeness data and was a better overall predictor of group membership (Likelihood ratio test, Model 1: 3.824, Model 2: 2.865).

CONCLUSION

Communication measures were positively associated with SE in skilled jobs after TBI. Clinicians should include assessment of communication for adults attempting return to work after TBI, paying specific attention to social inference and speed of verbal reasoning skills.

IMPLICATIONS FOR REHABILITATION

Traumatic brain injury (TBI) often results in communication impairments associated with the cognitive skills underlying interpersonal skills. Communication impairment after TBI has been anecdotally associated with job instability. This research associate communication functioning with work stability after TBI in skilled jobs. These findings indicate that communication impairment should be assessed in persons with TBI returning to skilled employment after injury.

Post-traumatic thrombo-embolic complications in polytrauma patients

INTRODUCTION

Thrombo-embolic events after trauma are considered to be life-threatening complications. Our aim was to determine the incidence of arterial and venous thrombo-embolic events (TE) in severely-injured trauma patients, and its associated risk factors by using a large trauma registry.

METHODS

Patients' data from the TraumaRegister DGU® (TR-DGU) were screened for TE (DVT [symptomatic deep vein thrombosis], PE [symptomatic pulmonary embolism], MI [myocardial infarction], and stroke) through the clinical course of severely injured adult trauma patients from January 2005 to December 2012. Univariate analysis was used to compare the clinical outcomes (endpoints: mortality, ICU and hospital length of stay, ventilator days), and a multivariate regression analysis was used to assess the independent risk factors associated with each TE event.

RESULTS

From a cohort of 40,846 trauma patients, 1122 (2.8%) patients developed a TE during their post-traumatic clinical course (313, 0.8% DVT; 425, 1.0% PE; 160, 0.4% MI and 231, 0.6% stroke). ICU length of stay [LOS], total LOS, days on mechanical ventilation, and incidence of multiple organ failure (MOF) and sepsis were significantly increased in patients with TE complications. Injury severity, major pelvic injury, and one or more operations were found to be independent risk factors for the development of DVT. Age ≥ 60 years, male gender, and more than one operation were risk factors for PE development. For MI age was the only significant risk factor. The occurrence of a stroke is increased in patients with an age ≥ 60 years, major head injury (AIS head ≥ 3), and more than one operation. Finally, mortality rates were significantly higher in the TE group when compared to the non-TE cohort (21.8% vs. 12.7%; p < 0.001).

CONCLUSION

TE complications were associated with longer ICU and hospital stay as well as a higher mortality. Overall, age and repeated operations were the most important risk factors for the development of TE events.

Quality of life two years after severe trauma: a single-centre evaluation

INTRODUCTION

Trauma related injuries are a main cause for long-lasting morbidity and disability especially in younger patients with their productive years ahead. On a routine basis, we assessed health related quality of life two years after trauma of severely injured patients at our level-I trauma centre via posted survey.

PATIENTS AND METHODS

The posted survey included (1) POLO-Chart questionnaire with European Quality of Life (EuroQoL), Short Form Health Survey-36 (SF 36) and the recently developed and validated Trauma Outcome Profile (TOP) combined with (2) single centre data according to TraumaRegister DGU(®) data sets including trauma mechanism, injuries and initial treatment. Inclusion criteria were severely injured patients ≥ 18 years, treated between 2008 and 2010. Exclusion criteria were death, cognitive impairment, lack of German language and denial of participation.

RESULTS

129 datasets were eligible for analysis reflecting a typical trauma collective with mean age 44 years, predominantly male (67%), mean ISS 22 and 98% blunt trauma. Two years after trauma, 62% of the patients reported of relevant remaining pain and 64% of severe functional deficit in at least one body region. Sixty-four percent of the patients suffered from decreased overall quality of life (EuroQoL≤0.8). Additionally, all domains of SF-36 were impaired compared to an age and gender adjusted cohort of healthy individuals, especially domains of pain and activity of daily living. These impairments were associated with decreased 'social functioning' and 'emotional role functioning'. TOP results confirmed these findings: Quality of life was decreased in almost every dimension. TOP additionally identified sequels especially in domains of "Mental Functioning" and impairments in psychological recovery including post-traumatic stress disorder, depression and anxiety. Socioeconomic impairments were frequent including further hospitalisations (62%), duration of inability to work ≥ 6 month (54%), financial disadvantages (45%) and work loss (26%).

CONCLUSION

Our results demonstrate that multiple trauma patients two years after injury suffer from impairments including persisting pain, functional deficits, mental and socioeconomic deficits. The 'Trauma Outcome Profile' instrument seems a proper tool to discover impairments in trauma patients early on and guide proper rehabilitation resources to the best of the patient.

A comparison of functional outcome in patients sustaining major trauma: a multicentre, prospective, international study

Objectives

To compare 6 month and 12 month health status and functional outcomes between regional major trauma registries in Hong Kong and Victoria, Australia.

Summary Background Data

Multicentres from trauma registries in Hong Kong and the Victorian State Trauma Registry (VSTR).

Methods

Multicentre, prospective cohort study. Major trauma patients and aged ≥18 years were included. The main outcome measures were Extended Glasgow Outcome Scale (GOSE) functional outcome and risk-adjusted Short-Form 12 (SF-12) health status at 6 and 12 months after injury.

Results

261 cases from Hong Kong and 1955 cases from VSTR were included. Adjusting for age, sex, ISS, comorbid status, injury mechanism and GCS group, the odds of a better functional outcome for Hong Kong patients relative to Victorian patients at six months was 0.88 (95% CI: 0.66, 1.17), and at 12 months was 0.83 (95% CI: 0.60, 1.12). Adjusting for age, gender, ISS, GCS, injury mechanism and comorbid status, Hong Kong patients demonstrated comparable mean PCS-12 scores at 6-months (adjusted mean difference: 1.2, 95% CI: −1.2, 3.6) and 12-months (adjusted mean difference: −0.4, 95% CI: −3.2, 2.4) compared to Victorian patients. Keeping age, gender, ISS, GCS, injury mechanism and comorbid status, there was no difference in the MCS-12 scores of Hong Kong patients compared to Victorian patients at 6-months (adjusted mean difference: 0.4, 95% CI: −2.1, 2.8) or 12-months (adjusted mean difference: 1.8, 95% CI: −0.8, 4.5).

Conclusion

The unadjusted analyses showed better outcomes for Victorian cases compared to Hong Kong but after adjusting for key confounders, there was no difference in 6-month or 12-month functional outcomes between the jurisdictions.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: a multicentre, prospective cohort study

BACKGROUND

Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome.

OBJECTIVES

To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong.

METHODS

Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS≥9 and aged≥18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome.

RESULTS

Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N=177) and surviving non-responders (N=163). However, there were significant differences between these groups and the group of patients who died (N=60). Only 16/400 (4%) cases reported a GOSE≥7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age>65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26-40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97).

CONCLUSION

For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury<1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score≥Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is≥Hong Kong norm.

Characterizing the relationship between in-hospital measures and workers' compensation outcomes among severely injured construction workers using a data linkage strategy

BACKGROUND

To characterize the relationship between acute measures of severity and three important workers' compensation outcomes associated with a worker's ability to return to work and the cost of a work-related injury.

METHODS

Probabilistic data linkage of workers' compensation claims made by injured construction workers from 2000 to 2005 with two Illinois medical record registries. Multivariable robust regression models were built to assess the relationship between three in-hospital measures and three outcomes captured in the Workers' Compensation data.

RESULTS

In the final multivariable models, a categorical increase in injury severity was associated with an extra $7,830 (95% CI: $4,729-$10,930) of monetary compensation awarded, though not with temporary total disability (TTD) or permanent partial disability (PPD). Our models also predicted that every extra day spent in the hospital results in an increase of 0.51 (95% CI: 0.23-0.80) weeks of TTD and an extra $1,248 (95% CI: $810-$1,686) in monetary compensation. Discharge to an intermediate care facility following the initial hospitalization was associated with an increase of 8.15 (95% CI: 4.03-12.28) weeks of TTD and an increase of $23,440 (95% CI: $17,033-$29,847) in monetary compensation.

CONCLUSIONS

We were able to link data from the initial hospitalization for an injured worker with the final workers' compensation claims decision or settlement. The in-hospital measures of injury severity were associated with total monetary compensation as captured in the workers' compensation process.

Factors associated with return-to-work and health outcomes among survivors of road crashes in Victoria

OBJECTIVE

To explore the relationships between injury, disability, work role and return-to-work outcomes following admission to hospital as a consequence of injury sustained in a road crash.

DESIGN AND SETTING

Prospective cohort study of patients admitted to an adult trauma centre and two metropolitan teaching hospitals in Victoria, Australia. Participants were interviewed in hospital, 2.5 and eight months post-discharge.

PARTICIPANTS

Participants were 60 employed and healthy adults aged 18 to 59 years admitted to hospital in the period February 2004 to March 2005.

RESULTS

Despite differences in health between the lower extremity fracture and non-fracture groups eight months post-crash the proportions having returned to work was approximately 90%. Of those returning to work, 44% did so in a different role. After adjustment for baseline parameters, lower extremity injuries were associated with a slower rate of return to work (HR: 0.31; 95%CI: 0.16-0.58) as was holding a manual occupation (HR: 0.16; 95%CI: 0.09-0.57). There were marked differences in physical health between and within the injury groups at both follow-up periods.

CONCLUSIONS

These results demonstrate that both injury type and severity and the nature of ones occupation have a considerable influence on the rate and pattern of return to work following injury. Further, persisting disability has a direct influence on the likelihood of returning to work. The implications of these findings and the types of data required to measure outcome post-injury are discussed.

Outcome after severe multiple trauma: a retrospective analysis

Background

Aim of this study was to evaluate prognosis of severely injured patients.

Methods

All severely injured patients with an Injury Severity Score (ISS) ≥ 50 were identified in a 6-year-period between 2000 and 2005 in German Level 1 Trauma Center Murnau. Data was evaluated from German Trauma Registry and Polytrauma Outcome Chart of the German Society for Trauma Surgery and a personal interview to assess working ability and disability and are presented as average.

Results

88 out of 1435 evaluated patients after severe polytrauma demonstrated an ISS ≥ 50 (6.5%), among them 23% women and 77% men. 66 patients (75%) had an ISS of 50-60, 14 (16%) 61-70, and 8 (9%) ≥ 70. In 27% of patients trauma was caused by motor bike accidents. 3.6 body regions were involved. Patients had to be operated 5.3 times and were treated 23 days in the ICU and stayed 73 days in hospital. Mortality rate was 36% and rate of multi-organ failure 28%. 15% of patients demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. 25% recovered well or at least moderately. 29 out of 56 survivors answered the POLO-chart. A personal interview was performed with 13 patients. The state of health was at least moderate in 72% of patients. In 48% interpersonal problems and in 41% severe pain was observed. In 57% of patients problems with working ability regarding duration, as well as quantitative and qualitative performance were observed. Symptoms of post-traumatic stress disorder were found in 41%. The more distal the lesions were located (foot/ankle) the more functional disability affected daily life. In only 15%, working ability was not impaired. 8 out of 13 interviewed patients demonstrated complete work disability.

Conclusions

Even severely injured patients after multiple trauma have a good prognosis. The ISS is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score.

Prevalence and predictors of return to work in hospitalised trauma patients during the first year after discharge: a prospective cohort study

OBJECTIVE

The aim of the study was to investigate the proportion of patients who return to work and predictors of return to pre-injury level of work participation the first year after trauma.

METHODS

A prospective single-centre study of 188 patients aged 18-65 years with different degrees of injury severity was carried out in a trauma referral centre. All patients were working or studying full or part time before the injury. The first assessments were performed a median time of 27 days after discharge. Participation in work/education was measured 3 and 12 months after the first assessment with self-report questionnaires. The Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale (IES) were independent measures of anxiety, depression and post-traumatic stress symptoms (PTS) at baseline and 3 months. The Life Orientation Test Revised (LOT-R) measured optimism and pessimism at baseline. Predictors of return to work were identified by multiple logistic regression analysis.

RESULTS

After one year, 131 patients (70%) had returned to the same level of participation in work or education; 95 (50%) had returned at 3 months. Independent predictors of return to work after 3 months were low age, low Injury Severity Score (ISS) score, not needing ventilator treatment and low score for depression symptoms, adjusted for gender (Nagelkerke R square 0.38). Low ISS, absence of serious head injury, low HADS depression score and an optimistic life orientation remained significant predictors of return to work at the same level after 12 months (Nagelkerke R square 0.38). In addition, good physical function (SF-36 PF score>65) at 3 months was an independent predictor of return to work at 12 months in the 93 patients who had not returned to work at 3 months.

CONCLUSION

Independent predictors of return to work at 3 months were low age, low ISS and absence of depression symptoms. At 12 months, independent predictors of return to work were low ISS, low depression score and an optimistic life orientation. To promote early return to work, trauma patients might be screened for depression symptoms and pessimism, and intervention or treatment provided for those in need.

Self-care after traumatic injury and the use of the therapeutic self care scale in trauma populations

AIMS

To report a correlational study of the relationship between gender, age, severity of injury, length of hospital stay and self-care behaviour in patients with traumatic injuries.

BACKGROUND

This study may provide a foundation for targeted nursing intervention and education programmes to help patients better recover from their injury, which is a fundamental aspect of nursing.

DESIGN

A longitudinal cohort study.

METHOD

This study of patients hospitalized for traumatic injury was conducted from May 2006-November 2007. The Therapeutic Self Care Scale along with demographic and clinical data, were completed at 3 and 6 months after hospital discharge. Using data from the 3-month survey, the validity and reliability of the scale was calculated. Multiple regression was used to identify predictors of self-care at 3 and 6 months.

FINDING

Participants (n = 125) completed the questionnaire at 3 months and 103 participants completed it at 6 months. Self-care was high on both occasions and high self-care at 3 months was related to high self-care at 6 months. Older participants reported higher self-care at 3 months compared with younger patients. Factor analysis of the scale revealed three clear components; taking medication, recognition and managing symptoms and managing changes in health conditions, which explained a total of 59·8% of the variance. The 10-item revised scale was reliable.

CONCLUSION

The findings indicate that self-care remains fairly high and stable in the first 6 months after trauma. The revised Therapeutic Self Care Scale was valid and reliable in the trauma population.

Long-term survival and health-related quality of life 6 to 9 years after trauma

BACKGROUND

Trauma systems have improved short-term survival of the severely injured but knowledge on long-term outcome is limited. This study aimed to assess outcome 6 years to 9 years after moderate to severe injury in terms of survival, Health-Related Quality of Life (HRQOL) and employment status.

METHODS

Patients admitted to Aarhus Level I Trauma Center in 1998 to 2000, aged 15 years or more, with an Injury Severity Score (ISS) ≥9 were included. Patients were divided into three groups based on ISS (ISS, 9-15; ISS, 16-24; ISS >24). Survival status was obtained from the Danish Central Person Registry. HRQOL was measured with the Short Form 36 (SF-36) questionnaire, which was mailed to survivors 6 years to 9 years after admission and compared with a matched control group.

RESULTS

Three hundred twenty-two patients were included. Seventy-one percentage were men, median age was 34 years (range, 15-89 years), median ISS was 17 (range, 9-75). In-hospital survival was 85%. After a median of 7.3 years, overall survival was 78%. After hospital discharge, no difference in survival was found between the three patient groups.Sixty-nine percentage of the contacted patients completed the SF-36. Mean SF-36 scores were significantly lower in the patient group than in the control group in all eight SF-36 domains (p < 0.001). Return to employment or education was 52%, whereas 20% of the patients reported to be on early retirement.

CONCLUSION

Six years to nine years after traumatic injury, 78% of the patients were alive. HRQOL was significantly lower for injured patients than a matched control group. Twenty percentage of the patients retired early.

Socio-economic outcome after blunt orthopaedic trauma: Implications on injury prevention

Background

Several large studies have identified factors associated with long-term outcome after orthopaedic injuries. However, long-term social and economic implications have not been published so far. The aim of this investigation is to study the long-term socio-economic consequences of patients sustaining severe trauma.

Methods

Patients treated at a level one trauma center were invited for a follow-up (at least 10 years) examination. There were 637 patients who responded and were examined. Inclusion criteria included injury severity score (ISS) ≥ 16 points, presence of lower and upper extremity fractures, and age between 3 and 60 years. Exclusion criteria included the presence of amputations and paraplegia. The socio-economic outcome was evaluated in three age groups: group I (< 18 years), group II (19 - 50 years), and group III (> 50 years). The following parameters were analyzed using a standardized questionnaire: financial losses, net income losses, pension precaution losses, need for a bank loan, and the decrease in number of friends.

Results

510 patients matched all study criteria, and breakdown of groups were as follows: 140 patients in group I, 341 patients in group II, and 29 patients in group III. Financial losses were reported in all age groups (20%-44%). Younger patients (group I) were associated with less income losses when compared with other groups (p < 0.05). Financial deterioration was more frequently reported in age group II (p < 0.05). Social consequences (number of friends decreased) were predominantly stated in patients younger than 18 years old (p < 0.05).

Conclusions

Economic consequences are reported by polytraumatized patients even ten or more years after injury. Financial losses appear to be common in patients between 19 and 50 years. In contrast, social deprivation appears to be most pronounced in the younger age groups. Early socio-economic support and measures of injury prevention should focus on these specific age groups.

A systematic review of studies measuring health-related quality of life of general injury populations

Background

It is important to obtain greater insight into health-related quality of life (HRQL) of injury patients in order to document people's pathways to recovery and to quantify the impact of injury on population health over time. We performed a systematic review of studies measuring HRQL in general injury populations with a generic health state measure to summarize existing knowledge.

Methods

Injury studies (1995-2009) were identified with main inclusion criteria being the use of a generic health status measure and not being restricted to one specific type of injury. Articles were collated by study design, HRQL instrument used, timing of assessment(s), predictive variables and ability to detect change over time.

Results

Forty one studies met inclusion criteria, using 24 different generic HRQL and functional status measures (most used were SF-36, FIM, GOS, EQ-5D). The majority of the studies used a longitudinal design, but with different lengths and timings of follow-up (mostly 6, 12, and 24 months). Different generic health measures were able to discriminate between the health status of subgroups and picked up changes in health status between discharge and 12 month follow-up. Most studies reported high prevalences of health problems within the first year after injury. The twelve studies that reported HRQL utility scores showed considerable but incomplete recovery in the first year after discharge.

Conclusion

This systematic review demonstrates large variation in use of HRQL instruments, study populations, and assessment time points used in studies measuring HRQL of general injury populations. This variability impedes comparison of HRQL summary scores between studies and prevented formal meta-analyses aiming to quantify and improve precision of the impact of injury on population health over time.

Are existing outcome instruments suitable for assessment of spinal trauma patients?

Object

Valid outcome assessment tools specific for spinal trauma patients are necessary to establish the efficacy of different treatment options. So far, no validated specific outcome measures are available for this patient population. The purpose of this study was to assess the current state of outcome measurement in spinal trauma patients and to address the question of whether this group is adequately served by current disease-specific and generic health-related quality-of-life instruments.

Methods

A number of widely used outcome measures deemed most appropriate were reviewed, and their applicability to spinal trauma outcome discussed. An overview of recent movements in the theoretical foundations of outcome assessment, as it pertains to spinal trauma patients has been attempted, along with a discussion of domains important for spinal trauma.

Commonly used outcome measures that are recommended for use in trauma patients were reviewed from the perspective of spinal trauma. The authors further sought to select a number of spine trauma–relevant domains from the WHO's comprehensive International Classification of Functioning, Disability and Health (ICF) as a benchmark for assessing the content coverage of the commonly used outcome measurements reviewed.

Results

The study showed that there are no psychometrically validated outcome measurements for the spinal trauma population and there are no commonly used outcome measures that provide adequate content coverage for spinal trauma domains.

Conclusions

Spinal trauma patients are currently followed either as a subset of the polytrauma population in the acute and early postacute setting or as a subset of neurological injury in the long-term revalidation medicine setting.

Factors associated with reduced longer-term capacity to work in patients after polytrauma: a Swiss trauma center experience

BACKGROUND

Knowledge of the factors associated with longer-term reduced capacity to work (RCW) is lacking in patients after polytrauma.

STUDY DESIGN

We studied a prospectively collected cohort of polytrauma survivors (n = 115; age 39.5 +/- 20.6 years [mean +/- SD]; 98% blunt trauma; Injury Severity Score [ISS] 27.5 +/- 8.2) at a university trauma center. Uni- and multivariable analyses of patient, trauma, and treatment characteristics as well as parameters of self-reported functional outcomes were studied to determine their association with a reduced capacity to work (RCW) at least 2 years after injury.

RESULTS

Postinjury quality of life was worse compared with preinjury status in univariate analysis (eg, Euro Quality of Life Group Visual Analogue Scale [EQ VAS] 66.2 +/- 24.4 vs 89.7 +/- 14.7; p = <0.001). In 53% of patients (n = 61), an RCW was found and functional outcomes were significantly lower than those in non-RCW patients (p < 0.001). Lower educational status (odds ratio [OR] 0.25; 95% CI 0.07 to 0.92; p = 0.036), higher ISS (OR 1.12; 95% CI 1.02 to 1.22; p = 0.017), less time in the emergency room (OR 0.92; 95% CI 0.86 to 0.97; p = 0.005), higher mean nurse labor per day and patient (OR 1.01; 95% CI 1.000 to 1.004; p = 0.033), and a reduced Nottingham Health Profile value (OR 1.10; 95% CI 1.06 to 1.15; p < 0.001) were associated with an RCW in the multiple logistic regression model (proportion of variance explained: 0.74).

CONCLUSIONS

In this cohort of patients surviving polytrauma, approximately 50% of patients sustained longer-term RCW. Several characteristics, such as level of education or trauma severity, showed an independent association with patients' capacity to work, which was significantly associated with patients' self-rated scorings of well-being.

[Surviving multiple trauma--what comes next? The rehabilitation of seriously injured patients]

The survival chances of multiple trauma patients have improved continuously over the last decades. Therefore, not only the question of whether the patient survives a serious accident arises, but rather how the patient survives it. The after effects of trauma are seen not only physically, but also psychologically and socially. These affect quality of life and are evident years after the accident. The International Classification of Functioning, Disability and Health (ICF) provides a system to classify the after effects of trauma, which can be measured with the help of assessment instruments. Knowing which parameters can influence trauma after effects is essential for the planning, organization, and implementation of a rehabilitation programme following severe injury. The requirements of an optimal rehabilitation process place high demands on the rehabilitation facility and on the rehabilitation team, which ultimately can only be fulfilled by specialized facilities.

Characteristics and outcomes of patients discharged home from the Emergency Department following trauma team activation

OBJECTIVE

Past research on trauma teams has largely focused on the outcomes of severely injured patients. Few studies have looked at patients who have activated the trauma team but are discharged home directly from the Emergency Department. The aim of this study was to examine the characteristics and outcomes of these patients following discharge.

METHODS

All adult Emergency Department discharged trauma patients who were contactable by telephone 7-14 days post-discharge and spoke English were eligible for the study. A 10-min questionnaire was conducted covering their perceptions of Emergency Department care, return to activities, discharge and follow-up care, missed injuries and pain management. Data were also collected on their age, sex, injuries and length of stay in the Emergency Department.

RESULTS

Over the 169-day study period, 158 trauma patients were discharged from Liverpool hospital, which formed 30.1% of all patients treated by the trauma team. Of these, 106 patients were contactable and 100 completed the follow-up questionnaire. They suffered mainly minor injuries but stayed a median 341 min in the Department. Most patients (87%) reported that their health had impacted on their daily activities and about half of all full-time workers remained off work for 1 week or more. A small number of patients had missed fractures or other serious injuries. Two-third of patients visited a medical practitioner after discharge and 8 required further specialist and/or in-patient care.

CONCLUSION

Most trauma patients discharged from the Emergency Department continue to suffer significant morbidity after their departure from hospital and require further medical care. A small number of patients also had significant missed injuries. This suggests that more comprehensive discharge and follow-up care for these patients is warranted.

Injury thresholds after motor vehicle crash--important factors for patient triage and vehicle design

INTRODUCTION

The Committee on Trauma recommends that older motor vehicle crash (MVC) victims or victims of crashes with significant vehicle intrusion of more than 12 in. be transferred to a trauma center since those older than 55 have an increased risk of death after injury. Yet, the precise injury thresholds as they relate to age, gender and velocity remain ill-defined. To maintain a low rate of under triage, reliable methods to identify patients at moderate injury risk are needed. We therefore characterized the likelihood of moderate to severe injury in MVC victims to determine the influence of age, gender and velocity.

METHODS

An analysis of drivers from the National Automotive Sampling System (1993-2001) was performed. Weighted logistic regression models were developed to predict the probability of head, leg, and torso injuries as a function of vehicle speed, age, and gender while controlling for confounders. A 10% probability of injury threshold was set and differences in velocity, gender and age were identified in terms of reaching this probability of injury threshold.

RESULTS

The analysis yielded 56,459 drivers which is equivalent to a population of 28,877,696 drivers nationwide. Restraint use, steering away prior to impact, breaking maneuver, gender, delta velocity, driver height and age were independent predictors of injury. Women had a higher velocity injury threshold than men for the 10% probability of injury cut-off to the torso or head which disappeared with increasing age. Conversely, men had a higher velocity injury threshold than women for the 10% probability of injury cut-off to the extremity which persisted even in older victims.

CONCLUSIONS

Our data indicate that age and gender must be considered in addition to crash velocity when making triage decisions. Furthermore, Federal Motor Vehicle Safety Standards may need to be modified to address the increased risk of injury among older adults at lower velocities given the increasing number of elderly drivers in the US.

Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury

OBJECTIVE

To review the literature addressing the assessment and management of pain in patients with polytraumatic injuries including traumatic brain injury (TBI) and blast-related headache, and to identify patient, clinician and systems factors associated with pain-related outcomes.

DESIGN

Systematic review.

METHODS

We conducted searches in MEDLINE of literature published from 1950 through July 2008. Due to a limited number of studies using controls or comparators, we included observational and rigorous qualitative studies. We systematically rated the quality of systematic reviews, cohort, and case-control design studies.

RESULTS

One systematic review, 93 observational studies, and one qualitative research study met inclusion criteria. The literature search yielded no published studies that assessed measures of pain intensity or pain-related functional interference among patients with cognitive deficits due to TBI, that compared patients with blast-related headache with patients with other types of headache, or that assessed treatments for blast-related headache pain. Studies on the association between TBI severity and pain reported mixed findings. There was limited evidence that the following factors are associated with pain among TBI patients: severity, location, and multiplicity of injuries; insomnia; fatigue; depression; and post-traumatic stress disorder.

CONCLUSIONS

Very little evidence is currently available to guide pain assessment and treatment approaches in patients with polytrauma. Further research employing systematic observational as well as controlled intervention designs is clearly indicated.

A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit

INTRODUCTION

Trauma centers successfully save lives of severely injured patients who would have formerly died. However, survivors often have multiple complications and morbidities associated with prolonged intensive care unit (ICU) stays. Because the reintegration of patients into the society to lead an active and a productive life is the ultimate goal of trauma center care, we questioned whether our "success" may condemn these patients to a fate worse than death?

METHODS

Charts on all patients > or =18 years with ICU stay > or =10 days, discharged alive between June 1, 2002, and May 31, 2005, were reviewed. Patients with complete spinal cord injuries were excluded. Demographics, Injury Severity Score (ISS), presence of severe traumatic brain injury (TBI; Head Abbreviated Injury Scale [AIS] score = 4 or 5), presence of extremity fractures, need for operative procedures, ventilator days, complications, and discharge disposition were collected. Glasgow Outcome Scale score was calculated on discharge. Patients were contacted by phone to determine general health, work status, and using this data, Glasgow Outcome Scale score and a modified Functional Independence Measure (FIM) score were calculated.

RESULTS

Two hundred and forty-one patients met inclusion criteria. Thirty-three patients died postdischarge from the hospital and 39 were known to be alive from the electronic medical records but were unable to be contacted. Sixty-nine patients could not be tracked down and were ultimately considered as lost to follow-up. The remaining 100 patients who were successfully contacted participated in the study. Eighty-one percent were men with a mean age of 42 years, mean and median ISS of 28. Severe TBI was present in 50 (50%) patients. Mean and median follow-up was 3.3 years from discharge. At the time of follow-up, 92 (92%) patients were living at home, 5 in nursing homes, and 3 in assisted living, a shelter, or halfway house. FIM scores ranged from 6 to 12 with 55% reached a maximal FIM score of 12. One quarter of patients had FIM scores < or =10 and 10% had locomotion scores of < or =2 (very dependent). Seventy percent considered themselves to be less active. Seventy-six patients were either working or in full-time school before their trauma. Of the 24 patients not working preinjury, 12 were > or =55 years of age. At the time of follow-up, 37 patients (49%) were back to work or school. Severe TBI patients (57%, 21 of 37) were less likely to return to work when compared with 38% (12 of 38; p = 0.03) without severe TBI. There was no relationship with age, ISS, presence of any TBI, head AIS, presence of any extremity fracture, extremity AIS, or ventilator days in patients who did or did not return to work.

CONCLUSIONS

These data demonstrate that ICU survivors >3 years after severe injury have significant impairments including inability to return to work or regain previous levels of activity and that the goal of reintegrating patients back into the society is not being met. Further studies better defining the limitations and barriers to improved quality of life are necessary. Survival, although important, is no longer a sufficient outcome to measure trauma center success.

Late death after multiple severe trauma: when does it occur and what are the causes?

INTRODUCTION

The information about the long-term mortality and causes of death after multiple injuries is sparse. In general, most follow-up studies report on 1 year to 3 years maximum follow up. The current literature focuses on causes of death immediately after trauma or during the initial in-hospital stay. We report on long-term mortality and causes of death in patients with multiple injures up to 30 years after the initial injury.

METHODS AND MATERIAL

We analyzed the causes of death using patient files, inquiries of patients' relatives, and death certificates. Inclusion criteria are (1) polytrauma (PT) (Injury Severity Score > or = 16) between 1973 and 1990; (2) age 3 years to 60 years at injury; (3) admission to the hospital alive; and (4) death during the study period. Patients were separated into two groups: patients deceased during the initial hospital stay (in-hospital deaths, n = 408) and patients deceased after discharge (postdischarge deaths, n = 103). The survival of the PT victims was compared descriptively with age- and gender-matched data from the general population (GP).

RESULTS

Causes of death in in-hospital deaths are head injury (37%), adult respiratory distress syndrome (14%), sepsis (11%), hemorrhagic shock (10%), pneumonia (9%), multiple organ failure (9%), and others (10%). Causes of death after discharge included cardiovascular diseases (23%), second major trauma (19%), neurologic diseases (16%), suicide (10%), malignancies (6%), and others (26%). The analysis of survival showed a higher mortality for PT compared with the GP group during the first year after the event (p < 0.05). Between 2 years and 10 years after the event, the annual mortality of the PT-group approximates the GP group.

CONCLUSION

PT patients who die after discharge from the initial hospitalization show other causes of death than age-matched controls of the general population. Among these are second major trauma and suicide. Future studies should investigate whether certain social or psychologic factors might play a role.

Factors influencing outcome after orthopedic trauma

BACKGROUND

Some recent studies have suggested that certain types of orthopedic trauma result in ongoing disability and that factors other than injury severity or location may influence outcome. This study aimed to evaluate outcome 12 months and 2 years after severe orthopedic trauma, as measured on the Short Form (SF)-36 Health Survey, relative to a control group, to examine change over time and to examine which demographic, injury-related and psychological factors are associated with persisting disability.

METHODS

One hundred thirteen orthopedic trauma patients, recruited during rehabilitation, and 61 demographically similar uninjured controls were followed up at 1 and 2 years postinjury. Measures included the SF-36 Health Survey, Symptom Checklist-90-R, Brief Pain Inventory, Hospital Anxiety and Depression Scales, and Posttraumatic Stress Disorder Checklist-Specific.

RESULTS

Results indicated presence of significant ongoing disability in all SF-36 physical and mental health domains, significant ongoing psychologic adjustment problems, including posttraumatic stress disorder (PTSD) symptoms, and pain, with little or no improvement between 1 and 2 years postinjury. The presence of ongoing pain, anxiety, depression or PTSD symptoms were the strongest predictors of outcome on most variables, with older age also contributing to negative outcomes. Injury severity and type did not predict outcome, although those with lower limb fractures had greater pain and poorer physical outcomes that those with fractures in other locations.

CONCLUSIONS

This study has highlighted pain and PTSD symptoms as frequent and disabling factors after othropedic trauma. There is clearly a need to focus on alleviating these problems as part of the rehabilitation process.